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Panelists of Strengthening and Scaling the Community Health Workforce and GHDonline staff

Jim Lloyd

Jim Lloyd
Panelist

What do organizations need to do to effectively integrate CHWs into their work?

Posted: 11 Jun, 2017   Recommendations: 4   Replies: 10

At the Center for Health Care Strategies (CHCS, https://www.chcs.org/), we have the opportunity to work with a variety of organizations throughout the United States who are engaged in caring for low-income Americans. As part of that work we collaborate with providers on the cutting edge of coordinating care for patients with complex medical and social needs, through running the Complex Care Innovation Lab (https://www.chcs.org/project/complex-care-innovation-lab/), which brings together innovators in improving care for high-need, high-cost patients, and managing the Transforming Complex Care Initiative (https://www.chcs.org/project/transforming-complex-care/), which supports six organizations that do such work in a diverse range of delivery system, payment, and geographic environments.

A number of the organizations with which we work employ community health workers and have integrated them into interdisciplinary care teams to address the complex medical and social needs of their patients. Drawing on the expertise of our partner sites and Drs. Heidi Behforouz and Clemens Hong from Anansi Health (http://anansi-health.launchrock.com/) – who have been collaborating in this area for 12 years, and will be providing their insights through our responses and discussions here at the Global Health Development panel – we conferred with our partner sites and learned about the “nuts and bolts” ways in which they successfully integrated community health workers into their care teams.

Reflecting on their experiences, my colleague Caitlin Thomas-Henkel and I identified common challenges and the ways in which the sites addressed them in an issue brief, Integrating Community Health Workers into Complex Care Teams: Key Considerations (attached). The brief identified several effective strategies for integrating community health workers to maximize their impact: (1) thoughtfully approach the hiring process; (2) provide training and clear tracks for career progression; (3) promote full integration within the care team; and (4) build in meaningful supports to prevent burnout, fatigue, and turnover.

In the course of our work on community health workers, we have identified common challenges that sites face, and would love to hear about other organizations’ experiences. We welcome feedback from participants on these ideas and their own challenges and opportunities for integration of community health workers into their practices. In particular, we found that opportunities to demonstrate the community health workers’ value to the team supported successful integration, and we are interested in how other organizations helped physicians and other health care professionals recognize the contributions of their community health workers.

Attached resource:

Replies

 

Amy Madore Replied at 4:08 PM, 12 Jun 2017

Thanks so much for kicking off this discussion, Jim. I'd be interested in hearing more about what you've seen organizations do to demonstrate community health workers' value to the team. What strategies have you seen work well? Which ones haven't, and why?

Your report highlights professional development and career advancement as key elements of integration and, I suspect, retention. It would be great to hear panel participants' experiences developing tracks for community health worker progression. What do these look like in your community, clinic, health system, etc.?

The report Caitlin and Jim authored (http://www.chcs.org/media/CHW-Brief-5-10-17.pdf) is a great resource; I hope participants have a chance to read it. I'm sharing a few additional articles and reports here that may be helpful as well. Each addresses integration at a different level: local, state, and national.

Amy

Attached resources:

Heidi Behforouz Replied at 11:00 PM, 12 Jun 2017

Hi everyone. Happy to be part of this community and discussion.
In short, CHWs rock! and it's a privilege to have worked along side of them for most of my career.
I see my job as helping legitimize and promote the CHW work force - ensuring that they have the financial support, institutional power, integrative and evidence-based workflows, and credibility to tackle both upstream and downstream determinants of health alongside other health care professionals.

Clemens Hong and I are now working at Los Angeles County Department of Health Services- a public entity that has committed to large scale deployment of community health workers (CHWs) to improve health and wellbeing for vulnerable patients in the United States' second largest safety net.

In the program I direct, the Care Connections Program (CCP), CHWs are integrated into patient-centered medical homes (PCMHs) to accompany high-need/high-cost individuals who are identified by the providers as needing home-based support to address their complexity of uncontrolled chronic disease, psychosocial stress, and poor health care utilization patterns.

CHWs are trained in motivational interviewing/patient activation, health coaching, medication adherence counseling, etc. and accompany patients as they contend with personal and structural barriers to better health. We are evaluating the efficacy of this program through a randomized controlled trial design and should have preliminary data in the early spring of 2018.

