Evidence Beyond Anecdotes for Community Health Workers in the U.S.

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By Samantha Kumar and Terri Jackson

Oregon’s Medicaid Coordinated Care Organizations (CCOs) are well-known for the air-conditioner story:  a community health worker (CHW) acquired a $200 air-conditioning unit for a 90-year-old woman with congestive heart failure and prevented a $50,000 hospital admission, which saved the state $48,800. The state’s 15 CCOs focus on accountable care and the ability of CHWs to engage with super-utilizers of health care services to reduce costs and improve health outcomes among Medicaid beneficiaries. CHWs often find that patients face barriers accessing quality health care that are non-medical in nature such as transportation, housing and limited health literacy. Addressing these non-medical needs could contribute to the success of CCOs in achieving the triple aim could also result in statistically significant evidence that CHWs are cost-effective and a promising component of efforts to bend the health care cost curve.

Although the use of CHWs in global health is well established, current evidence for the efficacy of community health workers in the U.S. is ambiguous due to a lack of funding for evaluation, inconsistent  training, variations in scope of practice and a fragmented health system. Outcomes from Oregon’s CCOs could result in the evidence necessary to scale up systemic mechanisms to deploy CHWs throughout the country because of several methodological strengths:

 

  • The network of CCOs can provide comprehensive cost, utilization and health outcomes data.
  • Certification and training of CHWs in Oregon facilitates consistency of capabilities among trained CHWs and a clearly defined scope of practice.
  • With 565,000 Medicaid enrollees (an additional 400,000 expected under the ACA’s Medicaid expansion) and significant investment in the CHW workforce, there is a large number of both patients and CHWs, which could ensure a sample size large enough to achieve statistical significance.
  • Many Medicaid patients are super-utilizers of health care services. The most costly beneficiaries account for 1% of the Medicaid population but 25% of spending. Of this top 1%, 83% have at least three chronic conditions, more than 60% have five or more chronic conditions and often lack access to care coordination.

 

The ability of CHWs to streamline the transition towards patient-centered care, accountable care, care coordination and medical homes has drawn ample attention from policy makers and funders. Until recently, non-profit organizations have used CHWs to connect patients with care and now payers and providers are starting to consider employing CHWs to improve health outcomes and elicit cost savings despite limited data. A clear demonstration of the utility of CHWs in the U.S. health care system will also provide a foundation for efforts to standardize training, define scope of practice, secure stable funding and integrate CHWs in established care coordination models.

CHWs have the potential to be an integral force in prevention, expanding rural access, reducing health disparities and providing culturally competent care while trimming costs. Key stakeholders are holding off until they have more concrete evidence beyond the air-conditioning anecdote.

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