In restructuring the delivery of primary care to improve the wellness of a community, every community must review its own circumstances for factors such as resources and capacities, health concerns, social and political perspectives, and competing priorities. Strengthening the health care team with community health workers to create a patient-centered medical home can enhance health care access and outcomes. Community health workers can serve as critical connectors between health systems and communities; they facilitate access to and improve quality and culturally sensitive medical care, emphasizing preventive and primary care.
Key points
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Evidence supports the positive impact of community health workers (CHWs) on some pediatric health care outcomes.
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Opportunities for continued integration of CHWs into the pediatric health care delivery system are expanding.
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Continued rigorous research demonstrating reduction in health care disparities and improved health outcomes is warranted.
| CHR | Community Health Representative |
| CHW | Community Health Worker |
| FHW | Frontline Health Worker |
| LHW | Lay Health Worker |
| PN | Patient Navigator |
| PS | Promotoras |
Introduction
Community health workers (CHWs) create connections between health care systems, local community residents, and community-based organizations to increase health care access, promote appropriate levels of care utilization, and improve health outcomes for individuals and populations. In the United States, CHWs are defined as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.” CHWs often focus on reaching socially and economically disadvantaged groups and bridging cultural divides between patients, communities, health care providers, and health care systems. CHWs also engage in policy advocacy and community-based research aimed at improving conditions necessary for health.
Ideally, a bidirectional flow of knowledge and resources enables CHWs and health systems to improve how health care services are delivered to specific populations. Knowledge of local health beliefs and practices can contribute to the development of culturally relevant health care service delivery. In addition, CHWs’ perspectives regarding community-level assets and needs can inform the structure of responsive, patient- and community-centered medical homes.
Variation exists in the level and type of training that CHWs receive. Job titles and roles also differ across settings. A 2002 integrative literature review reported evidence of CHW effectiveness in increasing access to care, particularly among underserved populations. A more recent systematic review found mixed evidence demonstrating the impact of CHW interventions on behavior change and health outcomes and low to moderate strength of evidence regarding health care utilization. The authors concluded that more rigorous research is needed. A systematic review of lay health worker interventions in pediatric chronic disease concluded modest improvement in urgent care use, symptoms, and caregiver quality of life. No reviews were located that focused specifically on the comparative effectiveness of pediatric CHW interventions across ethnic groups or geographic settings. However, selected studies in the United States have reported that programs using some variation of a CHW increased public insurance enrollment and insurance continuity for Latino children, improved childcare knowledge among American Indian adolescent mothers, and demonstrated the potential to impact early caries prevention among American Indian and Alaska Native children. Improved breastfeeding initiation and exclusivity, childhood immunization rates, and pulmonary tuberculosis cure rates as compared with usual care have been reported in the international literature. Less convincing evidence for the impact of lay health worker interventions on child morbidity and increases in pediatric health care seeking behavior were reported. A qualitative review of barriers and facilitators to lay health worker program implementation found that trusting relationships between lay health workers and participants are a hallmark of program strength.
Historical perspective
CHWs were recognized as critical to the success of the primary health care system by the World Health Organizations’ Alma-Ata declaration in 1978. To achieve optimal population health, the declaration emphasized the importance of “bringing health care as close as possible to where people live and work.” Thus, investing in CHWs emerged as a key strategy. Although the initial implementation emphasis focused on low- to moderate-income countries, acknowledgment of the importance of CHWs in the primary health care system spread across the globe.
Before the formal recognition of Alma-Ata, CHWs served in a range of formal and informal caregiving roles, defined by local needs, culture, and law. Health promotion roles for natural helpers are traced back at least 300 years. In China, “barefoot doctors” were deployed to rural areas to improve health in the 1940s. In Mexico and Latin America, “ promotores de salud ” have provided health-related services for decades. Importantly, other nations including Cuba and Iran have long invested in systems that link local health councils, CHWs and facility-based care.
Community Health Workers in the United States
Between 1966 and 2006, significant progress in CHW workforce development occurred in the United States. Initial community health work programs focused on addressing poverty, social problems, and their relationship to health. By the early 1970s, CHWs were used in short-term public and privately funded special projects, such as the Resource Mothers curriculum for CHWs developed by the Virginia Task Force on Infant Mortality. State and federal initiatives to incorporate CHWs emerged in the 1990s. In 1992, the Arizona Department of Health Services received state general funds to implement the Health Start Program, which continues to use CHWs to educate, support, and advocate for pregnant/postpartum women and their families.
