As the Affordable Care Act (ACA) transforms and reconfigures the health care system, we are all taking stock. Individuals are responding to changes in coverage and investigating new insurance options. Grumbling discontent is emerging as costs are increasing for some and the future benefits of these reforms are uncertain. While the ACA expands access to health insurance for millions, it is clear that our system still requires improved care coordination, patient-centered care and patient engagement. Are community health workers (CHWs) a panacea for our ailing system? If so, what is keeping us from effectively scaling up CHWs in every community?
CHWs are uniquely positioned to address barriers to care and non-medical factors that influence health outcomes. At the 141st Annual APHA Annual Meeting, we co-hosted a town hall on Health Outcomes, Cost Savings, the ACA and Community Health Workers in partnership with the Public Health Association of New York City. A dynamic debate with the town hall panelists and participants reiterated that CHWs are efficacious because they can establish relationships that empower individuals and mobilize behavior change. Additionally, they have potential to be a component of a tailored solution to geographic variations in utilization and access as well as health disparities.
Despite the sizeable volume and range of CHW experiences, the fact is there’s a lack of large scale, scientific studies to demonstrate the efficacy of CHWs to solve health care problems. However at the town hall, Dr. Chris Gibbons from the Johns Hopkins Urban Health Institute contended that fixating on the evidence-base as a roadblock to scalability is distracting us from confronting the more difficult and pressing implementation roadblocks. The logic model for CHWs has been established in a myriad of communities but the menacing obstacle is execution and replication. He reminded the audience that “we know a lot already, get on with it.”
Implementation trumps strategy, as exemplified by the troubled roll out of the ACA’s health insurance exchanges. While we know the steps required to establish a CHW program, the success of the program depends on its ability to activate its community and to develop credibility and trust. In practice, program managers are most concerned with operationalizing CHWs at every phase of implementation:
- Defining the scope of practice of a CHW require decisions about therapeutic areas, roles and responsibilities that align with the needs of communities.
- Adequate training and establishment of core competencies are necessary to equip CHWs, who are often considered a nontraditional workforce, with the health literacy and skills required for the job.
- Supervision and management entails a balance of oversight and guidance of CHWs often working autonomously in communities.
- Establishing sustainability through reimbursement models and third party payers is essential in a meager grant funding environment. CHWs often elicit cost savings and should be regarded as an investment in the future.
Overcoming these challenges is critical to formally integrating CHWs into the health care system. The utility in of CHWs in our system has yet again been reaffirmed by the role of enrollment navigators as a part of the solution to the ACA’s faulty health information exchanges. The use of these enrollment navigators is a timely reminder that community health workers are allies, coaches and advocates in an evolving health care system. The successful implementation of CHWs is essential for the effective and extensive deployment of CHWs in every community.