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Moderators of Population Health and GHDonline staff

Expert Panel: Opportunities for Impact - Community Health Workers in the United States, Dec 9 - 13

By Marie Connelly | 02 Dec, 2013

Embrace of community health worker (CHW) models lags in the United States relative to most low and middle-income countries. To those familiar with global health beyond US borders, CHWs function as integral components of health systems across the world. Consider Sub-Saharan Africa's push for 1,000,000 CHWs by 2015 – while we lack conclusive numbers, a 2007 report from the Health Resources and Services Administration (HRSA) estimates there may be as few as 120,000 CHWs currently employed in United States. While robust evidence supports the efficacy of CHWs in low and middle income countries, sound evidence has also shown that CHWs in the US context can improve health outcomes, lower resource utilization and cost, and create jobs in struggling communities.

If and how to mainstream community health worker models into US health systems is a large, complex topic, especially considering the widely varying capacities that CHWs can serve in any given setting. Instead of limiting this unwieldy topic into a single discussion, this forum represents the first in a series of panels about how CHWs can and should play a role in the US healthcare context. Our discussion begins with the following questions, with insight from our panel of experts on the utility of CHWs in US communities.

     ● Evidence suggests CHW programs are particularly effective in certain types of disease prevention, asthma management, certain types of cancer screening, and supporting appropriate health care utilization. What kinds of conditions or challenges have you worked with CHWs to address? Are there areas you believe CHWs are best equipped to have the most impact?

     ● CHW interventions have been particularly effective in some studies, while showing limited impact in others - in your experience, what are the key factors of successful CHW programs?

     ● CHW programs work closely with, and are often embedded in, the communities they serve. Since every community is different, how have you adapted CHW models or training programs for the communities you work with? What advice do you have for colleagues who might be beginning to develop CHW programs in their work - how can they ensure these programs are culturally appropriate for the communities they serve?

     ● Some evidence to suggests that CHW interventions have the potential to reduce costs across health care systems, primarily by supporting appropriate health care utilization. One opportunity for further cost savings lies in further integrating CHWs into care delivery teams and systems - what are the barriers to more robust integration? How can we overcome them - are the examples of systems doing this well?

We are pleased to have an exciting group of panelists joining us for this discussion:

     • Heidi Behforouz, MD, Founder and Executive Director of the Prevention and Access to Care and Treatment (PACT) project
     • Sheila Davis, DNP, ANP-BC, FAAN, Chief Nursing Officer at Partners In Health
     • Gail Hirsch, MEd, Director of the Office of Community Health Workers, Massachusetts Department of Public Health
     • Carl H. Rush, MRP, Project on CHW Policy & Practice, University of Texas School of Public Health

This panel is part of our US Communities Initiative, which is supported by the Agency for Healthcare Research and Quality (AHRQ), and aims to foster discussions between health care professionals on evidence-based practices, and translating these practices across disparate settings, to improve health care delivery in underserved populations in the US.

In an effort to understand the impact of our Expert Panels, please take our short (4 question) survey before the discussion begins:

Looking forward to a rich discussion next week – please join the conversation and share your questions or comments for our panelists!



Marie Connelly Replied at 1:47 PM, 4 Dec 2013

In preparation for next week's discussion, I wanted to share a few resources that might be of interest:

"Outcomes of Community Health Worker Interventions" (linked below - PDF) is an Evidence Report from AHRQ that provides a comprehensive overview of existing research on CHW programs in the United States.

"Community Health Workers: A Review of Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England" (linked below - PDF) is a more recent report (published July 2013) developed by the The Institute for Clinical and Economic Review and The New England Comparative Effectiveness Public Advisory Council (CEPAC) that outlines additional research findings since the AHRQ publication above and describes the effectiveness and economic impact of CHW programs.

"Community Health Workers — A Local Solution to a Global Problem" (linked below - open access) by Prabhjot Singh, MD, PhD, and Dave Chokshi, MD was published earlier this year (September 2013) in the New England Journal of Medicine, and highlights a variety of ways that CHW programs might be further developed and integrated into care delivery systems here in the US.

Last but not least, it was brought to my attention earlier today that our Expert Panel survey link may not have been working correctly earlier - I'm very sorry for any confusion this may have caused. The survey link should be working now, so if you attempted to take the survey earlier, or would like to start it now, please visit: - it's only 4 questions and shouldn't take more than 3 or 4 minutes to complete.

As always, we look forward to hearing from you - please don't hesitate to share any additional resources you might recommend before we begin our discussion on Monday!

Attached resources:

Sheila Davis Replied at 10:16 AM, 8 Dec 2013

Dear Colleagues,

My name is Sheila Davis and I am excited to one of the moderators of this weeks discussion starting Monday December 9th. I am honored to be co-moderating with such an esteemed group and look forward to learning from them and all of you in this weeks discussion.

I currently am the Chief Nursing Officer at Partners In Health (PIH) and we work in a number of countries globally delivering health care in some of the poorest regions of the world. The PIH model is a community based model of comprehensive health care and utilizes CHWs in all of our sites.

As background, I have worked in the field of HIV/AIDS since the mid-1980's as a nurse and have been a Nurse Practitioner in the Infectious Diseases unit at Massachusetts General Hospital since 1997 where I provide HIV primary care. In addition, I am a RWJ Executive Nurse fellow in the 2012 cohort and am very excited to start working with the PIH project COPE in Navajo Nation as part of my fellowship. Through my many years working in the HIV community in Washington DC and Boston and with PIH's sites, I definitely am committed to a community participatory model of care and am excited to see more activity and enthusiasm about CHW models to improve quality and access to care in the US.

Looking forward to a dynamic discussion,

Sheila Davis DNP, ANP-BC, FAAN
Chief Nursing Officer
Partners in Health

Sheila Davis Replied at 11:00 AM, 8 Dec 2013

Evidence suggests CHW programs are particularly effective in certain types of disease prevention, asthma management, certain types of cancer screening, and supporting appropriate health care utilization. What kinds of conditions or challenges have you worked with CHWs to address? Are there areas you believe CHWs are best equipped to have the most impact?

The majority of CHW programs have historically have been disease or condition specific and there have definitely been many success stories within this area. The PACT program you will hear about directly from Dr. Heidi Behforouz, the founder of the program and she will give a rich description of that program as one example of a HIV/AIDS successful program. Another HIV specific program I worked on was targeted to women of color with HIV who were paired with a ‘successful’ patient and they were paired to have similar backgrounds, language and age. The goal was to have the women be a buddy in the community so was a hybrid of a CHW, peer advisor and health navigator. Although successful for a short time, it was funded with a one-time grant and was never integrated into the overall program so stopped due to funding challenges.
I think CHW’s can have the most impact when we are able to successfully integrate them into a health system. A strong communication feedback loop from patient to CHW to providers and back again is essential and those communication pathways are critical to success. A CHW can be useful in short term and long term health needs. Short term—CHW’s can assist in the transition from hospital to home and can help integrate a patient back into the community and provide support for family members. Longer term--chronic disease management including medication adherence, nutrition and exercise coaching is also another area where CHW’s can assist patients in integrating their chronic disease into their life, not their life into the chronic disease.
As we look toward improved access to care with the ACA and health care reform, new models of polyvalent (not disease or condition specific) CHW’s are needed to move care out of the hospital and integrated into the community. Our focus and most importantly FUNDING streams need to shift away from tertiary hospital based care to community care.

Marie Connelly Replied at 1:58 PM, 8 Dec 2013

Thank you for these insightful comments, Sheila! I think as we see a range of strategies deployed to tackle the growing burden of chronic disease in communities across the US, community health workers will be able to play an important role in bringing solutions and support out of the hospital (or even the doctor's office) and into the community.

