June 28, 2018

Community health workers can help make the difference for patients

Leah Tuzzio, MPH, and colleagues describe an underutilized role that can help primary care become truly patient-centered

Kaiser Permanente Washington Health Research Institute (KPWHRI) scientists recently published findings that describe benefits of adding an important element to family medicine care teams: community health workers (CHWs).

CHWs are trained lay people who often have a socioeconomic background like the patients in the communities they serve. They offer a low-cost way to improve health care delivery while effectively addressing the disparities that impact our communities. When primary care practices maximize the use of lay people, it allows all team members to work at the top of their licensure and perform the work needed to provide quality care to patients. Although CHWs have been utilized for decades, there’s a lack of published research that describes what they specifically do to make the biggest impact.

“Community health workers have potential to enhance primary care access and quality, but remain underutilized,” the authors wrote. “To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis.”

KPWHRI Research Associate Leah Tuzzio, MPH, answers questions about CHWs and the new article she recently published that describes their contribution to the clinical workforce in Annals of Family Medicine: “Roles and Functions of Community Health Workers in Primary Care.” Her co-authors are Andrea Hartzler, PhD, Clarissa Hsu, PhD, and Ed Wagner, MD, MPH.

How do you describe a typical community health worker?
Community health workers (CHW) have been around for decades, and are part of health care all over the world. There are many different job titles for this type of worker, including promotora, outreach worker, and lay health worker. Trained individuals without formal medical education, CHWs use a variety of skills, knowledge, and experiences to engage family, peers, and community members around health and health care. They provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. Community outreach in the form of home visits and health screening can also be part of their job description.

CHWs often share similar characteristics as the people living in the communities they serve, such as ethnicity, language, and socioeconomic status.

Why does research on community health workers matter?
The existing research shows that people find CHWs easy to relate to, and that as such, they’re noted as a particularly effective part of health care teams. We know from our work on the LEAP project (Learning from Effective Ambulatory Practices) that they are making an enormous difference to patients and families.

In the literature review we conducted for our article, we studied the role of CHWs who work in primary care. CHWs have a large array of jobs, skills, and functions as team members in care delivery. But the scientific evidence hasn’t documented ways they can add value and be the most effective. It’s been difficult to describe what CHWs do, their qualifications, and how to support them. Teasing out these best practices and furthering this research area matters because CHWs may prove to be invaluable to achieving health equity.

Your paper described community health worker functions and roles. Why is that important?
We learned that the CHWs can be added into a primary care team to perform defined functions, be a relatable presence, and free up other team members to perform work most closely aligned with their skillset and licensure. CHWs can lift some of the burden from their fellow primary care team members while being a reassuring link between patients and doctors. To get to a place where family medicine routinely delivers team-based and patient-centered care, it’s essential to describe which team members do what. Our study showed that CHWs usually play three different roles on primary care teams: 1) provide clinical services; 2) help make connections with community resources (like the community resource specialists in Kaiser Permanente Washington clinics do);* and 3) provide health education and coaching.

We also found that CHWs can be utilized for twelve activities, or “functions”: care coordination; health coaching; social support; health assessment; resource linking; case management; medication management; remote care; follow-up; administration; health education; and literacy support.

How did you and your team arrive at these functions and roles?
Leah: We identified three types of CHWs as described in the LEAP program: 1) those who worked directly with patients in primary care; 2) those who were only community-based and not connected to a clinic; or 3) those who were administratively focused. Then, Dr. Andrea Hartzler led our team in identifying relevant papers about studies on interventions with CHWs. She and I abstracted the necessary information from the literature, we used a two-step approach called a modified Delphi card sort. We cut out relevant quotes from the literature that described what the CHWs did then grouped similar pieces of text (“cards”) into clusters that we named into different functions to see how they related. It was like scrapbooking or putting a puzzle together and a lot of fun! After that, Dr. Andrea Hartzler conducted the statistical analysis to see how the different groups aligned.

What interests you about improving health equity?
Leah: When we refer to health equity, we’re talking about making possible the chance for everyone to receive affordable, high-quality, person-centered health care. Much has been written elsewhere about this topic, so I’ll just say that health equity is not yet a reality. Like many of my colleagues at KPWHRI, I believe it really matters that everyone has the same opportunities to live a healthy life.

We are interested in knowing if we have the scientific evidence to support the idea that incorporating CHWs into primary care teams adds value and improves health equity in our communities. Can we bring a solid case to those who design health care and move system change forward? We’re getting close! I’m hopeful that this research moves us further towards that day.

As our communities grow and diversify, our health care systems need to provide the same chance for everyone to live a healthy life. We can increase that chance by adding members to primary care teams who bring a deep understanding of local communities and ethnic groups into the clinic.

I believe that routine implementation of CHWs into primary care teams can play a significant role in achieving the kind of health care and the kind of health that I wish for everyone.

When science can demonstrate that including community health workers in primary care teams leads to improving patient-centeredness, better long-term health outcomes, lower costs, and creates healthier communities, we’ll be able to make a solid case for building care teams that include them.

* Varied stakeholders, including patients, community members, providers, and researchers, worked together to develop the community resource specialist role, through a research project called Learning to Integrate Neighborhoods and Clinical Care (LINCC), funded by the Patient-Centered Outcomes Research Institute: See video. Pilot results showed that patients attributed their improved health and well-being to help from community resource specialists. Now the Kaiser Permanente Washington Learning Health System program is supporting the implementation of the community resource specialist role across Kaiser Permanente Washington’s primary care clinics.

By Dona Cutsogeorge

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