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Community Health Workers Moving to New Roles as More Seek to Age in Place
posted 02.09.2015

By Carl H. Rush

With the aging of the Baby Boomers (among whom I count myself), a renewed emphasis on “aging in place” and the growing burden of long-term care on state Medicaid programs, the era of community health workers (CHWs) has arrived. CHWs have been engaged in population health in disadvantaged and hard-to-reach communities for 50 years or more, but have moved rapidly into new roles as part of clinical care teams, spurred in part by healthcare reform.

CHWs complement clinicians in important ways: by developing and maintaining trust, rapport and candor with patients and families; by working directly on social determinants of health; by providing community-based follow-up to support clinic-based encounters; and by informing clinicians on important sociocultural considerations in patient care. As the ultimate high-touch element of the system, CHWs may spend an hour or more at a time with patients, in contrast to ever-shorter clinical encounters.

For the moment I will pass over the inevitable questions readers unfamiliar with CHWs are formulating about scope of practice, liability and financing; I’ll deal with them another time. Just keep in mind CHWs are your friends—neither a risk, a threat nor a burden.

Following are a few of the opportunities presented by recent research and by curiosity among the Centers for Medicare & Medicaid Services/Center for Medicare & Medicaid Innovation, Administration for Community Living, Department of Housing and Urban Development (HUD) and many others about CHWs’ potential to work with older populations.

Home- and community-based care: A five-year Medicaid waiver project in Arkansas has saved significantly on overall costs of care for individuals receiving care at home, by connecting them (and caregivers) to community resources. Results appeared in Health Affairs in 2011. This opportunity should appeal both to state Medicaid programs (preventing or avoiding facility-based care and acute episodes of illness), and to home health agencies (enabling them to retain clients for longer periods of time).

Care transitions (reducing hospital readmissions): CHWs may represent an archetype of the “warm handoff:” by being present in a hospital setting, coaching the patient on understanding of and adherence to discharge instructions, supporting follow-up appointments and connecting to non-medical services, the CHW can offer continuity of support and also alert clinicians to potential concerns.

A Philadelphia study showed that CHW-driven follow-up led to significant reductions in long-term readmission rates. Results appeared in 2014 in JAMA Internal Medicine. KentuckyOne Health’s “Transitions of Care” program (employing CHWs) had readmission rates of approximately 19 percent, while the comparison group’s rate was 41 percent. The Catholic Health Initiative recently awarded KentuckyOne a $1.5 million grant to expand the initiative.

Falls prevention: The Texas A&M CHW National Training Center is pilot testing a CHW curriculum developed in partnership with the UNC Chapel Hill Prevention Research Center, funded by the Centers for Disease Control and Prevention.

CHWs in senior centers and senior housing: HUD has been quietly experimenting with the stationing of CHWs in subsidized housing for a number of years. This line of investigation has attracted interest from the Local Initiatives Support Corporation, Mercy Housing, the National Council on Aging and others. CHWs can augment resident services in housing and enrich senior center programming by helping participants establish eligibility for benefits, offering wellness-related activities like exercise and cooking classes and, again, connecting older individuals to valuable community services.

What needs to be done?

In addition to support for piloting such initiatives and taking them to scale, advocates and researchers can join in policy advocacy for sustainable financing of CHW services at the state and federal level, and contribute to developing geriatric specialty curricula for CHWs to augment the growing network of CHW core-competency education and capacity-building programs.

The American Public Health Association (APHA) has an active CHW Section. You are invited to reach out to Section leadership with program ideas, and of course to join the APHA if you are not already a member. Further, members of the APHA Aging and Public Health Section can work with their own Section leadership to encourage joint activities with the CHW Section.

Carl H. Rush, MRP, is a research affiliate with the Project on CHW Policy & Practice at the Institute for Health Policy within the University of Texas School of Public Health.

This article was brought to you by ASA’s Healthcare and Aging Network.

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