Community Health Workers: Getting a Seat at the Table

MHE PublicationMHE July 2024
Volume 34
Issue 7

Community health workers can improve health outcomes and lower costs. So why haven’t they been fully incorporated into the U.S. healthcare system?

In a conference room 15 floors above downtown Philadelphia, 15 people are seated on either side of a table that runs the length of what would otherwise be a nondescript conference room. But the 15 white posters covered in colorful hand-drawn lines, circles, words, and stick figures taped to the walls and windows have transformed the drab meeting room into what looks like a gallery of street art.

It’s the second day of Jefferson Health’s yearlong Community Health Worker Academy. The drawings, dubbed “journey walks,” are metaphorical road maps that highlight important, sometimes traumatic, experiences that each person in the group has experienced and has inspired them to become community health workers (CHWs).

“The journey walk is what got [them] here,” says Cherida Hartzog, the academy’s program director and a certified CHW. “Part of the journey walk experience is who I am and what I have been through.”

The 15 young and middle-aged people (10 women and five men) in the room come from marginalized communities across the region. Some have been homeless, experienced hunger and witnessed or been the victim of physical violence. There is a cancer survivor in the group, and someone who has been incarcerated. What links them is a desire to serve their communities.

Tinysha Mims

Tinysha Mims

“A lot of them talk mostly about who they are and how they want to impact the community they grew up in,” says Tinysha Mims, the class’ facilitator and lead CHW. “Some talked about the changes in the community and how the changes affected their lived experience. They want to go back and give to Philadelphia as a whole.”

What they will learn at the Jefferson Health program in the coming year will enable them to return to their communities ready to help neighbors, many of whom are wary of the healthcare system and face obstacles to using it and various social services.

Just two days into training, they are anxious to get started.

“I’ve seen the wounds that people walk around with,” says Hope, 43, a recruit who is 10 years into drug addiction recovery. “I have lived that pain. I have been homeless, living in a tent to wake up surrounded by snow and not having anyone. Being able to be that person that someone can trust is very important. I just want to give someone that hope and let them know that it is possible, that you can be happy. It takes a lot of work, but you can do it.”

The return on investment is there

Community health workers have been around in the U.S. in one form or another for at least 70 years. Today there are approximately 59,000 working working CHWs in the United States. Jefferson Health, a sprawling healthcare system with hospitals and other facilities in southeastern Pennsylvania and southern New Jersey that is headquartered in Philadelphia, employs between 20 and 25 CHWs.

The term community health worker can be used expansively, according to the National Association of Community Health Workers. Promotores and promotoras de salud, community health representatives, aunties, peers, outreach workers — they may all come under the heading of community health workers depending on the context. The common thread, according to the association’s website, is people “… who share lived experience, trust, compassion, and culture with communities where they live and serve.”

It wasn’t until the passage of the Affordable Care Act in 2010 that interest in CHWs as a profession really picked up. A year later, the United States Department of Labor officially recognized CHW as a labor category. It did so, the Labor Department explained, because CHW employment was shifting from community-based organizations to hospitals and health systems that “value education and training more highly than traditional characteristics, such as peer status.”

Yet, it is that peer status, which the Labor Department seemed to look down on, that is the superpower of CHWs, say backers for this grassroots approach to healthcare. Ideally, CHWs live in the community of the people they serve. They are recognized as family, friends and neighbors. Advocates for CHWs say CHWs and the people they serve have similar lives and from that commonality comes trust.

Christine James, Ph.D., M.S.W.

Christine James, Ph.D., M.S.W.

“They have this really important lived experience that helps them connect very quickly with patients and community members,” says Christine James, Ph.D., M.S.W., director of the Community Health Workers Collective at Thomas Jefferson University Hospital in Philadelphia. “We train them so that they know part of their role is to give voice to people who may not speak up otherwise.”

Several randomized clinical trials have shown that CHWs are a managed care twofer, saving money and producing improved health outcomes.

