Community Health Workers Offer Critical Supports for Patients with Complex Health and Social Needs: An Evidence Review

Lorie Martin, Center for Health Care Strategies
Aditi Vasan, MD, MSHP

Community health workers (CHWs) are health care system force multipliers who can improve health outcomes as well as reduce costs. Many come from the populations they serve and can bridge gaps between health professionals and their patients’ communities, including for example, by connecting families to prevention and other resources that reduce expensive emergency care.

The Better Care Playbook recently spoke with Aditi Vasan, MD, MSHP, a health services researcher at the University of Pennsylvania’s Perelman School of Medicine. She is a co-author of Community Health Worker Integration with and Effectiveness in Health Care and Public Health in the United States, a systematic review recently published in Annual Review of Public Health. The systematic review examines evidence on the effectiveness of CHW interventions across dozens of recent randomized control trials and studies. Drawing on her research, the conversation with Dr. Vasan delves into how CHWs can be helpful to patients with complex health and social needs.

Q. CHWs have been working in the U.S. for 70 years. Why are they getting more attention now?

A. It's partly because there’s been an increased recognition of the role that social and structural determinants of health play in informing health outcomes. We recognize that these factors can play a huge role in determining whether people can be healthy. CHWs are natural partners, with the knowledge and ability to help families navigate complex and sometimes confusing health care-related processes, as well as community-based resources.

Q. Tell me about what CHWs bring to help people with complex health and social needs.

A.  CHWs' strength lies in their lived experience and their ability to build trust with patients and families, especially those from marginalized communities. They are often people who are empathetic and excited about connecting with people with similar backgrounds to their own. They not only build trust and connect with the families and caregivers of the patients they serve, but they also have a community-informed view of what resources might be available for someone who needs help with food, transportation, or utilities in a way that we as physicians or other clinicians within the health care system might not.

Q. Can you discuss how the evidence base for CHWs has grown in recent years and how is the field changing as a result?

A. There's more high-quality evidence that CHWs are effective, in part because this is being studied more rigorously. We're also starting to standardize the work that CHWs do a bit more and how we define it.

There's been a lot of evaluation work recently looking at how CHWs can improve health across the triple aim: improving chronic disease control and population health, improving patient experience of care, and notably, there is some recent evidence that suggests that CHWs may be able to reduce costs of care by reducing acute care utilization.

With this growing evidence base, the field is trying to standardize the process of CHW hiring, training, and support. For CHW programs to be effective, they need effective streams for hiring recruiting people who are natural helpers, empathetic, and have the ability to connect with others, including people whose backgrounds are similar to their own. Our hope is that those key factors can be translated into the characteristics we look for when CHWs are hired, the areas we focus on in CHW training, and the kinds of supports that we build in for CHWs.

Q. How do those improvements in training and hiring relate specifically to dealing with patients with complex health and social needs?

A. For individuals with complex health and social needs and their caregivers, there's a whole extra level of health-system-based support that CHWs need to provide. To be a CHW serving that population, you need to be really familiar with how to navigate the health care system, and sometimes how to navigate multiple health care systems, and be able to support people through that.

CHWs who have dealt with chronic conditions themselves or been caregivers to children or adults with chronic conditions are sometimes best suited to that role, because they really understand firsthand what it's like to navigate a system from the perspective of a patient or family caregiver, sometimes even better than some of us in the health care system.

Q. Is there supporting evidence that CHWs can address health behaviors and outcomes and reduce costs?

A. There's some evidence in each of those areas. CHWs can improve chronic disease control in patients with chronic conditions like diabetes or heart disease. Studies show CHW interventions improve rates of cancer screening and rates of access to primary care or rates of post-hospital follow-up for patients who are admitted. And there's emerging evidence of cost savings, which may be associated with decreased acute care use and improved engagement with preventive care. So, instead of waiting for their disease to get severe enough that they need to be seen in the emergency room, CHWs may help family or patients figure out how to reach their primary care doctor.

Q. How can health care organizations integrate CHWs into their care teams?

A. One particularly promising model is having CHWs directly employed within health care systems. CHWs are sort of an extra layer of support, with a focus on resource connection, health and social service navigation, and supporting patients with self-management of chronic diseases. In an ideal world, CHWs can let everyone work at the top of their license. So, doctors and nurses don't have to feel like they need to hold all the information about social resources available for families, and social workers can work with individuals who have needs that require their expertise, like intimate partner violence or mental health needs, while CHWs address a lot of the other social needs that come up.

There's an opportunity for health systems, especially in states that have models for funding CHW work, to hire CHWs to work alongside those care teams, in the inpatient setting, in the outpatient setting, and in subspecialty clinics, including specialized clinics for individuals with medical complexity.

Q. How can CHWs address health equity?

A. There are three levels at which CHWs can help advance health equity. The first level is by directly advocating for clients to receive equitable access to resources and health care.

The second level is institutional. CHWs can help a health system provide more equitable and higher-quality care. For example, a CHW based in the inpatient setting could learn from a family about their preferences for communication and then relay information that to the medical team, so the medical team can provide more effective care.

The third level is advocacy. CHWs can advocate for social justice on a community level or societal level. One survey that we cite, conducted in 2014, found that 45 percent of CHWs identified as Hispanic or Latinx, and 20 percent as Black or African American. A lot of CHWs are themselves from marginalized groups and then are able to serve these groups and advocate for their needs at the community, city, state, and federal levels.

Q. What are the barriers to effectively implementing CHWs?

A. A big barrier is not having sustainable financing for CHW programs. Historically, a lot of CHW programs have been funded through short-term grants. In our article, we are advocating for investments in health system transformation that would allow CHWs to be hired, recruited and trained to be a permanent part of the health care workforce.

There's a shift toward value-based care that has made a lot of organizations interested in CHW programs. About half of U.S. states have some form of Medicaid financing for CHWs, which is great. But often, Medicaid funding for CHWs is restricted to specific diagnoses, meaning these programs may not address the unique needs of people with multiple chronic conditions, who might not be best-served by a diabetes-specific program or an asthma-specific program.  

There is a need for health systems to adopt CHW programs, but also to adopt them with an eye to make sure that they're carefully designed and CHWs are adequately trained and supported which includes both adequate support and supervision in the work they do and adequate compensation. And I also think there's an opportunity for health systems to make the case to the payers that they work with that this really is a model of care that we need to push forward.

Q. What have I not asked you that I should have?

A. One additional issue we touched on in the review is CHW certification. CHW certification is sometimes cited as a potential way to standardize CHW training and support. One concern that arose from our review is that when you require certification, sometimes you're privileging people who have had more educational opportunities, rather than the people who would be best for the role in terms of their character traits.

We found in one of the sources that we cited that CHW certification increased wages among men and white CHWs with no effect for women or non-white individuals, who are the majority of the workforce. Certification is a bit of a double-edged sword, where it has the potential to allow for standardization but could result in people who would be great CHWs not being eligible or adequately compensated for their work.

Q. Is it fair to say you came away from this research upbeat about the potential of CHWs?

A. Definitely. We came away excited about the potential for patient- and family-centered CHW programs in particular, and about the role that CHWs can play in leveraging their lived experience and expertise and working across health systems and their surrounding communities to keep people healthy.