Abstract
Integrating community health workers (CHWs) into health care systems has been associated with enhanced patient experience, improved population health, and reduced costs and unnecessary utilization of resources. 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. This health policy brief is focused on the benefits of integrating CHWs specifically into the patient-centered medical home (PCMH). CHWs in the PCMH can 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. Despite the important role of CHWs, there are some barriers to integration into existing systems of care. The Society of Behavioral Medicine (SBM) recommends overcoming these barriers by establishing standards that ensure a skilled CHW workforce, clearly defining roles for CHWs, and expanding the scope of reimbursable prevention and primary care services to include those provided by CHWs.
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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:
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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.
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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]:
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Holding staff-wide trainings on cross-cutting evidenced-based competencies and best practice models
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A priori planning by administrative staff to ensure clear roles and procedures for all health professionals
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Assigning specific access, roles, and tasks in the PCMH electronic medical record for CHWs
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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:
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1)
Clearly define and support the role of the CHWs within the PCMH by the following:
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Determining roles of CHWs based on need as well as training and skill prior to hire
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Developing clear intervention protocols and referral processes for CHWs to follow
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Training all PCMH health care professionals to collaborate across disciplines
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2)
Expand the scope of reimbursable prevention and primary care services to include those provided by CHWs.
References
Center for Health Law & Policy Innovation at Harvard Law School, NCLR, Peers for Progress, and Society of Behavioral Medicine. (2015). Call to action: integrating peer support in prevention and health care under the Affordable Care Act. Retrieved from http://www.sbm.org/UserFiles/file/CALLTOACTION-communityhealthworkerstatement.pdf on June 25, 2015.
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Centers For Disease Control And Prevention, A summary of state community health worker laws, 2013. Available at http://www.cdc.gov/dhdsp/pubs/docs/CHW_State_Laws.pdf. Accessed December 13, 2014.
Rush CH. Basics of Community Health Worker Credentialing (2012), available at http://www.chw-nec.org/pdf/Basics%20of%20Community%20Health%20Worker%20Credentialing.pdf. Accessed December 13, 2014
Miller P, Bates T, & Katzen, A. Community health worker credentialing: state approaches. June 16, 2014. Available at: http://www.chlpi.org/wp-content/uploads/2014/06/CHW-Credentialing-Paper.pdf. Accessed December 13, 2014.
Center for Health Law and Policy Innovation, Harvard Law School; National Council of La Raza (NCLR); and Peers for Progress, American Academy of Family Physicians Foundation. (2015). Recommended model guidelines for credentialing community health worker programs and community health workers.
Gutierrez Kapheim M, Campbell J. Best practice guidelines for implementing and evaluating community health worker programs in health care settings. Chicago: Sinai Urban Health Institute; 2014.
Acknowledgments
This manuscript was supported in part by PCORI Contract No. IH-12-11-5420, US Department of Veterans Affairs RCS 98–352, and the National Cancer Institute under award number R25CA057699. DMH was supported by PCORI and US Department of Veterans Affairs. JB was supported by the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of PCORI, US Department of Veterans Affairs, or the National Institutes of Health. The authors wish to gratefully acknowledge the expert review provided by the Society of Behavioral Medicine’s Health Policy Committee, Health Policy Council, and the Integrated Primary Care Special Interest Group.
Conflict of interest
Denise M. Hynes, Joanna Buscemi, and Lisa M. Quintiliani declare that they have no conflict of interest.
Compliance with ethical standards
All procedures were conducted in accordance with ethical standards.
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Implications
Practice: Health professionals providing care in PCMHs should be required to receive training on interprofessional collaboration, including training on specific roles of each team member and clear intervention protocols and referral processes for CHWs.
Policy: Policymakers should expand the scope of reimbursable prevention and primary care services to include those provided by CHWs.
Research: Further research is needed to evaluate specific protocols for integrating CHWs into the PCMH.
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Hynes, D.M., Buscemi, J., Quintiliani, L.M. et al. Society of Behavioral Medicine (SBM) position statement: SBM supports increased efforts to integrate community health workers into the patient-centered medical home. Behav. Med. Pract. Policy Res. 5, 483–485 (2015). https://doi.org/10.1007/s13142-015-0340-1
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DOI: https://doi.org/10.1007/s13142-015-0340-1