Sinai Urban Health Institute, part of the Sinai Health System in Chicago, has 24 years of experience training and embedding CHWs. During the past seven years, its consulting arm, the Center for CHW Research, Outcomes, and Workforce Development, has trained more than 2,000 CHWs nationwide and consulted with 70 organizations. In 2012, physicians at Sinai enrolled 70 Black children in a pilot program to improve asthma management. Over a six-month period, CHWs conducted asthma education sessions during three to four home visits. They also served as a liaison between families and the
healthcare system.

The results found “symptom frequency was reduced by 35% and urgent health resources utilization by 75% between the pre- and post-intervention periods.” The return on investment was $5.58 for every dollar spent.

Other studies have been conducted since, most producing evidence supporting the value of CHWs. One of the most rigorous was led by Shreya Kangovi, M.D., an associate professor of medicine at the University of Pennsylvania in Philadelphia. Kangovi and her colleagues randomly assigned about 300 residents of high-poverty neighborhoods with two chronic diseases to receive CHW or regular care. The CHW services, provided by six CHWs, entailed weekly communication and help with fulfilling “action plans” that went beyond traditional healthcare and encompassed social and recreational activities that would have health benefits. At the same time, the CHWs worked closely with outpatient primary care practices. The results were impressive: The total cost of healthcare on an annual basis was 38% lower for the participants in the CHW group than those in the control group ($2.45 million versus $3.85 million). Factoring in the cost of the CHW program (about $568,000), they calculated that the return on investment was $2.47 for every dollar invested, realized within a single year. Kangovi and her colleagues reported the results in 2020 in an article published in Health Affairs.

In an article published last year in the Annual Review of Public Health, Kangovi and her co-authors said that CHW interventions “can lead to improvements in patient experience of care, with the added benefit of reducing costs and the advancing health equity.” But they also warn that “community health workers are at a crossroads in the United States” and that “several key challenges have emerged along with opportunities to support effective integration with health care.”

The biggest of those challenges is finding a sustainable source of funding. While Sinai and Kangovi’s CHW program, called Individualized Management for Patient-Centered Targets, may be on solid footing, others are just an expiring grant or depleted gift away from shuttering, a precarious status of which James at Thomas Jefferson University Hospital is well aware. Jefferson Health’s Academy is underwritten by a philanthropic gift from an anonymous benefactor.

“What we are trying to do is be creative about other models,” James says. “Can we look at value- based models in addition to philanthropy and longer-term grants? Because Jefferson is committed, we are going to look at how we can keep this in place long-term.”

Building a ladder

Jefferson's first class of CHWs graduated in 2017. But last year the program was restructured and expanded into a yearlong, immersive experience starting with 10 weeks of foundational instruction and experiential-based training. “Although the curriculum was amazing, it needed some adjusting,” Mims says. “We took from our own experiences and developed a conversation piece, discussion pieces that allow them (students) to express who they are.”

In December, James put out the word that a new CHW class was forming. Rather than advertise, she contacted community organizations and practicing CHWs. Within weeks there were 100 applications for 16 seats. James and her staff conducted telephone interviews with all 100 candidates listening for that “lived experience” and passion. The first day of class, James and Mims knew they had chosen wisely.

“When [the students] walked through the door, for me it was their posture,” Mims says. “They walked in with a posture of confidence.”

For 10 weeks, the students will learn how to navigate the healthcare system and support people with chronic or long-term health and wellness issues. They will also learn to manage social needs, like food insecurity, housing security, safety, utility assistance, and insurance issues. Then it’s off to a worksite where they will spend the rest of the year building skills and earning their certification.

While in training, the recruits will be paid a full-time salary at an hourly rate higher than the state’s $15-per-hour minimum wage. (The average CHW rate nationwide is about $23 an hour.) They also receive benefits. James knows the pay isn’t enough to survive in a big city. But for now, it’s the best she can do.

“We are finding that we are not paying enough in terms of a livable wage in this area,” James says. “Often, we find there are CHWs who are doing more than one job. So, they are getting this as a full-time job with benefits and maybe instead of three jobs, they are working one extra [job].”

In a 2021 national survey conducted by the National Association of Community Health Workers, 83% of 867 CHWs who responded were employed full time. Less than half (46%) agreed that they were paid a livable wage. “One way to ensure a thriving wage is that CHWs should co-develop employment policies to reflect what they do. Compensation for CHWs’ labor should reflect CHWs’ lived experience, trust among the community, and the depth of knowledge for the community served,” the association said in an email to Managed Healthcare Executive.

