INTRODUCTION

In a recent “call to action,” a number of organizations including the Society of Behavioral Medicine (SBM), Center for Health Law & Policy Innovation at Harvard Law School, NCLR, and Peers for Progress provided compelling evidence as to the benefit of integrating community health workers (CHWs) and peer support into existing health care systems [1]. The “call to action” highlighted several benefits of the role of CHWs including enhanced patient experience, improved population health, and reduced costs and unnecessary utilization of resources [1]. Under the Affordable Care Act (ACA), care provided by CHWs is eligible for reimbursement. However, optimal integration of CHWs into health care requires purposeful implementation.

PURPOSE

As a follow up to the recent “call to action,” SBM focuses this brief on increased efforts to integrate CHWs specifically into the patient-centered medical home (PCMH). There are numerous opportunities for CHWs to support and enhance primary care [2], and integration could be facilitated by (1) establishing standards that ensure a skilled CHW workforce, (2) clearly defining roles for CHWs, and (3) expanding the scope of reimbursable prevention and primary care services to include those provided by CHWs. SBM supports specific actions that would promote sustained development of a well-qualified CHW workforce, consensus on how to best integrate CHWs in a PCMH team, and compensation guidelines that are transparent and equitable.

CHWs IN THE PCMH

PCMH is a model for organizing primary health care that emphasizes team-based care coordination in an effort to provide higher quality at lower costs and improve both the patients’ and providers’ experience, with the goal of maximizing health outcomes. The PCMH emphasizes patients’ individual preferences and values. Given the unique needs of individual patients, PCMHs aim to integrate health care providers from across disciplines, including CHWs who specialize in patient-centered care. Within the PCMH, CHWs serve as primary providers of culturally relevant information and advocacy, assist providers in understanding the influence of patients’ environment on disease management, and enhance motivation for self-care management among patients with chronic diseases. There are significant benefits to integrating CHWs into the PCMH. Namely, clinical outcomes improve when CHWs are integrated into primary care teams [3–7]. Additionally, CHW-based interventions have demonstrated reduced health care use and costs for chronic care conditions [5, 6, 8, 9].

OVERCOMING BARRIERS TO INTEGRATION

CHWs serve an important role in providing patient-centered, tailored, evidence-based care. Integrating CHWs in the PCMH may be facilitated by the following:

  1. 1)

    Establishing standards that ensure high-quality CHW programs and a skilled CHW workforce

Only 16 states regulate CHWs [10–12]. Among these 16 states, only five have adopted a certification system of credentialing. Regulatory rules and certification requirements vary markedly. No states license CHWs or offer educational programs that allow applicants to quality for a license. Model guidelines exist that provide for credentialing of both CHW programs as well as individual CHWs [13]. The lack of and variation in regulations and certification standards can raise questions about how to use CHWs, thereby undermining the likelihood that PCMHs will integrate CHWs into their team-based systems of care.

  1. 2)

    Clearly defining roles for CHWs

A primary goal of the PCMH is team-based care. However, models on how to develop training to accomplish the most efficient and effective team-based care are still in progress. Given the wide range of roles and duties of CHWs, there can be some confusion among staff about the best way to utilize and integrate the CHW on an interprofessional team. In their best practice guidelines for implementing and evaluating CHW programs in health care settings, Gutierrez Kapheim and Campbell recommend the following [14]:

  • Holding staff-wide trainings on cross-cutting evidenced-based competencies and best practice models

  • A priori planning by administrative staff to ensure clear roles and procedures for all health professionals

  • Assigning specific access, roles, and tasks in the PCMH electronic medical record for CHWs

  1. 3)

    Expanding the scope of reimbursable prevention and primary care services to include those provided by CHWs

The PCMH improves upon traditional primary care models by incorporating patient-oriented care that often includes coordinating care with community-based health programs and other health services outside of the provider office. Unfortunately, the traditional reimbursement model, fee-for-service (FFS), does not always reimburse for care delivered by phone or email. There have been recent short-term changes to the chronic care management (CCM) coordination codes to help to reimburse for care that is not face-to-face, but further reform is needed to provide adequate reimbursement for care provided by CHWs.

SUMMARY

CHWs have the ability to increase the reach and effectiveness of care in the PCMH, in addition to reducing excess resource utilization. As more health care systems adopt the PCMH model, it is important to highlight factors that will facilitate integration of CHWs into interprofessional teams. SBM supports expanding the use of CHWs to enhance primary care, prevention, and chronic disease management programs within PCMHs to improve patient outcomes and reduce unnecessary utilization of resources. SBM offers the following policy recommendations for integration of CHWs into the PCMH:

  1. 1)

    Clearly define and support the role of the CHWs within the PCMH by the following:

    • Determining roles of CHWs based on need as well as training and skill prior to hire

    • Developing clear intervention protocols and referral processes for CHWs to follow

    • Training all PCMH health care professionals to collaborate across disciplines

  1. 2)

    Expand the scope of reimbursable prevention and primary care services to include those provided by CHWs.