Health Policy$ense

To Protect Public Health During And After The Pandemic, We Need A New Approach To Financing Community Health Workers

Shreya Kangovi for Health Affairs

[Original post: Shreya Kangovi, To Protect Public Health During And After The Pandemic, We Need A New Approach To Financing Community Health, Health Affairs Blog, June 5, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200603.986107/full/. Copyright ©2020 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.]

Americans are dying at startling rates, not only of COVID-19 but of all its reverberating effects. To save US lives, we will need to solve not one problem but four. First, we need to reduce community spread of the virus; contact tracing has been highlighted as a solution but is unlikely to be effective unless it is coupled with culturally appropriate, trusted support. Second, millions of people are losing their jobs and struggling to pay for necessities such as food, housing, and medication. Third, many people with chronic conditions such as diabetes and asthma have had to forgo routine care that is critical to maintain their health because they have lost employer-sponsored health insurance or because routine appointments have been suspended. And finally, the stress and isolation of the pandemic is affecting Americans’ mental health, and experts worry that suicide deaths will spike. The combined effects of COVID-19, under-treated chronic disease, financial strain, and stress threaten to create a tsunami of illness that will strike precisely when the US health care system is at its weakest, when health systems are laying off “non-essential” workers by the thousands due to declining revenue.

Community Health Workers Play A Critical Role

The enormity of the challenges associated with the pandemic will require an unprecedented mobilization of resources and cross-sector collaboration to protect all Americans. Community health workers have the abilities, experience, and community connection to address each of the multifaceted problems that are killing Americans right now: They are trusted individuals from within communities who can be hired to provide social support, arrange access to needed health and social services, promote healthy behavior, and improve the quality and cultural competency of services. Community health workers are trusted because of who they are and what they do. They share life experiences with the people they serve and have often walked in their shoes; this empathy is a critical ingredient of trust. Community health workers also build trust by letting patients drive the agenda, rather than dictating or being prescriptive. 

My team at the University of Pennsylvania supports a network of organizations across 20 states that is using the IMPaCT model–a standardized model for hiring, training, and deploying community health workers—to respond to COVID-19. These community health workers make outreach calls in their communities and use a semi-structured interview guide to get to know people holistically. They learn each individual’s life story, their accomplishments, and their goals. They probe for challenges including COVID-19 infection or exposure, difficulty making ends meet, need for resources such as food and housing, stress, and social isolation. In the course of these conversations, they ask each individual what they think will help improve their life and health. Community health workers then provide tailored support based on individuals’ specific needs and preferences. They help arrange food delivery, advocate with employers for protective equipment, and help people access public benefits such as unemployment and Medicaid. They reduce isolation through virtual support groups and just by listening to people’s concerns. They connect marginalized patients to health care and thus help avert preventable hospitalizations. They reinforce COVID-19 public health messaging by sharing evidence-based recommendations for COVID-19 prevention, and they often work with health departments to conduct or support contact tracing efforts.

A growing body of evidence has demonstrated the effectiveness of community health workers. Three separate randomized clinical trials of IMPaCT demonstrate that community health workers can improve health and the quality of health care while reducing costly hospitalizations. A recent economic analysis using data from one of these randomized trials demonstrated a return on investment of $2.47 for every dollar invested.

There Are Not Nearly Enough Community Health Workers

The most recent Bureau of Labor data available indicate that as of 2019, approximately 59,000 community health workers were employed in the US. This number—about one for every 5,500 residents—is not nearly enough to support disadvantaged communities during and after the pandemic with contact tracing and social, economic, behavioral, and preventive health care support.

US public health, health care, and community-based organizations should hire community health workers to make critically needed support available to disadvantaged communities. In addition, increased hiring of community health workers can help address the unemployment crisis because community health workers often come from within disadvantaged communities, and many are unemployed or underemployed.

This type of hiring can be done quickly and at large scale. The University of Pennsylvania’s IMPaCT program has developed a standardized approach to hiring that organizations can use to recruit “natural helpers” who are already serving in local communities. Job interviews can include multimodal assessments and case scenarios to screen candidates for important traits such as empathy, a non-judgmental nature, and trustworthiness. Based on how long it takes organizations in our national network to ramp up programs, we estimate that the US could double the workforce of community health workers within six months. More than 100,000 community health workers, embedded in communities hard hit by COVID-19 across the country, could support contact tracing efforts, help people access COVID-19 testing and treatment, and support community-based initiatives to address chronic disease, financial strain, and stress.

Even though hiring and ramp-up of community health worker programs can occur quickly, these positions should not be considered temporary. Community health workers should remain in these jobs even after the pandemic to support long-term public health.

New Short- And Long-Term Financing Solutions Are Needed

Community health workers are paid through a patchwork of funding options, such as Medicaid demonstration waivers, health homes, Medicaid managed care plans, and grants. In its 2014 final rule, the Centers for Medicare and Medicaid Services (CMS) allowed states to use Medicaid funds to cover community health workers who provide preventive care services. However, states interpreted these services narrowly and thus few filed State Plan Amendments to take advantage of the funding.

The patchwork approach to financing community health worker services is not sufficient to scale up the workforce to the level needed. To bridge the gap, we, along with a coalition of health organizations including the American Public Health Association, the National Association of Community Health Workers, the National Association for the Advancement of Colored People (NAACP), the Institute for Healthcare Improvement, the American Diabetes Association, and the Society of General Internal Medicine, call on Congress and CMS to create new short- and long-term solutions to funding community health workers.

In the short term, to help immediately mobilize community health workers as part of COVID-19 response efforts, we ask Congress to authorize $3.6 billion in emergency supplemental funding. In addition, we ask CMS and Congress to create a sustainable, ongoing funding stream. CMS should act quickly to broaden the 2014 regulation, so that Medicaid funds can cover a more broadly defined range of preventive care provided by community health workers, including those addressing the social determinants of health, health promotion, advocacy, and COVID-19 prevention. Congress should add community health worker services as an optional benefit in Medicaid. This change would elevate coverage of these services from one of dozens of administrative options to an explicit, clearly defined benefit that can be take advantage of by states and territories. In addition, we suggest that Congress offer an increased federal match, as it has done for COVID-19 response efforts during the pandemic, which could incentivize states and territories to cover community health worker services. National standards for community health workers—such as those being developed by the National Committee on Quality Assurance around hiring, supervision, training, and work practice—can serve as quality guardrails for federal funding. This combination of short- and long-term financing, coupled with evidence-based standards, can catalyze development of an effective workforce that can save lives during the pandemic and the recovery that follows.

Just as we were in January when national health officials first learned of COVID-19, we are in a state of inaction before a second storm created by surging rates of infection, untreated chronic illness, and socioeconomic strain. Community health workers are the test kits and the masks that will protect the health of the US public during the pandemic. We need new short- and long-term financing solutions to scale up this resource and make it available for years to come.