One thing I was surprised by in reviewing the AHRQ materials on CHWs (linked in my reply above), was how mixed the evidence seemed to be with regard to the impact of CHWs on chronic disease management (pp 84 - 100). I suspect this may be a result of the study designs of some of the programs reviewed, but would be interested to hear from others on this issue.

A particular highlight from this section of the AHRQ report, however, and one that I think showcases Sheila's point on the potential for CHWs to assist patients in integrating their chronic disease into their life, instead of the other way around, are two studies on CHW interventions for patients and families living with asthma:

"Two trials demonstrated that high-intensity CHW interventions are more effective than either low-intensity interventions or a control group in reducing unscheduled use of health care services and improving psychological outcomes for caregivers. Both studies demonstrated changes in behavior, such as increased use of bed encasements and vacuuming, associated with the materials distributed by the CHW, but not for other behaviors that may have required external or additional resources or change, such as removal of mold or reduced exposure to environmental tobacco smoke [...] Nevertheless, for health outcomes demonstrating a difference between trial arms such as symptom days, the more intense arm was more effective than the less intense or control arm."

The two studies mentioned looked at the Seattle-King County Healthy Homes Project, and an Detroit-based adaptation of that project, Community Action Against Asthma. I've linked to both studies below in case they might be of interest.

Last but not least, a reminder that our very short Expert Panel survey is open until Monday morning - your responses to these 4 questions will help us evaluate the impact of these types of discussions here at GHDonline and provide us with incredibly helpful feedback. Please take a moment to fill out the survey if you haven't already:

Attached resources:

Erlyn Rachelle Macarayan Replied at 1:51 AM, 9 Dec 2013

This is a truly interesting topic and thank you so much for sharing resources on CHWs. I am Erlyn Macarayan, a PhD student at the University of Queensland in Australia. My thesis is focusing on assessing health system performance in low and middle income countries by exploring which health system characteristics are more likely to lead to better health outcomes for child survival and non communicable diseases.

I just would like to share some of my thoughts on the area. Given my limited knowledge on CHW models and just based on my prior work, I have found a significant contribution of decentralization on health service delivery, which is also somehow related to how CHWs work. However, I have also found that although more localized services improve health outcomes, there are a lot of other factors to consider to achieve the target health goals, particularly in resource-challenged settings. There are some notable endeavors like the Integrated Management for Childhood Illnesses, but there still exists some gaps on its implementation and delivery, particularly on ensuring quality of care. I am also excited about how the panel will discuss innovations on CHW models and how to ensure maximizing its potentials, particularly on low and middle income countries. Recently, there has as well been numerous efforts of social entrepreneurs to innovate community health work with the use of mobile phones and other means of technology. Has this really innovated the CHW towards achieving better health? It is also interesting to note other resource constraints and any cultural challenges that those working in CHW are experiencing. I sure look forward to this expert panel! :)

Sonya Shin Moderator Emeritus Replied at 9:59 AM, 9 Dec 2013

Dear colleagues,

I'm excited to serve as a moderator for the Population Health community! By way of background, I'm a physician who has work at Partners In Health programs since 1995. My work has ranged from providing technical assistance to the community-based management of multidrug-resistant tuberculosis in Peru to training support for the Boston-based community health worker program (PACT, which Sheila has already referenced), to my current role as Director of COPE, a partnership with the Navajo Nation Community Health Representative Program in the Four Corners Region of the Southwest. My focus is on supporting CHWs across various models of care.

A couple of comments from Sheila and Erlyn strike me.

First of all, Sheila has raised an issue at the crux of maximizing CHW impact (and Marie, this may be one reason why data are mixed on outcomes): CHWs MUST be integrated into the healthcare system. Even the most highly-trained CHWs will have limited impact on the individuals and the communities they serve if they are not part of the healthcare team at a system-level. I have witnessed many programs where a provider champion works closely with CHWs, coordinating patient management, communicating about patient issues and care plans, etc. But, if that champion leaves, the CHW may find that she is once again "outside" of the care system. SYSTEM-LEVEL changes must be in place that truly embed CHWs as part of the team. While I've seen plenty of outstanding curricula and training materials for CHWs, "implementation toolkits" on integrating CHWs are needed.

Second, Erlyn mentions technology. In rural Navajo Nation, we are very interested in using technology to improve the efficiency and integration of community health representatives. Ideally, every CHW should have some form of mobile technology so that he or she can document electronically, communicate real-time with the clinic-based team, use multi-media teaching materials, and link bio-monitoring data directly into their electronic records. Imagine the possibilities! Technology, however, is really a platform to enhance the CHW's work, and not a quick-fix. Behind the technology, we need the elbow grease of careful training and clear care processes so that CHWs are well-supported when they actually deploy their technology.

I'd be interested in hearing other folks' opinions!

Sara Selig Moderator Emeritus Replied at 6:38 PM, 9 Dec 2013

Hello! I, too, am excited to be a part of this new community and to learning from so many different people and experiences! I am a physician based in Boston and have spent many years working with underserved communities mainly in the US and Africa-- specifically, looking at issues of improving access to, and quality of, care to vulnerable communities. I completed a global health and internal medicine residency at Brigham and Women's Hospital and am now an Associate Physician in the Division of Global Health Equity working on the COPE project in Navajo Nation with Sonya Shin and others.

As others have discussed, I think integration of the CHWs into the healthcare system is key. One big component of this, though, that I don't think we have a good grasp on is how to define the role of the CHW and how it differs from other outreach workers and/or other providers. For example, in Navajo Nation, there are different roles people are playing in the community-- from CHWs, health educators, public health nurses, etc. Some challenges have come about in defining who is responsible for what "pieces of the pie." There is so much need and I think there is a huge opportunity here for collaboration to make everyone's work more effective, but the discussion around what roles each position will take and how these roles will work together is a key factor in helping the integration that needs to take place and leading to sustainability of the system as a whole.

I am curious if others have experience with defining roles for different community outreach workers and what has worked and what has been challenging for you?

Sheila Davis Replied at 7:13 PM, 9 Dec 2013

Getting a jump on tomorrows discussion question below

CHW interventions have been particularly effective in some studies, while showing limited impact in others - in your experience, what are the key factors of successful CHW programs?

In my opinion THE key factor of successful CHW program include is community participation throughout the entire process. Ideally the program should be in response to an identified need by the community and involved in the program development, setting hiring criteria, program evaluation and planning for the future.

Heidi Behforouz, MD Moderator Emeritus Replied at 7:18 PM, 9 Dec 2013

Good evening!
It's a pleasure to join you as we discuss the current and future impact of CHWs in both achieving community health and improving health care delivery.

I have had the privilege of working with CHWs for the past 20 years- and, in my view, they are an incredibly gifted and empassioned group of people with a variety of skills that can be mobilized to achieve virtually any "health" outcome at any point along the continuum of care and at any impact level (individual patient, community, or system.)

CHWs make sense. Developing a work force with lived experience to complement and contextualize the work of health care or social service providers makes sense AND empowers the community from within. In my opinion, failures to see "benefits" of CHWs have less to do with the CHWs and more to do with the disfunctional systems into which they are integrated and the inability to systemically harness and nurture their potential.

For me...the relevant question is not "do they add value?" (we certainly have not applied the same amount of energy and rigor to proving the merits of doctors and nurses) but rather, how do we integrate, utilize, and support them in high quality and sustainable ways that are scalable?

