Transcript Community Health Workers

Community Health Workers:
New Roles and Policy
Challenges
NASHP 24th Annual State Health Policy Conference
Kansas City, October 4, 2011
Carl H. Rush, MRP
Project on CHW Policy and Practice
University of Texas Institute for Health Policy
San Antonio, Texas
Community Health Worker definition
American Public Health Association (1)
The CHW is a frontline public health worker
who is a trusted member of and/or has an
unusually close understanding of the
community served.
This trusting relationship enables the CHW to
serve as a liaison/link/intermediary between
health/social services and the community to
facilitate access to services and improve the
quality and cultural competence of service
delivery.
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Community Health Worker definition - APHA (2)
The CHW also builds individual and
community capacity by increasing health
knowledge and self-sufficiency through a
range of activities such as
outreach, community education, informal
counseling, social support and advocacy.
•APHA CHW Section (formerly SPIG), 2006
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What Is Distinctive About CHWs? (1)
• Do not provide clinical care
• Generally do not hold another
professional license
• Expertise is based on shared culture
and life experience with population
served
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What Is Distinctive About CHWs? (2)
• Rely on relationships and trust more
than on clinical expertise
• Relate to community members as
peers rather than purely as client
• Can achieve certain results that
other professionals can't (or won't)
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Pro-active Vs. Reactive Roles
• Many stakeholders think of CHWs in
limited terms, mainly outreach
(proactive)
• Many CHWs also are assigned to patients
or receive referrals (responsive)
• Roles touch entire continuum of care
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“Rules of Engagement” – How CHWs can be engaged in the health care system
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CHW PRO-ACTIVE
(in-referral by CHW)
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HEALTH SYSTEM/
CONTINUUM OF CARE
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CHW RESPONSIVE
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SCREENING/
PREVENTIVE CARE
ROUTINE
PRIMARY CARE
SECONDARY CARE
(specialists)
TERTIARY CARE
(hospital etc.)
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The promise of CHWs
• Proven impact in important areas:
▫ Access to care
▫ Prenatal/perinatal
▫ Chronic disease management
▫ Long term care
▫ Utilization / ER diversion
• Significant cost saving potential
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CHW Cost Effectiveness Studies
• Baltimore Medicaid Patients with Diabetes, with or
without Hypertension: average annual savings of
$2,245 per patient.
• Denver Health Study: increased use of primary and
specialty care, and reduced use of urgent care. ROI
2.28:1.
• Hawaii Asthma Management Program: decline in ER
visits and increased quality of life. Asthma-related
per capita cost decreased 75%.
• Arkansas Community Connectors. Avoiding need for
nursing home care by connecting to community
based services: ROI to Medicaid 2.9:1
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Unpublished data from CHW employers
• Neglected until recently as potential
sustainability strategy
• Less incentive to publish than
researchers
• Results can be dramatic
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Care Partners
Care Managed Clients
Average Cost of Care By Region
Average Cost of Care
N = 424
Average Cost of Care (Pre) equals annual ED and IP cost divided by N
Rush, CAverage Cost of Care (Post) equals annual ED and IP cost less payments divided by N
Source: HPM
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CHW roles in PCMH and ACO
• Team member with expertise in cultural
factors, social determinants
• Facilitate patient-provider communication
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More time with patient
More complete communication (candor)
Frequency and continuity of communication
Fewer “lost to follow-up”
• Example: care transitions/readmissions
• Skills applicable to population health as well as
patient care roles
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Policy challenges re: CHWs
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Sustainable funding streams
Occupational regulation
Workforce development resources (training)
Research standards and funding
• Policy-related environmental factors
▫ Occupational identity (internal, external
awareness)
▫ Professional association/network activity
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Financing/sustainability options
• Medicaid waiver/SPA: MN example
• Medicare – the door is open
▫ Example: diabetes education
• Incentives to third party payers
• CHW employment policies in state procurement
• Provider/payer internal return on investment
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CHW credentialing
• Only Texas and Ohio have general CHW
certification
• MN authorizes Medicaid reimbursement
for services by CHWs who meet standards
• All 3 States base qualification on
completing an approved training
program, not direct assessment of skills
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CHW credentialing (2)
• IN, AK have certification for CHWs only in
specific programs
• Opposition to credentialing exists
• NIH national strategy workshop Nov. 2010 –
recommended:
• Only broad common skill standards at
national level
• Possible national specialty certification
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CHW credentialing (3)
• Mass. has established state CHW
credentialing commission
• NY, FL initiatives moving in direction of
state credentialing
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Opportunities in State Policy to
Promote Employing CHWs
• Standards for “patient-centered medical
homes” and “community health teams”
• Outreach for Health Insurance Exchanges
• Rules for health insurance Medical Loss Ratios
• Standards for insurance preventive care
benefits
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Oregon House Bill 3650 (2011)
• Creates “Integrated and Coordinated Health
Care Delivery System” for public programs
• “Coordinated Care Organizations” must provide
assistance from CHWs in “navigating the health
care delivery system and in accessing
community and social support services”
• Potential national initiative for FQHCs
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Required reading!
Volkmann, K.; Castañares, T. (July 2011)
Clinical Community Health Workers: Linchpin of
the Medical Home. J Ambulatory Care Manage
34(3) 221–233.
(Entire July 2011 issue devoted to CHWs)
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Potential employers uninformed
• Need for major effort in stakeholder education
• Provider staff are seen as either clinical or
administrative: CHW is neither
• Other professions and scope of practice
• Stages of employer development:
▫ Clueless
▫ “Why here?”
▫ “Nice, but…”
▫ “True believer”
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What is needed now?
• Employers and other stakeholders join
with CHWs for policy change
• Coordinated effort in all policy arenas
at state level
• Learn from/network with other states
• What are you willing to do?
• What support do you need?
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Resources
• APHA CHW Section
• Univ. of Texas Institute for Health Policy:
Project on CHW Policy and Practice
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Useful links/papers handout
http://bit.ly/oIUb7O
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Contact info
Carl H. Rush, MRP
Project on CHW Policy and Practice
PO Box 5533
San Antonio, TX 78201-0533
(210) 775-2709
(210) 241-3983 mobile
[email protected]
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