In the program Clemens directs, Whole Person Care (WPC), LA County has received an enormous grant from the Centers for Medicaid and Medicare services to improve the health of vulnerable Medicaid beneficiaries across the county. Clemens and his team have hired hundreds of CHWs to provide 3-6 month transitional support to high need/high cost patients who were recently incarcerated, homeless, mentally ill, and/or frequent utilizers of emergency rooms and hospitals.

Happy to share philosophical, logistical, and other details as requested.
Thanks

Jim Lloyd Panelist Replied at 9:17 AM, 13 Jun 2017

Amy:

Thanks for the response, for the opportunity to participate, and for the resources posted here!

Regarding the demonstration of value to the professionals on the team, I think that's still a challenge that many organizations are dealing with. But the organizations that we work with have identified some ways to address it.

1. When introducing CHWs into an organization, it's important not only to train the CHWs with whatever knowledge -- clinical, administrative, cultural -- you have decided they ought to have, but to train the other members of the care team as well. Physicians, nurse practitioners, and nurses may not be familiar with what CHWs can do, and some members of the team may feel threatened. We think you really have to train the organization as a whole on the use and integration of CHWs.

2. Additionally, we think that regular case conferences provide an opportunity for all members of the care team to recognize the contributions of each member (in addition to the clinical benefits of the discussion, which can be quite substantial for patients with complex medical and social needs). It may seem obvious that "getting people to talk with each other" is a solution, but formally establishing case conferences in the organization's workflow is something that an organization can do to promote integration.

With respect to your point about career progression and retention, I think that professional development IS an important part of the picture, and I'm also eager to hear other organizations' experiences with that.

A/Prof. Terry HANNAN Replied at 3:24 PM, 13 Jun 2017

This is great, thank you!

Rebecca Weintraub, MD Replied at 7:11 AM, 15 Jun 2017

Thanks so much for your insights, Jim and Heidi. Related to the information you've provided, I wanted to share a piece The Commonwealth Fund published two years ago (link below) that highlights various US organizations (including the LA County Dept. of Health Services) that have integrated community health workers into multidisciplinary teams and the approaches they took to doing so. The authors point to several barriers to integration, including concerns about funding, training, and "cultural differences between CHWs and clinicians."

Heidi, Lloyd, and other panel participants:
What experiences have you had with addressing the cultural element of integrating CHWs into teams?
What examples of successful efforts can you share?
Where organizations have struggled with this, what went wrong?

Heidi and Clemens, it also would be great to learn more about how CHWs in the programs you're supporting interact with other providers. What patient health information do the CHWs have access to, and are they responsible for any data entry?

Rebecca

The Commonwealth Fund: Integrating Community Health Workers into Care Teams, http://www.commonwealthfund.org/publications/newsletters/transforming-care/20...

Giorgio Cometto Replied at 10:46 AM, 15 Jun 2017

thanks for a fascinating exchange.

The support for community health workers and their integration into the health system are uneven across and within countries; good practice examples are not necessarily replicated and policy options for which there is greater evidence of effectiveness are not uniformly adopted. Although they should be considered as an integral part of the health system, CHW programmes are often fraught with challenges, including: poor planning; unclear roles and education pathways; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision, quality control and support; and under-recognition of CHWs’ contribution. These challenges can contribute to wastage of both human capital and financial resources: many well-intentioned and performing CHW initiatives fail to be properly integrated in health systems, and remain pilot projects or small scale initiatives that are excessively reliant on donor funding. resulting in sub-standard qualifications, management and support for these cadres in many contexts. Accordingly, the performance of community health worker programmes is highly variable, hindering the full realization of their potential contribution to the implementation of health policies based on primary health care.

The WHO Global Strategy on HRH: Workforce 2030 http://www.who.int/hrh/resources/pub_globstrathrh-2030/en/ recognizes the potential of involving CHWs as part of a multi-disciplinary health workforce that offers people-centred, integrated primary health services. Translating this vision into reality and leveraging the potential efficiency and equity gains requires, among other things, that: (i) national policy-makers move towards the full integration of CHWs in public health strategies, allowing these cadres to benefit from formal employment, education, health system support, regulation, supervision, remuneration and career advancement opportunities; (ii) development partners and funding agencies see the value of investing in these cadres and contribute to the capital and recurrent costs incurred when expanding this workforce; (iii) normative agencies such as WHO and ILO address the evidence and classification gaps by developing more precise definitions and categories for these cadres.

