The Evidence on Community Health Workers
In a recent opinion piece in STAT News aptly titled The problem with American health care is the care, LDI Senior Fellow Shreya Kangovi writes “…our health care system hasn’t caught up with the evolving face of disease in America. It is still mostly a workforce of doctors and nurses who dutifully treat patients in hospitals with expensive drugs and high-tech medical devices.” Kangovi, who founded and heads the Penn Center for Community Health Workers, suggests that training lay people from the local community to support patients in addressing the root causes of poor health is one part of the solution.
She’s not alone in this belief in the importance of community health workers (CHWs). With a growing interest in how to deliver more health for the money in the U.S. health system, CHW programs have been gaining attention and proliferating. Nearly every state has taken some steps toward integrating CHWs into new systems of care that can address social determinants of health. And CHWs have been a prominent feature of 15 State Innovation Models funded by the Center for Medicare and Medicaid Innovation to test new ways to pay for and deliver care.
CHWs work with people to detect and address the root causes of chronic illness, and to improve aspects of their lives that are contributing to poor health. This isn’t a new idea, but it seems like one whose time has come. But does the evidence support the use of CHWs as an effective and sustainable solution to the problems that Kangovi highlights? The short answer is, it depends.
Evidence on the effectiveness and cost-effectiveness of CHWs had been complicated by a lack of standardization across programs. You’ve seen one CHW, and well, you’ve seen one CHW. The Penn Center for Community Health Workers aimed to change this with their IMPaCT model, a standardized and scalable CHW intervention that they developed and tested at Penn, and are now supporting its rollout across the country.
In two separate randomized trials, the IMPaCT model has been shown to improve outcomes. In the first study of 450 hospitalized patients, the intervention improved discharge communication, access to primary care, and mental health, and reduced 30-day readmissions.
In a second randomized trial, the intervention reduced hospitalization and improved outcomes in uninsured or publicly insured patients with multiple chronic conditions. In the study, more than 300 high-poverty patients trying to manage diabetes, obesity, hypertension, or quit smoking set a disease management goal with their primary care provider. One group then worked with a CHW for six months to meet their goal, while the other group had usual care. After six months, compared to the control group, the CHW group had 30% fewer hospitalizations, and modest but significant improvements in managing diabetes, obesity, and smoking.
From the Penn Center for Community Health Workers, here’s a 60-year-old man with chronic obstructive pulmonary disease describing how a CHW, hired and trained through the IMPaCT model, affected his health:
I had to go to the hospital four times in the first six months of (the year). I had recently lost my job and my purpose in life. I spent the days chain-smoking. During a hospital stay I met Mary, an IMPaCT CHW. She was so warm and easy to talk to. She turned me on to a community center in our neighborhood and helped me get a quit-smoking patch. It has been nearly 2 years, and I haven't had a cigarette. I teach music at the community center. I feel like I have a home there now.
Based on the reduction in hospitalizations, the researchers estimate a return on investment of $2 for every $1 spent on IMPaCT. Other work by Kangovi and her team has demonstrated how to make a CHW program financially sustainable. They documented how they were able to grow the Penn Center for Community Health Workers from a small grant-funded project into a program serving 2,000 patients annually and funded through the health system’s operational budget.
With the current interest in CHWs, the variability in quality of CHW programs may prove a risk for this approach. We need more evidence not only on the effect of CHWs but best practices for CHW programs. This will help to ensure that they stand up to scrutiny, deliver on their promise of more health for the money, and importantly, ensure the best possible outcomes for the patients that they serve.