My particular interest has been in the contributions that CHWs can make in improving health care outcomes and utilization patterns among complex patient populations who are 'failing" traditional health care. Our work at PACT has consistently demonstrated that partnering primary care providers/ HIV provider teams with community-based CHWs can improve health and reduce health care expenditures among the sickest 10-15% of AIDS patients in Boston while increasing patient capacity, provider satisfaction, and meaningful workforce development opportunities. We have developed CHW training syllabi and evidence-based field-based guides to inform their work and have accompanied other entities (clinics, public health departments, insurers,and community based organizations) as they have successfully integrated CHWs into the fold. We have learned how critical it is to train other members of the care team in utilization of and management of CHWs, how to bolster team-based care in general/particularly to care of vulnerable patients with multiple socio-economico-psychologico-historico-cultural-political determinants of health, how to use data in real time to deliver the right intensity care in the right place by the right provider in the right time, and how to mend the gap that has developed between health care and public health, health care delivery systems and community, and technology and humanism.

Many challenges remain for wider-scaled adoption of CHWs. These include confusion about their roles/responsibilities in isolation or vis-a-vis other "paraprofessional" worker types, limited sustainable reimbursement mechanisms,a financial system that weights payment for treatment of disease rather than prevention and promotion of health, territoriality (other professionals feeling threatened or wary of CHW scope and liability), poor people deployment and management/organizational skills within health care, silo'd health care delivery with poor communication within/across care systems, lack of guidelines or practice for CHW training/certification/professionalization , an emphasis on the biomedical paradigm/technological fixes as opposed to the vulnerability paradigm and holistic fixes, and general lack of know-how in addressing the array of health determinants that impact our most vulnerable patients.

The time is now- though- to rethink how we define health and how we deliver care. Im excited to be an advocate for CHWs, as I feel their integration will be critical to success, allow us to achieve the quadruple aim, and enable community empowerment through creation of jobs and stabilizing/healthful norms.

I look forward to continuing the discussion over the next few days

Sara Selig Moderator Emeritus Replied at 7:21 PM, 9 Dec 2013


That is a great point-- community involvement is definitely key. I am wondering what experience others have with bringing communities together to achieve this involvement? We have used a range of activities from meetings with leadership to focus groups with community members, interviews with different stakeholders, partnerships with local organizations, etc. What techniques have others used that have been helpful? Also, it seems that sometimes the perspective of leadership differs somewhat from perspectives of providers and then perspectives of community members and I wonder how others have managed these differences?

Erlyn Rachelle Macarayan Replied at 7:42 PM, 9 Dec 2013

Dearest Sheila and Sara, I do agree on community involvement. Without the support of the community, it will be really difficult for CHWs to be successful. In one community that I had been involved with in Southeast Asia, the belief for traditional healers is still prominent. People may have access to rural health centers but they still go to traditional healers that may have a different opinion than that of the medical staff and CHWs. I believe this has been one of the challenges, but there has been recent effors for both medical staff and those in CHW to work collaboratively with traditional healers. However, this still poses many challenges to work.

Also, I agree that technology should have been ideally incorporated into CHW, but there are a lot more far flung places that don't have access to mobile phones and computers. In one area that my colleagues have been involved with, it will still take them hours and even days just to get to the nearest computer facility and encode their data into the central systems. Bringing with them some information materials that are highly illustrated (rather than narratives that others couldn't still read) have been helpful to them.

I hope to hear as well how others have overcome these challenges.

Gail Hirsch Replied at 8:32 PM, 9 Dec 2013

Hi everyone,

My name is Gail Hirsch and I work at the Massachusetts Department of Public Health, where I've been coordinating state efforts to promote and support CHWs for 20 years. Our state public health department has for years valued CHWs as an essential public health workforce, and as a bridge to health care for our most vulnerable residents. To that end, we have supported a number of program and policy initiatives designed to better clarify the role and scope of CHWs and to better integrate and sustain them in public health and health care.

Additionally, part of our efforts to promote CHWs has been targeted towards supporting CHW organizing and leadership development. As the previous comments have stated so well, the voice of the community is essential to truly addressing the needs of our most vulnerable residents. We are actively engaged with the Massachusetts Association of Community Health Workers, and this partnership led to the inclusion of CHWs in several key pieces of state legislation: our 2006 health reform law; the 2010 establishment of a board of certification of CHWs; and a key role in Chapter 224 (2012), the Massachusetts cost containment legislation.

A diverse array of programs at DPH support CHW services, and also CHW training, although sustainability remains a concern. Through our contracting policies we aim to achieve some of the objectives my co-commentators have mentioned: adequate CHW supervision, training of CHW supervisors, high quality core training for CHWs, and practices that support the equal inclusion of CHWs into multidisciplinary teams.

While much of our work is aimed at the state policy level, I have also been actively engaged for a number of years with some of the national efforts, most significantly through the CHW Section of APHA, to build recognition for the field and inclusion as key informants to, and shapers of, public health policy. I look forward to the continued conversation this week, and am delighted to engage with my Massachusetts and other partners in this dialogue.

DPH is currently developing standards for certifying individual CHWs, as well as CHW training programs, and we are also seeking opportunities to support the work of CHWs through our Prevention and Wellness Trust Fund and exploring what options the new CMS rule change may contain for financing CHW services.

The most rewarding work I do is with CHWs as they find their voice and get the tools and support they need to become stronger advocates for their communities.


Donna Bjerregaard Replied at 12:02 PM, 10 Dec 2013

I work more in the international arena, however I think many of the support issues are central to both global and US-based programs. In many countries, CHWs are often not given the tools they need to properly deliver services. Supervision and referral are generally areas of weakness. I would like to how these important elements of quality and continuity of care are handled in the US.

Donna Bjerregaard

Sara Selig Moderator Emeritus Replied at 1:13 PM, 10 Dec 2013


I agree that many of the issues are central to all global programs. Working in Navajo Nation, we are also struggling to identify the best form of support and supervision for CHWs and how to integrate that piece into the overall system as well. Gail, I wonder how the DPH has approached these questions in the context of further developing the program for the state? I also wonder if you can expand on what you mean by focusing on organization and leadership development for CHWs? In my mind, this type of support is also critical and can lead directly into better support and supervision as well as better teamwork within CHW teams can help make integration into the over all system more effective... would love to hear more!


Carl Rush Replied at 4:47 PM, 10 Dec 2013

Hello all, sorry to be late in joining. There's so much to say, we need to be selective. I wanted to comment in general on the question of judging the effectiveness of CHWs, and the factors that seem to contribute to the greatest success of programs that involve CHWs. First, as has been noted earlier, the history of employment of CHWs in the US has been one of narrowly focused interventions for the most part, generally targeting specific health issues, and evaluation has generally used a biomedical model. For many reasons this limits our ability to assess the overall impact of CHWs, because commonly they have impact on many aspects of people's lives other than the immediate health issue for which the program was created. And indeed the non medical issues with which the CHW assists an individual or family may be more important in the spectrum of determinants of health than the role of the CHW in connecting the individual or family to medical care.

We certainly know from anecdotal evidence that key elements in the implementation of programs involving CHWs include recruitment and selection, training, and supervision. In many short-term projects these elements receive short shrift. We really do need more integrative or holistic studies looking at contribution of the structural factors to the success of programs involving CHWs.

There are more subtle issues in the relation of the CHW to the organization or program of which she or he is a part. I know of a number of large organizations in which the CEO or other senior personnel are hardly aware at all of the existence or the performance of a "project" involving CHWs. In attempting to survey employers and potential employers of CHWs for theHRSA CHW national workforce study (2007), one of our biggest challenges was identifying the most appropriate person to complete the survey. Senior executives might not really know anything about CHWs, whereas direct supervisors or program managers might not have a sufficient overview of the organization.