By the end of the 1990s, state legislation calling for study of training standards and certification of CHWs was passed in Texas, followed by legislation authorizing a CHW certification program in Ohio in 2003. The Patient Navigator Outreach and Chronic Disease Prevention Act passed in 2005, codified a specific role for CHWs in the US health care delivery system.
The Patient Protection and Affordable Care Act (ACA) provides increased policy-level support for the community health workforce in the United States. The law allows services provided by CHWs to be reimbursed by Medicaid under specific conditions; grant funding for CHWs through the ACA is earmarked for outreach to medically underserved communities, health behavior promotion, health insurance enrollment, home visitation for maternal and child health, and referral to health care and community-based resources.
Introduction
Community health workers (CHWs) create connections between health care systems, local community residents, and community-based organizations to increase health care access, promote appropriate levels of care utilization, and improve health outcomes for individuals and populations. In the United States, CHWs are defined as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community they serve.” CHWs often focus on reaching socially and economically disadvantaged groups and bridging cultural divides between patients, communities, health care providers, and health care systems. CHWs also engage in policy advocacy and community-based research aimed at improving conditions necessary for health.
Ideally, a bidirectional flow of knowledge and resources enables CHWs and health systems to improve how health care services are delivered to specific populations. Knowledge of local health beliefs and practices can contribute to the development of culturally relevant health care service delivery. In addition, CHWs’ perspectives regarding community-level assets and needs can inform the structure of responsive, patient- and community-centered medical homes.
Variation exists in the level and type of training that CHWs receive. Job titles and roles also differ across settings. A 2002 integrative literature review reported evidence of CHW effectiveness in increasing access to care, particularly among underserved populations. A more recent systematic review found mixed evidence demonstrating the impact of CHW interventions on behavior change and health outcomes and low to moderate strength of evidence regarding health care utilization. The authors concluded that more rigorous research is needed. A systematic review of lay health worker interventions in pediatric chronic disease concluded modest improvement in urgent care use, symptoms, and caregiver quality of life. No reviews were located that focused specifically on the comparative effectiveness of pediatric CHW interventions across ethnic groups or geographic settings. However, selected studies in the United States have reported that programs using some variation of a CHW increased public insurance enrollment and insurance continuity for Latino children, improved childcare knowledge among American Indian adolescent mothers, and demonstrated the potential to impact early caries prevention among American Indian and Alaska Native children. Improved breastfeeding initiation and exclusivity, childhood immunization rates, and pulmonary tuberculosis cure rates as compared with usual care have been reported in the international literature. Less convincing evidence for the impact of lay health worker interventions on child morbidity and increases in pediatric health care seeking behavior were reported. A qualitative review of barriers and facilitators to lay health worker program implementation found that trusting relationships between lay health workers and participants are a hallmark of program strength.
Historical perspective
CHWs were recognized as critical to the success of the primary health care system by the World Health Organizations’ Alma-Ata declaration in 1978. To achieve optimal population health, the declaration emphasized the importance of “bringing health care as close as possible to where people live and work.” Thus, investing in CHWs emerged as a key strategy. Although the initial implementation emphasis focused on low- to moderate-income countries, acknowledgment of the importance of CHWs in the primary health care system spread across the globe.
Before the formal recognition of Alma-Ata, CHWs served in a range of formal and informal caregiving roles, defined by local needs, culture, and law. Health promotion roles for natural helpers are traced back at least 300 years. In China, “barefoot doctors” were deployed to rural areas to improve health in the 1940s. In Mexico and Latin America, “ promotores de salud ” have provided health-related services for decades. Importantly, other nations including Cuba and Iran have long invested in systems that link local health councils, CHWs and facility-based care.
Community Health Workers in the United States
Between 1966 and 2006, significant progress in CHW workforce development occurred in the United States. Initial community health work programs focused on addressing poverty, social problems, and their relationship to health. By the early 1970s, CHWs were used in short-term public and privately funded special projects, such as the Resource Mothers curriculum for CHWs developed by the Virginia Task Force on Infant Mortality. State and federal initiatives to incorporate CHWs emerged in the 1990s. In 1992, the Arizona Department of Health Services received state general funds to implement the Health Start Program, which continues to use CHWs to educate, support, and advocate for pregnant/postpartum women and their families.
