Housing, transportation, access to quality nutritious food, and other social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. But doctors and other clinicians often have a limited ability to address these things during the typical office visit or hospital admission. Increasingly, though, community health workers (CHW)—who provide preventive and supportive care and health education within their community—do.

The use of community health workers is growing rapidly across the United States and around the world. These individuals can deliver care that extends beyond the capacity of hospital systems. They often focus on improving the health of communities that have been poorly served by the health system. Critically, their work includes the remediation of social determinants of health, which LDI Fellows Shreya Kangovi and Aditi Vasan wrote, “often play a greater role in health outcomes than health care does.” 

In their new review article, Molly Knowles, Kangovi, Vasan, and coauthors summarized evidence showing how CHWs can improve care, increase access, and reduce costs for the chronically ill. CHWs can also improve health equity by serving as a crucial link between health systems and marginalized communities. The authors noted that “CHWs’ lived experiences and trust-building qualities make them uniquely equipped to improve access to care and increase uptake of preventive services, particularly among communities harmed by the health care system or deterred by limited insurance access, language barriers, or other systematic barriers to care.”

They cited evidence that the country’s approximately 60,000 CHWs enhance population health, improve patients’ experiences of care, and reduce costs, especially among those with chronic conditions. CHWs can also provide individual-level advocacy for their clients, improve cultural and structural competence in institutions, and push for social justice at a community and societal level. 

CHWs have played a role in U.S. health care for more than 70 years. Efforts to embed them into health care got a boost in 2010, when the expansion of the CHW workforce was catalyzed by the Patient Protection and Affordable Care Act (ACA) and the growth of value-based payment. Federal legislation such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 and the Reconciliation Act (American Rescue Plan) of 2021 further provided funding to support CHW capacity and integration into state and local public health departments. But the evidence suggests communities could benefit if CHWs played an even larger role in health care.  

Looking forward, Kangovi and Vasan suggested three areas to further the development of the CHW program and promote its integration into health care systems:

Expand Sustainable Financing Options

A lack of sustainable financing has slowed the expansion and integration of CHW programs into health systems. Until recently, most programs were funded through short-term grants, leading to high turnover rates and service interruptions when grants ended. While some payers and providers have internally financed CHW programs, this approach often relies on leadership support and institutional financial power. Shifting to value-based payment models has created funding incentives because CHWs can reduce costs of care and provide needed service to patients who typically face structural barriers when accessing health care. Some states also have implemented new mechanisms to support CHW programs, but these programs are often limited and inconsistent across the country, and no federal sources consistently fund CHWs.

Ensure Rigorous, High-Quality Evaluations of CHW Programs

The number of useful evaluations of CHW programs remains small. A new collaboration of researchers from five states has created the Community Health Worker Common Indicators (CI) to promote CHW-led development and standardized measures to assess their performance. This initiative is among the first initiatives to collect and standardize metrics to measure the care provided by CHWs. The data generated by evaluations can produce high-quality research and provide evidence to support sustainable funding sources. Kangovi and Vasan recommend that CHWs be engaged and involved in all stages of program evaluation.

Translate Evidence Into Best Practices

In 2018, the World Health Organization released health policy guidelines for CHW programs. The organization recommended combining theoretical and practical training; adopting supportive supervision practices; providing financial compensation with a clear scope of work and pathways for career progression; integrating with primary health care teams; and supporting CHWs in engaging communities. 

Groups such as the National Center for Quality Assurance and the Community-Based Workforce have identified specific best practices in the United States. These include using community-based recruitment and hiring, engaging CHWs in planning and implementation, defining clear yet flexible roles, and creating sustainable financing along with effective supervision. 

Attempts to institute requirements for CHW programs should be done carefully. For example, when some states introduced certifications for CHW, this requirement may have increased income inequalities within the CHW workforce, resulting in less CHW diversity and opportunity. According to researchers, certification requirements for CHWs should not be used to exclude individuals who might lack academic qualifications but otherwise possess the skills and character traits – like empathy and compassion – that are important to success in this role. 

If properly funded and supported, CHWs offer “a significant opportunity for the U.S. healthcare system,” according to the authors. As support for CHWs grows among U.S. legislators and health system and public health leaders, they posited that “a future in which CHWs are recognized as key members of the health workforce and have sustainable funding streams is on the horizon.”

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The review, “Community Health Worker Integration With and Effectiveness in Health Care and Public Health in the United States,” was published April 2023 in the Annual Review of Public Health by Molly Knowles, Aidan P. Crowley, Aditi Vasan, and Shreya Kangovi.

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