A related phenomenon, and a key barrier to the growth of this field, is the persistent low level of understanding or even awareness of CHWs among key stakeholders. I would challenge participants in this discussion group: how confident are you about your level of understanding of the most commonly accepted definitions of CHW in the US? The American Public Health Association (2009) defines the CHW as follows:
"A Community Health Worker (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.
"A 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."

in Sara's post above, she refers to "outreach workers" as essentially separate from CHWs (forgive me if I misinterpreted your statement). Even if that's not what you meant, lots of folks out there think of patient navigators, outreach workers, peer support workers, and even the Promotoras de Salud as different from CHWs. The intention of CHW leaders for years has been to use the term CHW as an umbrella for all the various workers who rely for their effectiveness on their trusting relationship with community members based on shared life experience.

another challenge has been to view this workforce as generalists under the definition above, rather than a collection of specialists in specific health issues. So the emerging consensus on the preparation (education, training, experience) of CHWs is that it should emphasize some common Core Competencies and leave most of the knowledge base about specific health issues to workplace-based learning.

Much of the discussion above has focused on integrating the CHW into clinical care provider organizations. I believe we need to keep a focus as well on the community rootedness of the CHW and acknowledge the importance of CHWs based in grassroots and other community-based organizations. In some ways CHWs apply a skill set like an advanced practice community organizer rather than a clinical professional. As healthcare returns its focus to the importance of the social determinants of health, the CHW can act as the "social determinants expert" For both healthcare and non-healthcare organizations. There are interesting examples of community-based organizations who employ CHWs and serve as contractors to healthcare providers and others.

In closing (for now), I want to reinforce a specific point Sonya made above about the importance of having a "champion" for the CHW as part of a patient care team. The most influential "champion" may or may not be the CHW's direct supervisor, but regardless, we should consider the importance of adequate training and preparation for the supervisor in view of the unique qualities and working style of the CHW. supervisor will need to serve as an advocate for the CHW's role within most organizations. I would amplify on Sonya's point by saying that the continuity of advocacy on behalf of of the CHW is crucial.

Attached resources:

Heidi Behforouz, MD Moderator Emeritus Replied at 6:41 PM, 10 Dec 2013

As we start to think about scale up in the era of health care reform, what are some possible mechanisms for getting CHWs reimbursed in a sustainable way?

Heidi Behforouz, MD Moderator Emeritus Replied at 6:47 PM, 10 Dec 2013

Another question
If you ask my CHWs...what is it that you do that makes a difference? It is not the educational curriculum or phone calls to Medicaid or disease self management skills-building that they mention...but " I teach the person how to learn to love herself again."
How do we teach and support this sentiment? and measure its impact?

Sonya Shin Moderator Emeritus Replied at 9:23 PM, 10 Dec 2013

Hi everyone, I think that Heidi's comments about how a CHW might describe his or her work resonates with Carl's comment that CHWs provide a very essential "service" of social support and connectedness to some of the most disconnected folks in our society. In this way, they represent the social fabric of the community rather than simply serving in a medical capacity. In fact, that basic solidarity, trust and cultural understanding is what makes CHWs effective in their medical roles (e.g. health education, connecting to services, etc). Some of the misunderstanding among how providers and organizations want to "use" or "deploy" CHWs is in conceptualizing the CHW through a medical and clinical lens.

Heidi, I do think we can teach this sentiment (although often we don't have to). I also think there is a danger of "un-teaching" this holistic approach as the potential to scale-up and mainstream the CHW workforce unfolds before us. Supporting a community of leaders within the world of CHWs is essential to make sure that their agenda is moved forward. It is telling, I think, that all of the experts and moderators (including myself) are not CHWs but rather CHW-experts (and please forgive me if I'm wrong). If there are any CHWs or CHW supervisors who are part of this community I would really invite their thoughts about how your most ardent supporters, including folks like myself, can support the CHW community, our champions.

Ranu Dhillon Replied at 9:34 PM, 10 Dec 2013

I have a comment that is tangential to what Heidi laid out but links to the previous discussion and does tie back to her questions.

I think we need to move past monolithic definitions of CHWs and, instead, should think about different types of CHWs who play different roles based on the delivery context into which they are integrated. This would be similar to the way we already have different types of healthcare professionals (i.e., nurses, doctors) and specialization within these cadres (i.e., urologists, internists).

As societies become more developed and/or urbanized and variegated in terms of social and economic groupings, so do disease patterns, health and social needs, and, thus, the ways CHWs could best be integrated into the healthcare delivery chain in order to optimize health. The notion of a standard CHW profile may emanate from the poor, rural settings abroad in which they have been most widely deployed. The health issues and community structure (in terms of geography and size) across these settings are more similar than what is typically found in developed/urbanized settings. As a result, CHW programs in developing countries have been somewhat amenable to a degree of consistency in terms of structure, function, and integration.

Given the diversity in the US – of patient populations, geographic settings, openness to community-based workers, etc. – there may be a need to calibrate different variations of CHWs to these considerations. “Hot spot” patients with frequent and chronic healthcare needs would benefit from a CHW who provides regular accompaniment at the household level and coordinates social and health services. In concentrated low-income urban areas (i.e., housing projects), CHWs may play a more proactive role in identifying households with social and health problems while coordinating the community around health promotion. In suburban communities, CHWs as health coaches (akin to the Iora Health model) may be best placed to play a facilitative, promotive, and coordinating role.

All of this is to say for any given population and the subgroups within it, one can consider what is needed to optimize health and then determine what type of CHW-like cadres are required. Rather than taking conventional definitions of CHWs as the departure point, we could think in terms of ‘functionalities’ required and build systems and roles around that.

The notion of “one size fits all” is beginning to fall away in most sectors and blunt approaches are becoming context-specific. Healthcare should be the same way and the possibilities with data and analytics allow customization like never before. No two Whole Foods stores, for example, apparently have the same inventory; each uses incoming data to customize to the local habits.

Bringing this back to Heidi’s questions, this type of variegation and customization usually bodes poorly for sustainability in social service systems given the complexity created for training, deployment, etc. and challenges posed for regulation. However, as healthcare systems evolve, bundled payments and other incentive approaches focused primarily on outcomes and less on processes open the door for innovation and customization to localities.

The core goal of helping a patient “learn to love herself again” could best be achieved by personalizing the care and support she receives. And emotional wellbeing and happiness can now be measured and should be central to the outcomes that are incentivized by these payment approaches.

Steven Rothschild Replied at 11:27 PM, 10 Dec 2013

This is Steve Rothschild in Chicago -- I am a family physician who has worked with CHWs in various roles for about 30 years, and in the past few years have been conducting NIH-funded trials on the efficacy of CHWs working with persons with diabetes. This is a rich discussion and the insights wonderful.

I do, however, want to challenge Ranu's very inclusive approach to CHWs. While I respect the work of Patient Navigators, I don't feel they are CHWs. Navigators help make people more comfortable with our community -- the world of hospitals and health care systems. This is valuable, but it really isn't community work as Carl and others have described it here: with a focus on "the community rootedness of the CHW and acknowledge the importance of CHWs based in grassroots and other community-based organizations. In some ways CHWs apply a skill set like an advanced practice community organizer rather than a clinical professional. As healthcare returns its focus to the importance of the social determinants of health, the CHW can act as the "social determinants expert" For both healthcare and non-healthcare organizations."

As a physician, I often feel like the medical system can be like a black hole, pulling all energies into the medical-industrial complex. The point of CHWs is to draw health care out of the hospital and back out into the community, where people must struggle with decisions about diet, activity, lifestyle, adhering to medications, competing demands of family members, etc. While I believe that CHWs are especially effective when linked to health systems, their work must remain firmly embedded in homes and communities -- where people live work and play, and where health is really determined.

Thanks for a great discussion.