By the end of the 1990s, state legislation calling for study of training standards and certification of CHWs was passed in Texas, followed by legislation authorizing a CHW certification program in Ohio in 2003. The Patient Navigator Outreach and Chronic Disease Prevention Act passed in 2005, codified a specific role for CHWs in the US health care delivery system.
The Patient Protection and Affordable Care Act (ACA) provides increased policy-level support for the community health workforce in the United States. The law allows services provided by CHWs to be reimbursed by Medicaid under specific conditions; grant funding for CHWs through the ACA is earmarked for outreach to medically underserved communities, health behavior promotion, health insurance enrollment, home visitation for maternal and child health, and referral to health care and community-based resources.
Training and certification
Federal labor policy recognizes and tracks the CHW workforce. Duties are related broadly to outreach, support, informal counseling, and referral to improve health. In 2013, the Bureau of Labor Statistics estimated that 45,800 individuals were employed as CHWs nationally. States with the highest employment level for the occupation included California, Texas, Illinois, New York, and Florida. The median hourly wage reported in 2013 was $16.64, and CHWs were employed in a variety of settings including individual and family services, local government, and outpatient care centers. Some workforce studies estimate that between 25% and 35% of CHWs are volunteers, suggesting that a greater number of individuals function in this capacity.
Some states have legislated training and certification standards for CHW practice. Qualitative data reported by Kash and colleagues indicates that the impetus for CHW training and certification initiatives grew from recognition of unmet needs among cultural, economic, or geographic populations. Well-organized networks of CHWs are involved in advocacy for the profession, and for the people and communities they serve. Other states are less formalized. Training is offered via a variety of venues including community colleges, area health education centers, and workforce development agencies. Local nonprofit organizations and academic researchers also develop training specific to the health concern identified. Variation in criteria for selecting CHWs, and in the length and content of training impedes comparison of outcomes across studies. O’Brien and colleagues report that only 41% of intervention studies using CHWs described selection criteria for CHWs, and 59% included description of CHW training.
Debate regarding the benefits and potential negative impacts of formalized training and certification continues. Formalized training runs the risk of sapping CHWs of the interpersonal qualities that have been identified as necessary for success, such as empathy, warmth, nonjudgment, and acceptance. In health care professions, it is well-documented that as formal education proceeds future health care providers report declines in empathy over time. Exposure to the culture of medicine and development of an “insider” identity for CHWs may increase the potential for explicit and implicit bias toward marginalized social groups, despite shared identity. Provider bias can be a contributing factor to health care disparities. Thus, although integration of CHW as members of the health care team is recommended specifically as an important strategy to address health care disparities, continued attention to the potential for unintended negative consequences of professionalization is warranted.
Evidence of effectiveness
Facilitating Access to Health Care: Patient Navigators
Patient navigators (PN) help to facilitate successful progression through the health care delivery system, to achieve optimal outcomes. Early PN interventions focused on reducing social disparities in cancer outcomes among adult women. Evidence for PN effectiveness with pediatric populations is emerging. Szilagyi and colleagues reported increased preventive care visits and immunization rates among an urban adolescent, largely low-income population, using a PN intervention. Hambidge and colleagues used master’s level PNs who lived in the predominantly Spanish-speaking urban community being served to deliver a tiered intervention aimed at increasing pediatric immunization and well-child visits. Improvements in public insurance enrollment and underimmunization in the first 15 months of life were achieved. Conversely, Schuster and colleagues reported no improvement in well-child care visits for low-income African-American children using a case management/home visiting intervention. Of note, the case managers and home visitors were experienced, had college degrees or more, and were described as African American. They were trained and tasked to address barriers to access by providing health education and advocacy, but did not have direct access to resources within a health care system. The authors do not discuss interpersonal qualities related to trust building, which are often cited as critical for success in typical PN interventions.