Stacy Ignoffo, M.S.W.

Stacy Ignoffo, M.S.W.

James is working on building a career ladder to not only retain CHWs but also encourage them to go further in the medical or social work fields. Stacy Ignoffo, M.S.W., executive director of Community Health Innovations at Sinai, found that creating a career ladder was very important. Recruits at Sinai start out with the title CHW 1. From there, they can progress to a CHW 2, 3, and, eventually, supervisor.

“Creating these career ladders within the CHW role we found [to be] really important to allow career growth, mobility, and providing support for a CHW who maybe wants to get into nursing or social work,” she says.

Relationships can be tense

CHWs can work in almost every healthcare setting imaginable, from emergency rooms and inpatient and outpatient trauma units to primary care and specialty practices, such as maternal health, pediatrics, oncology, and addiction clinics.

A new CHW’s first assignment is often their hardest. Being immediately accepted as a teammate into a field that until now has been made up primarily of doctors, nurses and social workers, is not automatic.

“CHWs don’t get acknowledged,” Mims says. The attitude often is, “You’re new. What are you doing here?”

The fact is, many doctors and nurses don’t know anything about CHWs. They have no idea what a CHW does or where they fit into a practice. A CHW is not a nurse or a social worker. And a CHW most certainly is not a secretary. So, it takes time and education to understand the CHW’s role and get things running smoothly. “We’ve done some broader kinds of presentations to help people understand that, hey, here are CHWs, and if you happen to work in a practice where one is embedded as part of the team, this is how they can contribute and this is what they work on,” says James.

Ignoffo says things can get a little tense when embedding a CHW in a practice for the first time. To ease the tension, she assigns a supervising CHW to work hand in hand with the clinical team to develop protocols and solve workflow issues.

“I do think there is some initial hesitation, and I think it comes from a place of not really understanding,” she says. “I think that hesitation really does go away because they see the value to the patients.”

The message seems to be getting through. In an email to MHE, the American Nurses Association called CHWs “essential interprofessional collaborators” adding that “a key way to move health care further upstream is by collaborating with CHWs, as they are trusted stakeholders in their communities.”

Recognizing the confusion about who CHWs are and what they can do, the Community Health Worker Core Consensus Project developed a checklist of the profession’s 10 roles and 11 competencies. The list, released in 2022, is based on an analysis of “previously accepted CHW roles and competencies from the National Community Health Advisor Study compared to current benchmark documents.”

“I think, in part, some of this slowness [of financial support] has to do with the fact that there hasn’t been, until fairly recently, a consistent definition of competencies for the work of CHWs,” Ignoffo says. “We’re moving forward and making progress in the area of defining the workforce. I think that is all kind of changing and leading toward more awareness, more interest.”

In the U.S., Medicare coverage is often the make-or-break factor in whether a new service becomes a stable part of healthcare. In March 2024, Senator Bob Casey, a Pennsylvania Democrat, introduced the Community Health Worker Access Act, which calls for improving Medicare reimbursement and creating an optional Medicaid benefit to cover CHWs helping patients with health and social needs.

Meanwhile, Medicare’s new physician fee schedule will allow CHWs working with a physician to bill in a few categories. States have also been working to get Medicaid to reimburse for work performed by a CHW. In Pennsylvania, there is a CHW collaborative that has been in discussions with that state’s Department of Human Services on a plan to amend Medicaid to allow reimbursement for CHWs. “There is movement and advocacy and talk around that,” James says. “But nothing that has come to fruition.”

Nevertheless, the payment landscape for CHWs seems to be evolving and with it, rising hopes forsustainability and acceptance. Ignoffo says more needs to be done. While she thinks the federal and state governments will be the key to funding, institutions and philanthropic gifts also have a role.

“I really feel we need this graded approach to sustain CHWs,” she says. “I think it takes all these pieces to make it work most effectively.”

Robert Calandra is an independent journalist in the Philadelphia area.

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