Kate Dieringer Replied at 9:24 AM, 11 Dec 2013

Dear colleagues,

Thank you for your expert insight into the role and impact of CHWs within the US health care delivery system. I am curious about the panel's experience and thoughts on expert clients (EC) as a piece of the CHW model (and ultimately if this initiative that has been successful in resource challenged settings has been, or potentially could be used to improve access to services, adherence and social support).

ECs reinforce decentralized care that does not require intensive training of new, specialized health care providers. The programs focus on integrated community based support across the continuum, with an invested navigator that has experience and training on holistic management of a particular disease as a key team member.

The role of the expert client,as well as the CHW, is highlighted in Carl's post: "A 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." This person also has extra value added experience as a patient living with a particular disease with which his/her client is also afflicted.

While expert client programs inherently focus on disease specific accompaniment (HIV/TB in particular), could this model be adapted to a program Stateside that would yield effective outcomes as it has in Uganda and Malawi (see below). A system of community navigators that commands technical knowledge related to the management of the particular disease from which they suffer is invaluable and has far reaching influence, especially in relation to anti-stigmatization and adherence. Do you know of any programs that have adapted this EC model in the US? What are your thoughts on the potential of a program that has an EC component?

Thank you for an illuminating dialogue on CHWs! Ultimately, we as a community want our patients to have assistance in navigating the experience of disease and the behemoth of the healthcare system. Perhaps we can take lessons learned from programmatic activities in other countries that would serve our population well.

Kate Dieringer RN BSN MPH
Zanmi Lasante-Partners in Health-Haiti

Attached resources:

Jay Bhatt Replied at 9:39 AM, 11 Dec 2013

This is a fascinating discussion and one that is emerging as a critical discussion for the workforce of the future in health systems and public health. The challenge is around the standardization of CHWs. Many folks get distracted around certification and standardization. It shouldn't be a barrier to implementation. I agree with robust training. How do we not get distracted from this challenge so that we can help cities and health systems think about implementing pilots to show that there is long term benefit?

Thomas Crea Replied at 10:54 AM, 11 Dec 2013

Hi everyone, this is Tom Crea, associate professor of social work at Boston College. I've been following this discussion and can't help but wonder what role social workers can or should play in this context. My experience with CHWs is limited, but many of these activities, and the community-based perspective which drives them, seem closely linked with social work. In particular, I would envision social workers as being particularly relevant in targeting the social determinants of health outcomes.

What are people's experiences in working with both CHWs and social workers? In what ways are these roles professionally distinct, or not? Thanks for an interesting topic and discussion!

Thomas M. Crea, PhD
Associate Professor
Graduate School of Social Work
Boston College

Christina Jeffrey Replied at 11:10 AM, 11 Dec 2013

Hi everyone,

I work for a mobile health technology company which has specifically designed software for CHWs internationally which is used on cell phones (anything from an outdated nokia to a modern smartphone) and tablets. Our largest-scale projects are in India and now Haiti. Although having basic mobile data collection software is critical to gathering information and generating reports on the need for CHWs within the care team, the quality of content really impacts performance. Additionally, supervisor participation in CHW initiatives helps boost quality and accountability.

Our technology allows CHWs to deliver surveys and health education materials one question or concept at a time. Supported by multimedia (pictures, videos, diagrams, etc), the CHWs can worry less about remembering how to explain information and fill out cumbersome paper forms and more time fostering the candid relationships with patients.

We've worked with many CHW groups using many mobile health and computer-based platforms and have learned quite a bit about how to support CHW performance through technology and care team participation. Content is key to delivery and collection of accurate and compelling data!

Christina Jeffrey, MPH
Dimagi, Inc.

Attached resource:

Christina Jeffrey Replied at 11:17 AM, 11 Dec 2013

In reply to Thomas's question:

I do think that there are some similarities to the work that CHWs and Social Workers do, however there is a primary distinction between the two regardless of what type of initiative in which they're both working - Social Workers are not necessarily derived from the populations they serve. In most cases, CHWs are hired because they have a unique understanding of a certain group of people (think culture, language, health status, neighborhood) and have an ability to find and assist even the hardest to reach individuals who may never access healthcare otherwise.

CHWs certainly do a lot of work that social workers do, but there are differences in education/training and community connection.

Maggie Sullivan Replied at 1:35 PM, 11 Dec 2013

I'm enjoying the depth and variety of this discussion. Not least because of the considerable experience everyone brings to the table. I appreciate the comments about medicine being like a black hole and pulling everything into it's medical-industrial complex. As a nurse practitioner in primary care, that comparison sounds just about right. We can talk about pulling CHWs into this black hole of a complex, or we can begin to imagine something different.

What I keep coming back to is, there is something that necessitates CHWs - if there wasn't, if the role of CHWs was superfluous then this topic would have already come and gone. But instead, it is a role that sticks, because it is necessary. Medicine is arriving late to the game when it comes to how social determinants of health create and perpetuate illness. As a result, we need CHWs. This might be a different reason for needing CHWs than in other countries, but it is a need none the less.

And as Dr Behforouz mentioned, no one is having to prove the value of doctors and nurses. We are swimming in doctors and nurses in the US, but that is not making us a healthier country. Yet this does not start anyone thinking about how we need fewer doctors and nurses. I think once everyone gets over the hump of acknowledging the need for CHWs (and yes, as fully integrated into our health system), then each area can parse out their varied roles, training and supervision.

Carina Katigbak Replied at 3:51 PM, 11 Dec 2013

This is Carina Katigbak, Assistant Professor at the School of Nursing (Boston College) - just across the street from Thomas!

Thanks for this forum to highlight the importance of CHWs, and for urging us to begin thinking about how CHWs can be fully integrated as part of the US health system. While there is much discussion on the need for certification and role standardization, some may argue that these efforts are detrimental to the role - specifically its characteristic of being a peer support model and grounding in grass roots/community based approaches. What strategies can be employed to ensure that what makes CHWs so unique (and perhaps effective) are not lost in the rush to include CHWs as part of the ACA?

Carina Katigbak, PhD, RN
Assistant Professor
William F. Connell School of Nursing
Boston College

Talya Salant Replied at 4:35 PM, 11 Dec 2013

I wanted to give my albeit limited perspective on the various important questions that have been raised around measurement, sustainability, and integration (and say hello to Heidi, Sara, and Ranu!). I am far from a CHW-expert like many others in this discussion chain, but I am currently involved in a localized attempt to figure out how a CHW can be a valuable and valued part of a community health center medical home. In the process, I am realizing how situating a CHW within a traditional medical setting brings many practical and philosophical challenges. For instance, it is true that biomedical research models are poorly suited to capturing the complex array of health determinants and ways of achieving wellness, and so we should continue to find better ways of demonstrating the wide spectrum of CHWs' benefits. But -and I struggle with this- at the same time we have to play at the game, speak the same language of those in positions of power and leadership and produce outcomes "data" that satisfy conventional standards in order to ensure sustainability. This is true even in a world of bundled payments as those doing the hiring of CHWs need to be convinced that investing limited operating resources will show return. In the short-term, as I am learning, this means compromising on what kids of interventions the CHW is able to perform and what patients she works with, in order to prioritize a more limited set of patient-related outcomes. My hope is that this short-term compromise will provide necessary credibility and buy-in to ultimately expand the role and scope of what she does, without compromising the integrity of her ongoing work.