Improving Health Care Quality and Outcomes by Community Health Workers
Well-child care redesign research indicates that adding nonmedical providers to the health care team has the potential to improve the experience and outcomes of low income-children and caregivers with developmental and behavioral concerns. Farber reported that incorporation into the well-child care of bilingual, college-educated parent coaches with specific training in parent–child interaction resulted in positive developmental outcomes. Brown and colleagues provided brief communication training to bilingual, paraprofessional medical assistants to improve identification of mental health concerns in a pediatric primary care setting. Improvement in parents’ perceptions of care and willingness to discuss mental health concerns was reported. No studies specifically focused on CHWs addressing emotional and behavioral concerns in the pediatric primary care setting were located. However, Wissow and colleagues tested a common factors approach, which emphasized a range of relationship-based factors associated with child and adolescent mental health outcomes. Children of color randomized to pediatric primary care providers trained in these skills experienced significant decreases in impairment as measured by the Strengths and Difficulties Questionnaire, a brief validated measure of emotional and behavioral problems in children. Of note, the common factors model specifically scopes a role for paraprofessionals. Recommendations related to practice organization highlight recruitment of “aides” from the community served by the practice. Although the authors do not use the CHW job title, the job description mirrors the responsibilities often associated with CHW roles. Key functions include “creating expectations about care, influencing the kinds of concerns for which patients seek help, and supporting patients in carrying out treatment recommendations.”
Lessons learned from efforts to incorporate CHWs in the adult primary care setting can inform efforts to improve management of emotional and behavioral disorders in pediatric care. Waitzkin and colleagues tested a collaborative model of depression care, pairing promotoras who focused on social and contextual influences, with primary care providers. No significant differences between the promotora -enhanced intervention and control group were found. However, qualitative data indicated strong agreement across primary care physicians, administrators, and nonprofessional support staff regarding the value of the promotoras. Challenges to implementation of a clinic-based promotora intervention included identifying adequate space, primary care physician and promotora turnover, and balancing multiple workplace demands.
Stronger results from CHW interventions are reported for physical health outcomes. A 2009 systematic review by Postma and colleagues of CHW interventions for children with asthma indicated consistent positive outcomes. In a sample of low-income, ethnically diverse pediatric patients, home-based asthma self-management delivered by CHWs combined with clinic-based nurse education resulted in better self-reported caretaker quality of life and more patient’s symptom-free days, compared with only clinic-based care. Study authors concluded that CHWs were successful in promoting effective asthma-related behavior changes because trusting relationships with families built on shared experiences and community identity. Margellos-Anast and colleagues also reported significant improvement in asthma control and caregiver quality of life resulting from a CHW health education intervention delivered to African-American children and caregivers living in low-income communities. Authors noted that selection criteria for CHWs emphasized the importance of having a “cultural connection” to the target communities, and passion for positively impacting the health of neighborhood residents. Prior disease specific experience or knowledge was not necessary.
Community Health Workers Enable Culturally Relevant Medical Care Through Patient-Centered Medical Homes and Accountable Care Organizations
CHWs who may share experiences, language, and culture can be well-equipped to help patient families (particularly those with complex conditions) coordinate care across health care delivery systems in patient-centric and culturally effective ways, critical attributes of the patient-centered medical home (PCMH). Pediatric health systems now appreciate the benefits of a “medical home” for patients, and the ACA incentivizes the development of patient centered medical homes. The Agency for Healthcare Research and Quality describes 5 attributes and functions of the PCMH: (1) comprehensive care, (2) patient centered, (3) coordinated, (4) accessible services, and (5) quality and safety. The American Academy of Pediatrics promotes a slightly expanded definition of medical home for the pediatric population, which includes care that is accessible, continuous, comprehensive, patient- and family-centered, coordinated, compassionate, and culturally effective. Each definition acknowledges the influence of myriad factors on health outcomes – including individual factors, the influence of family norms and behaviors, access to health systems, the influence of communities, and larger societal and global influences – and the PCMH’s role in facilitating health across all domains ( Fig. 1 ). A population-based model of patient-centered care recognizes that physicians and patients each bring cultural experience and values into the care process. In many cases, the lived experience of providers and patients is vastly different. To facilitate the provision of comprehensive, patient-centered care that meaningfully engages patients in ways that respect their unique needs, culture, values, and family norms, PCMHs may effectively incorporate CHWs as a component of the care delivery team.
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