Who are "Community Health Workers" and why are they important? Community Health Workers (CHWs) are frontline health promoters. They visit patients in their homes and encourage healthy behaviors. In one home the worker may remind an elderly man to take his blood pressure medicine, and in the next she may work with a diabetic woman to improve her diet. The worker checks on pregnant teens to remind them of medical appointments and provide education about breastfeeding. In another city the CHW is encouraging those with high risk behaviors to get HIV testing and helping people get access to health insurance. The worker is a member of the healthcare team who can describe an ethnic diet to nurses and translate health information for physicians. Community Health Workers can be found in both rural and urban communities, and they share ethnicity, language, socioeconomic status, and life experiences with the community members.
Community Health Workers can be the glue that holds members of a community and the healthcare providers together. Their role is unique because they live in the communities that they serve and are accepted and trusted by those that live there. Speaking the language and understanding the culture allows them to identify and address both political and social barriers of underserved communities which results in reduced health inequities. They promote wellness by educating the members about access to healthcare and the healthcare system. Community Health Workers are also able to communicate to nurses and physicians about the needs of the community. They are an important extension of the healthcare system, and they are trusted by those who have avoided healthcare in the past. They also play an important role as social supporters, and help health care systems to improve universal access and coverage for primary care services.
Why Didn't We Think of This Before?
Health promoters within the community are not a new concept. Many other countries have found CHWs to be important members of their healthcare teams for decades. Brazil provides an excellent example of a country that began using CHWs in the 1980's. The improved health outcomes attributed to the CHWs were so substantial, that in 1994 the government included them in the primary healthcare teams of the national Family Health Program.
Today each team is comprised of one physician, one professional nurse, one technical nurse, other health professionals and six or more community health workers. Each team serves 3450 to 4500 people.1 After about three decades of organization and collective struggles, Brazilian CHWs all carry an associate's degree and are well respected by the health professionals and people of Brazil.1 The United States can look to Brazil as an excellent model of team care that includes community workers in promoting health and wellness of their population.
There are many studies showing that integrating Community Health Workers into the healthcare system of the United States has increased access to care, improved healthcare quality, reduced health disparities, improved service delivery and reduced healthcare costs. Despite the documented benefits of Community Health Workers, the U.S. has been slow to recognize and accept them as members of the healthcare team. The Institute of Medicine (IOM) released reports in 2002 and 2012 recognizing CHWs as essential members of the healthcare team.
The 2002 report identified significant barriers to the effective use of CHWs as inconsistent scope of practice, training and qualifications; lack of sustainable funding mechanisms; and lack of recognition by other health professional, and the 2012 IOM report recommended using CHWs to address hypertension in underserved communities.2,3 Progress in the area of education for CHW's has been slow since the 2002 IOM report. Statistics provided by the Center for Disease Control in December of 2012 show that only eight states have identified a scope of practice for CHWs, including Massachusetts and Rhode Island. Five states in the U.S., including Massachusetts, require CHW certification or documentation of completion of a training program.2
Role of Community Colleges
Despite the growing interest in CHWs, wide variability exists in their training. Lack of consistency in the education of CHWs has led to confusion of the healthcare team regarding their role, responsibilities and abilities. Some workers are trained informally on-the-job while others complete a more formal program. Community colleges are the ideal educational facilities to provide standardized training for CHWs. They have experience in providing education to a diverse student body, low tuition rates and locations that are easily accessible. Community college professionals also have experience in breaking down the walls that prevent members of lower socio-economic communities from seeking formalized training. They can assist in finding funding for education and understand the fears related to immigration status and lack of documentation of previous education. These colleges have a unique opportunity to assist in developing a diverse healthcare workforce which reflects the populations of our country.
SEE ALSO: Population Health
So What Can We Do?
The Patient Protection and Affordable Care Act is guiding us on the right track by emphasizing prevention and promoting wellness. The act provides support for workforce development initiatives that include using CHWs to promote positive health behaviors and outcomes in medically underserved communities.4 States can form advisory bodies that define a scope of practice and core competencies for CHWs. Training programs can be developed based on these competencies. Including reimbursement for CHW services in Medicaid cost claims and providing incentives for private insurers to use CHWs will allow for them to be integrated into team-based care.
Let's get serious about healthier lives for everyone. Understanding and embracing the concept of Community Health Workers as valuable members of the health care team is the first step. Nurses can help in spreading the word about the need for these front line health promoters.
- Pinto R, Wall M, Yu G, Penido C, Schmidt C. Primary Care and Public Health Services Integration in Brazil's Unified Health System. American Journal of Public Health. November 2012;102(11):e69-76.
- Center for Disease Control. State Law Fact Sheet: A Summary of State Community Health Worker Laws 2012. http://www.cdc.gov/dhdsp/pubs/docs/CHW_State_Laws.pdf. Accessed March 16, 2015.
- Mirambeau A. November 13, 2012. CDC Evaluation Coffee Break: Evaluating Community Health Worker Programs. http://www.cdc.gov/dhdsp/pubs/docs/cb_november_2012.pdf. Accessed March 27, 2015.
- Islam N, Nadkami SK, Zahn D, Skillman M, Kwon SC, Trinh-Shevrin C. Integrating community health workers within Patient Protection and Affordable Care Act implementation. Journal of Public Health Management and Practice. 2015 Jan-Feb;21(1):42-50. doi: 10.1097/PHH.0000000000000084.
Diane J. Bordonaro is associate professor at the University of Hartford in Connecticut. Helena Maria S. Leal David is an associate professor at Univerisadade de Estado de Rio de Janeiro