As our CHW has been retrained from a different staff position, integration for us has also had to contend with role dilution and role confusion and the process has involved continuous boundary setting and clarification of core skills/duties, as well as ongoing training of the CHW to increase her self-identification and confidence in her role. To this end, I do believe that customization of CHW activities must be always balanced by a common set of competencies and values that can be easily communicated to others less familiar with the role. Lastly, I underscore the importance of trust and of building and sustaining relationships to the success of integration. Just as the CHW builds trust and rapport with her clients/patients using a shared language, set of experiences, and/or cultural background, integrating the CHW into medical teams requires that she speak and understand a similar (medical?) language and forge relationships through shared values and experience. However, this can be very difficult for those who have limited knowledge of a particular health center's organizational culture or of the medical "culture" more broadly. How do we simultaneously celebrate the rootedness and unique knowledge of CHWs who represent their local communities and also support their acculturation into medical teams?

Heidi Behforouz, MD Moderator Emeritus Replied at 8:16 PM, 11 Dec 2013

Thanks for Marie for pulling out some key themes from our conversation...
I'll take a stab at some of these and welcome feedback!

How can CHWs be reimbursed in a sustainable way? There are an increasing # of ways in which CHWs can be reimbursed.
*In some states (like Minnesota/Texas)- legislative actions have resulted in regulatory changes at the state level recognizing CHWs as health care professionals who can be reimbursed through fee-for-service mechanisms by payors such as Medicaid. Some of the legislation also included clauses that helped fund community colleges to educate/train CHWs and create career ladder opportunities for clinic employees.
*Another example: an FQHC in MA negotiated an alternative quality contract with a Medicaid MCO for care of patients with co-morbid medical and behavioral illness: they receive an enhanced payment for the care of these patients (which continues as long as they meet certain quality outcome/cost metrics) and use the enhanced payment to hire CHWs.
*Another example:in Oregon, Medicaid has established coordinated care organizations (CCOs) in which care management is regionalized across the state and is made available to patients based on where they live/not where they receive their medical care. CCOs received bundled payments for their services and hire CHWs as part of their care management teams. Large ACOs can also choose to invest their global payments in community health workers- either by investing internally and hiring CHWs as their own employees or through contracting with community-based organizations who provide CHW support.
*Another example: Massachusetts Prevention and Wellness Trust will invest $60 million of state revenue in community based interventions for community prevention activities: CHWs will likely be key players in these initiatives.

How do we measure the non-biomedical impacts of CHWs - their impact on the social determinants of health, on a patient's sense of self and wellbeing, etc.?
*This is a hard question to answer. I defer to the qualitative researchers in the room...but want to point out that we need to figure this out writ large! not just for measuring impact of CHWs but for measuring the impact of everything we do in the health and public health arena as "interventionists.". We have a lot to learn from CHWs in seating their agendas/actions based on patient-directed goals and desires.

Have there been successful "Expert Client" programs in the United States? Can CHW programs have an EC component?
*There is a great deal of experience with "peer" case management or support services- notably in HIV, prenatal care, homeless care, mental health care, diabetes care.. in which the "peers" suffer from or have lived the same condition as the clients they serve. I don't really see a clear difference in peer workers vs CHWs...they are both utilizing their lived experience/solidarity to help their clients achieve better outcomes and are both viewed as "lay" or paraprofessional.. I think the CHW designation does lend some benefits. ; CHWs can more easily be identified as a "work force" type in state/federal lingo and have regulations passed to enable their certification/hire/unionization, etc. Peer subtypes can easily be embraced within.

How can we help cities and health systems implement pilot programs that show CHWs have a long term benefit to the communities they serve?
*Clearly rallying resources: fiscal, training/technical, logistical- is important. However, I think we, as CHW champions, need to get out there and educate/light fires/spur imaginations. Many places don't think about CHWs or if they do, are not sure how to go about integrating them into their systems. Im continually surprised at how many places in our country are only now starting to "formally" talk about social determinants of health or community health let alone CHWS and how they need to be educated/accompanied on how to fold this understanding into their innovation or renovation plans. Part of the education also surrounds the fact that the return on investment will not be immediate. It's fair to say- that in some communities where access to care has been poor and patients undiagnosed/further on in disease- cost of care will initially INCREASE once community-based interventions are in place. However, in the long run, avoidable/preventable costs of care through unnecessary hospitalizations or potentially avertable procedures/drugs will decrease...and our efforts will be more cost-beneficial/cost effective.

How do we ensure that the unique nature of CHWs (as peer supporters, rooted in the community) is not lost in efforts to scale up initiatives - particularly in light of ACA implementation? How do we celebrate the rootedness and unique knowledge of CHWs who represent their local communities and also support their acculturation into medical teams?
*This is a challenging proposition but critical. Key to this is initial education of employers and managers and giving them the know how/tools to maintain CHWedness/nurture this special workforce as well as meet their targets/needs. We have often found that the recruitment/capacitation of CHWs is the easy part. The harder part is training the Csuite about how important it is to embrace/maintain the "differentness" of CHWs. The point is not to hire "cheaper social workers or medical assistants." It is not task shifting or physician extension. Rather, it's investment in uniquely qualified/ non-interchangeable community assets to enhance the health care delivery system and empower the community through providing jobs/creating strong alliances. It is also important to train the managers and supervisors of the CHWs: the workforce is different and has different needs. They need both programmatic/task oriented supervision as well as clinical supervision. They may need more support but the pay off is tremendous. Finally, it is important to train the team members working with the CHWs re their roles/responsibiltiies and how to utilize them in the best way. This is not a natural leap for health/social service providers...they need to be taught/supported in how to play in the sandbox with others and maximally utilize the expertise/talents of the CHWs.

Carl Rush Replied at 11:46 PM, 11 Dec 2013

It's very gratifying to see the wisdom, commitment and insight in these many posts. I'm also beginning to feel overwhelmed by the range of issues that have been addressed. I would like to take up the question of sustainability from a couple of different points of view. First: is anyone concerned about the sustainability of doctors and nurses? No, because in our society, the services they provide are universally valued as essential. Their role in our society is financially fairly secure, not because we place a high value on maintaining the employment of doctors and nurses as individuals, but because we place a high value on their ability to produce certain clinical results. The "system" is designed to value and pay for the production of clinical results and the delivery of clinical services. The system is not designed to value and pay for caring, empathy, and relationship.

Therefore, one way of looking at the challenge of sustainability is to find evidence that caring, empathy and relationship building contribute to clinical results and the effective delivery of clinical services. We have always had a harder time showing that primary prevention, working on the root causes of illness, injury and disability, produces long-term clinical results (or financial benefits).

So I have come to describe the potential pathways to sustainability of CHW roles in mainstream organizations in three ways. First, conventional structures of the financing of healthcare are open to the arguments that community health workers contribute to more efficient care delivery, better management of chronic conditions, and addressing the social determinants of health, which clinical care providers are increasingly ready to acknowledge they are powerless to change. So healthcare providers and third-party payers are increasingly open to specific CHW roles financed through the inherent flexibility of managed care organizations and the increasing willingness of provider organizations such as hospitals to employ CHWs out of their core budgets on the basis of internal return on investment (cost savings).

Second, CHWs have a major public health role in population-based primary prevention through community change, advocacy and capacity building. These roles can be financed through mechanisms such as the Massachusetts prevention and wellness trust fund and the Delivery System Reform and Innovation (DSRIP) projects under the Texas statewide Medicaid 1115 waiver.

Third, a powerful argument can be made for CHW roles in the new payment and accountability structures under health care reform, such as the patient-centered medical home and the Accountable Care Organization. These structures cannot achieve their goals of improved outcomes and cost savings without improved communication between patient and provider, and without strategic interventions in primary prevention at the community level. We are seeing growing numbers of examples of this such as the Oregon Coordinated Care Organization model,PCMH designs in Vermont, and the Accountable Care Community model pioneered in places like Akron Ohio.