At WHO, we are keenly interested in this agenda, and to this end we are currently in the process of developing guidelines on the health policy and system support to effectively integrate CHWs in health systems. http://who.int/hrh/community/en/
The guidance, which we expect to be available in 2018, will reflect on state-of-the-art evidence, and will cover a range of related issues which have also been highlighted in this conversation, including the selection criteria, the education contents and modalities, regulation, remuneration, performance, quality and career advancement prospects of these cadres.

We have an ongoing stakeholder perception survey that will inform the deliberations of the Guidelines Development Group in formulating the guidelines recommendations, and I would invite you all to share your perspectives on the feasibility and acceptability of the emerging areas under consideration as part of the guidelines recommendations. It is available here http://who.int/hrh/community/better-understand-of-views/en/

Elizabeth Shipiki Replied at 11:03 AM, 15 Jun 2017

Thanks for a fascinating information. Your contribution is highly appreciated.

Linda McCreary Replied at 3:04 PM, 15 Jun 2017

Very interesting discussion. A number of years ago, we instituted the use of Spanish-speaking CHWs to work with Spanish-speaking clients in urban diabetes ambulatory care clinics. The attached is a publication that came out of the work. Note that we worked simultaneously with the non-Spanish-speaking health care providers, to help them improve their linguistic and cultural competency, so that they better understood their clients thinking about their diabetes and the constraints that limited adherence to their return clinic visits and prescribed self-care.
Linda McCreary

Clinical Associate Professor, Department of Health Systems Science
Interim Associate Dean of Global Health
Co-Director, PAHO/WHO Collaborating Centre for International Nursing Development in Primary Health Care
University of Illinois at Chicago College of Nursing

Attached resources:

Jim Lloyd Panelist Replied at 8:55 AM, 16 Jun 2017

Dr. Weintraub:

On the topic of cultural differences, we’ve seen that organizations should commit to “making the case” for the CHWs, so the clinicians understand how CHWs can enhance the care for their patients. Sometimes you get physicians who understand this already (such as Heidi and Clemens!), but when implementing CHWs, we think that training for the organization – not only the CHW candidates – is useful in ensuring that everyone understands their role and value. I also think that regular case conferences that involve the CHW and other staff can provide the opportunity for everyone to recognize the CHW’s contributions, which addresses the cultural differences. These meetings also can help make a case for continued investment in CHWs through face-to-face demonstrations of their value to leadership, which is useful in places like the U.S. where financial sustainability for a program can be an issue.

And thanks for the Commonwealth Fund piece!

Professor McCreary:

Thanks for the resources; we appreciate them, and your example is fantastic. Your points about working with the organizations themselves to help integrate the Spanish-speaking CHWs into the practice, and in identifying CHW candidates with the cultural experience to better serve their patients are right in line with other successful programs with which we’ve worked.

Jim

Connie Gates Replied at 1:24 PM, 16 Jun 2017

Sorry I am late at contributing to these conversations, and I’m in India now so it’s after 10pm my time – not my most ‘productive’ brain functioning, but I did want to write something, on most of the topics, but hope that just writing in a few of them, everyone will be able to read. And it’s my first time participating in GHDonline.

I work with the Comprehensive Rural Health Project, Jamkhed, India, started by Drs Raj & Mabelle Arole in 1970. In the early 1970s, they had organized men’s groups in various villages; they had placed ANMs in the villages to provide primary health care, but that didn’t work out because the ANMs were not accepted by the villagers. So what to do? The men asked the Aroles if one of their women couldn’t be trained to help with improving health in their communities. In the early 1970s women were illiterate, and the Aroles weren’t sure how much they could learn, but thought they could at least help with nutrition and other health education. Once they started working with these women, they were amazed at how eager they wanted to learn, how capable they were, and how motivated they were to share their knowledge and skills with others in their villages.

http://jamkhed.org/programs/village-health-workers/

Relation to the organization – from the early years, VHWs have been at the core of transformation of their villages. After CRHP builds a relationship of trust with communities, and the VHW is selected, the organization supports the VHWs and community groups. CRHP’s primary purpose is to build the capacity of communities to take care of themselves – this is a sustainable approach.

This Expert Panel is Archived.

While this Expert Panel is no longer active, we invite you to review and recommend past replies and resources. Membership for this Expert Panel is closed, but we hope you'll join us in one of the many communities on GHDonline.

Panelists of Strengthening and Scaling the Community Health Workforce and GHDonline staff