None of these fundamental funding strategies can be pursued without simultaneous attention to agreement on skill standards for the occupation of CHW, and investment in workforce development. And all of these activities will be frustrated by the general lack of awareness and understanding of CHWs, their roles and their value, among stakeholders. If we don't address the awareness challenge, everything is likely to take twice as long...

Attached resources:

Ranu Dhillon Replied at 7:15 AM, 12 Dec 2013

This really is a great conversation and I'm looking forward to continuing discussions past the end of this panel.

There are a few comments speaking to how one could concretely move forward on this issue: Jay raised the point of finding pragmatic ways for cities and systems to initiate pilots, Talya and Carl noted the need for organizational and skill standards, and Carl underscored the need for awareness and advocacy (which is sadly just not about having evidence).

I don’t pretend to have a perfect or all-encompassing answer but can propose a few thoughts based on which side of the line one sits when it comes to determining funding priorities and structuring incentives.

There are so many needs and so many areas where CHWs could have a role. If you have a hand in controlling funds and setting incentives (lucky you!), there is then an opportunity to distill what roles or issues you feel are most important and use funding with linked stipulations to configure practical entry points and standards for CHWs, even if, initially, with budget only enough for pilots.

For example, I am involved in a project with the West Harlem Development Corporation (WHDC) which has an endowment of funds they can use to catalyze progress in the community. We are currently defining overall goals and targets that should be achieved in the community within a set timeframe including for health. There are so many health needs and a range of ways CHWs can be of value to address them. Once we narrow down to what we think would be the most pressing health priorities (based on social wellbeing, epidemiology, etc.), the WHDC can use its funds to incentivize community organizations, non-profits, hospital systems, etc. to address them. This approach may or may not explicitly request CHWs to be part of the response but could ensure CHWs’ activities align with areas where ongoing funding priority will exist and also provide focus to the roles and, thus, skills and standards CHWs should have. If efforts are successful, there could be other funding streams (i.e., municipal, insurers with patients in the catchment) joining in to support ongoing work and similar initiatives elsewhere. I’m in India right now and, though extremely different from the US, this is somewhat how CHWs (although largely poor-performing due to broader governance failures) became entrenched in what is a predominantly privatized system.

If not on the side of setting incentives, the key, to me, would be to understand where the funding exists (i.e., ACOs, DSRIP, for particular conditions) and CHW impact can be sufficiently measured. Even if different from what you feel it should ultimately be (i.e., primary prevention, social determinants), you could pragmatically initiate CHW activities around these funded areas. Once these efforts take hold – with measured results – there could then be opportunities to use this initial success to widen and expand CHWs’ role in the system.

Gail Hirsch Replied at 11:55 AM, 12 Dec 2013

Lots to chew on; I will try to focus some thoughts now.

Going back to Sara’s question on how the state (DPH to be specific, in Massachusetts) is working to integrate quality supervision into the overall system, we have, for example, a contract policy (which is currently under revision) that articulates standards for supervision for all of the community-based vendors that we fund that employ CHWs. Additionally, we consistently publicly articulate the importance of good training for CHW supervisors, and we have, as possible, financially supported supervisor training (in addition to CHW training).

We hope that by demonstrating visible leadership on these issues from both the Commissioner level and program staff, we will influence other state agencies and private funders as well. The need for technical assistance for CHW employers has been expressed to us over and over again, and my Office of CHWs provides TA to program managers at DPH who in turn provide TA to their vendors.

This also applies to contracting standards for team integration – which, as many previous comments have also expressed, is heavily dependent on role clarity and developing best practices for multidisciplinary teams. For example, if the funder is doing a site visit, CHWs should be included. Case meetings should include CHWs, and optimally mechanisms to encourage CHWs to actively participate. Other providers have so much to learn from CHWs and it is important to create situations that encourage sharing like that.

With regards (as well to another of Sara’s points/questions) as to how DPH supports CHW organizing and leadership development, there is a lot to say. Twenty years ago we understood that without a viable CHW organization in Massachusetts, led by CHWs, we would not be successful in advancing the field because CHWs KNOW BEST what they need to be effective. Additionally, CHWs can convene key stakeholders in a more powerful way that the rest of us. Early on we engaged CHW leaders in Massachusetts in attempts at organizing, and supported the organization to get funding connected to advocacy, access and initial attempts at health reform. Building a collaborative partnership among key stakeholders in Massachusetts (the CHW network, the state public health department, the Massachusetts Public Health Association and others) laid the essential foundation for securing the inclusion of CHWs in our 2006 universal health care reform law.

Our CHW association (Massachusetts Association of CHWs – MACHW), played, with DPH support, a key role in the implementation of the CHW section of the 2006 health reform law, which paved the path for a hefty report on CHW sustainability to our legislature, including 34 recommendations in 4 distinct areas: professional identity, workforce development, financing, and state infrastructure. As a result, we now have a law that establishes a certification process for CHWs and CHW training programs at our state public health department. The Board of Certification of CHWs contains four seats for CHW representation, and DPH has financially supported the vetting of all decisions in CHW focus groups across the state.

The way to ensure the authentic (and successful, I believe) development of the field is to create spaces, opportunities, and support for CHWs to actively participate in and lead all phases. Someone here commented on the notable absence of CHWs in our discussion, and to that I say: “Here, here!” Including CHW voices will help to ensure that we do not lose the grassroots nature of this vital work.

We each need to think of (and take the time to actually carry out) ways to include CHWs in our meetings, publications, planning, presentations, etc.

I am especially fond of the concept of “social determinants expert” because I think it has the potential to help people understand the unique (and ESSENTIAL) contribution of CHWs. I have been lucky to work at a department of PUBLIC health (as opposed to a department of health) because our mission is broader and it is clear that CHWs support every articulated priority.

There is so much more to say, of course, but I would like to post this for now.

Donna Bjerregaard Replied at 2:24 PM, 12 Dec 2013

Preserving the community roots of CHWs so that they can continue to provide services in a comprehensive and culturally appropriate manner is not only important, but vital to health outcomes. Yet it is also being pointed out that their needs to be wider understanding of what CHWs do and need. It brings to mind the assessment tool, CHW AIM - which is used to review a programs status on 15 elements of functionality. The assessment process calls for full staff review of the program - meaning everyone from CHW to program manager discusses and determines how functional the program is in areas, such as recruitment, role definition, training and retraining, supplies, supervision, referral, etc. The assessment obviously helps the group come to consensus on needs and actions, but more importantly it brings all the players together in an effort to understand how it is perceived by all cadre. The tool can be found on CHW Central. It would require adaptation for the US programs - but the beauty lies not just in the finding the strengths and weaknesses but in the understanding and team building that results.

Attached resource:
  • CHW AIM (external URL)

    Link leads to:

Susan Auger Replied at 12:29 PM, 13 Dec 2013

This is Susan Auger in Durham, NC. Over the last 19 years, as a social worker and now as a PhD student, I’ve been developing and testing a group facilitation process for CHWs, called the Teach-With-Stories (TWS) Method, among pregnant Latinas. All of our work is grounded in the voices and lived experiences of community members, CHWs, as well as health professionals. Note: The TWS Method is a skill set for CHWs, not training to be a CHW.

First, I’d like to say how much I value the multifaceted discussion and questions that have been raised so far. It’s so heartening to hear such support for CHWs and validation of their unique contribution to the health of our communities, particularly in their ability to address social determinants of health.

I would like to provide an example from our work that speaks to Dr. Behforouz’ question ‘about how do we teach and support the sentiment “I teach the person to love herself again” ?
When developing the TWS Method, we looked deeply at the Institute of Medicine’s call to transform the healthcare system into a patient-centered model. In order to implement a patient-centered approach, the underlying relational paradigm must shift from a hierarchical, power-over model to a power-sharing model based on cultural humility (i.e., we are all teachers and learners).

The heart of our CHW and coordinator training emphasizes this ‘shared power’ way of relating, or what we call ‘teacher as facilitator.’ In order to implement the TWS Method with fidelity, the CHWs must relate from a ‘mindset’ of shared power and ‘heart set’ of caring, as well as follow the five TWS steps. In other words, a person’s way of being in relationship is just as important as their ‘doing.’ Any topic can be addressed. The TWS Method, use of stories, and group format are designed to facilitate social and emotional support and behavior change. The results so far have been powerful and transformative for everyone involved. (We are currently working on an article for publication.)

One of our biggest challenges has been to develop ways to support and maintain this way of relating and not revert back to power-over patterns, or what we call, ‘teacher-as-expert’ (the expert is on top, with the ‘right,’ important information; the learner is below, a passive recipient).
This is difficult since most of us have experienced this type of relating since childhood. and is the dominant paradigm in our educational systems. Also, this mode is typically associated with respect, status, and authority and therefore, there is a strong desire to emulate. Issues of internalized oppression further complicate behavior change efforts. However, once the CHWs and participants get a taste of the difference and experience the benefits of the ‘teacher-as-facilitator’ approach, it becomes intrinsically motivating and easier to integrate.

Since these relational patterns are implicit, we’ve learned that we must make them explicit. So we’ve included continual reflection and assessment about how we relate as part of our orientation, training and evaluation processes. We also developed interactive and video training components to help people literally see, experience, and articulate specific behaviors that facilitate shared power in relationships (or do not).

To answer Dr. Crea’s question about social workers and CHWs (By the way, I am also a BC alum), I’ve used my clinical social work experience in domestic violence and substance abuse, and also in early childhood development to inform the development of the method. With NIH funding through NIMHD, we have been working together to explore how to teach and support the use of fundamental empowerment-based relational skills in communities. Looking deeply, one can see that they involve the same relational skills now being promoted for parenting to foster attachment and the development of healthy brain architecture in early childhood. CHWs can work with immediate needs, while helping model and reinforce a relational paradigm based on love, respect, and mutuality.

I share the questions about how to measure and communicate the impact of the program and CHWs. References to mending and strengthening of the ‘fabric’ of our society, the connectedness of individuals and communities, restoring the love of self through love and caring of others all relate to fostering emotional resonance, and limbic regulation and revision through relationships.

From what I am observing in our work and reading in the literature, I think recent developments in neuroscience and emotional intelligence could help support the wide-spread adoption of CHWs as a core strategy for promoting population health and addressing social determinants of health and health equity. I am wondering if others have also considered this connection and perhaps are doing any related research?

Marie Connelly Replied at 2:49 PM, 13 Dec 2013

Many thanks to everyone for sharing such insightful comments and asking such thoughtful questions in the panel this week!

As we have just a bit of time left today, I would be eager to hear what everyone thinks the future of CHW programs looks like as the Affordable Care Act goes into full effect. How have agencies and organizations been preparing to leverage the ACA to further support or expand CHW programs, and what might we learn from their examples?

Looking forward to hearing your thoughts!

Sara Selig Moderator Emeritus Replied at 3:36 PM, 13 Dec 2013

Thank you to all who have participated in this discussion-- it is is very valuable and I agree with Ranu that I hope we can continue this discussion and idea sharing moving forward!

As others have mentioned, I think the ACA opens up many new avenues for improving care for all, and vulnerable populations in particular. Reimbursement for a wider variety of services will be possible and measuring outcomes in innovative ways will be an important piece of this. As Carl points out, in a culture of focusing on improving outcomes and cost savings, thinking about innovative ways to better support patients in the community and reach those who are not well linked with the healthcare system right now is crucial. While engaging CHWs is not necessarily "innovative" to those in this discussion, it is innovative to our current system in the US and so will need us, as Heidi discussed, to be champions for this way of thinking and approaching care.

Right now, in Navajo, we are looking at what is required to be able to "certify" the CHWs with whom we are working in order to have their services be reimbursable and this will definitely take some time to figure out in each location, but it will be great to continue this discussion so that we can continue to learn from each other as we move forward with this process!

Andrew Goldstein Replied at 4:08 PM, 13 Dec 2013

Hi all, I realize that many topics have been discussed and I've been happily reading and seeing the desire to continue these and many more discussions regarding CHWs.

Stepping back, I think we all recognize some sector-wide issues. I find the CHW sector as a whole to be under-funded, under-researched, and under-adopted. For a while I asked myself why this is the case, considering the potential of this method of healthcare delivery to be less doctor/hospital-centric, to be more equitable, to be more cost-effective.

Ultimately, I feel it is because those in field are operating in fragmentation. This fragmentation has led to insufficient knowledge curation/dissemination, networking, and collective action.

To address this I've been working on the FHW Network, which seeks to:
1) Find and engage organizations operating CHW programs and professionals working in the space.
2) Find, curate, and disseminate information. For now this includes who is out there doing what, training resources, the evidence base.
3) In the future, I would hope this network of practitioners and organizations can collectively act to increase program funding and research funding, to advocate on issues of certification, and to promote the utilization of CHWs by organizations not currently implementing them.

So far we've found >100 organizations, >100 training programs. Currently this is entirely volunteer-driven, we've crowdsourced the research.

Would love to hear feedback on this panel discussion if it's considered relevant. Would also love to connect - please feel free to be in touch via email and to check out our website at

Marie Connelly Replied at 8:56 AM, 16 Dec 2013

Many, many thanks to our exceptional panelists, and all of our community members who participated in this incredibly rich discussion. We greatly appreciate the insights everyone has shared, and look forward to continuing to discuss these important topics in 2014.

We will be working on a Discussion Brief to summarize the key points from this Expert Panel, and will share details as soon as that is available on the website.

In the meantime, we would be grateful for your feedback in our short, 9 question follow up survey. These surveys help us understand the impact of our Expert Panel discussions, and your feedback is incredibly valuable to us. Please take the survey now, by visiting:

Marie Connelly Replied at 3:40 PM, 21 Dec 2013

Hi everyone,

While we're working on creating a summary of this Expert Panel discussion, I wanted to send one final reminder about our follow-up survey, which closes on Monday morning.

The survey is 9 questions long, but should only take 2 - 3 minutes to complete (really!) - your responses help us understand the impact of these Expert Panels and how we can improve these kinds of discussions in the future.

If you haven't taken the survey already, your feedback would be greatly appreciated:

With thanks,

Isabelle Celentano Replied at 12:16 PM, 5 Feb 2014

It was great to read everyone's contributions to this valuable discussion. There was a very pertinent article in the Atlantic yesterday about the possible positive impact of CHWs that I think would be an interesting read for everyone. You can read the article here:

I particularly appreciated the mention of the role of CHWs in the United States, including examples of initiatives and legislation regarding the implementation of CHWs in our current health care system.

Marie Connelly Replied at 8:58 AM, 10 Mar 2014

Many thanks again to our panelists and members who participated in this Expert Panel discussion last December!

To help us understand the longer-term impact of these Expert Panels and plan future events, we have created a very short, 5 question, follow-up survey. This survey will only take 2-3 minutes of your time—please take the survey now at:

Many thanks,

Evelyne MUKAKABANO Replied at 8:01 AM, 20 Nov 2014

I thank so much our panelists,on my understanding,CHWs play the main role of monitoring of health instructions implementation while the professional social workers analyze the social economic impact on health scheme and provide social indicators to stakeholders.
Also professional social worker influence ,convince and advocate for the vulnerable population(voiceless) to access to basic needs.

Best regards,


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