Community Health Workers Bring Health Systems New Benefits, Value During COVID-19
// By Kyle Hardner //
As COVID-19 has spread throughout the United States, it has shed new light on a decades-old question: the role of social determinants of health in defining overall health outcomes.
The pandemic is hitting hardest among certain racial, ethnic, and minority groups. Through mid-June, non-Hispanic Black people had a COVID-19 hospitalization rate about five times that of non-Hispanic White people, according to the Centers for Disease Control and Prevention. Hispanic or Latino people had a hospitalization rate four times that of non-Hispanic White people.
In addition, multiple socioeconomic factors play a role in potential increased risk for COVID-19 and negatively impacted patient outcomes. These factors include housing conditions, sanitation, overcrowding, public transportation usage, access to health insurance, and access to high-quality care, according to the Center for Primary Care at Harvard Medical School. Job type also factors into the equation, with essential workers serving on the pandemic’s frontlines, often out of economic necessity.
These trends spotlight the continued importance for health systems to invest in programs that impact social determinants of health. Community health workers play a key role in such programs. And recent studies indicate not only a boost in quality metrics from such programs, but also a real dollars-and-cents return on investment for health systems.
“It’s up to each health system to determine how to improve quality and lower costs, and the answer looks different for different populations depending upon the root causes of health concerns within a community,” says Jill Feldstein, chief operating officer of IMPaCT (Individualized Management for Patient-Centered Targets) at the Penn Center for Community Health Workers.
Why Social Determinants of Health Matter
Numerous studies have determined that medical care accounts for only 10 to 20 percent of a population’s overall health outcomes. The remaining 80 to 90 percent of outcomes are driven by social determinants of health, including socioeconomic factors (education, employment, income, social support, and safety), health behaviors (diet, exercise, sexual activity, tobacco, alcohol or drug use), and physical environment (air and water quality, housing and transit).
The passage of the Patient Protection and Affordable Care Act of 2010 (ACA) sparked a move to value-based care — health systems receiving reimbursement based on outcomes. Over the past decade, models such as Accountable Care Organizations (ACOs), patient-centered medical homes, and Medicare Shared Savings programs have emerged to both incentivize health systems to focus on social determinants and to drive improved population health outcomes.
Effectively identifying and addressing social determinants requires resources at the local level. For example, men with type 2 diabetes and a hemoglobin A1C level of 12 may have different factors affecting their condition. “One person fitting that health profile may only have access to fast food on his way to a minimum-wage job,” Feldstein says. “Another person might not have the will to get out of bed because he lost his son to violence. Another might not be able to afford his medication.” Community health worker programs provide the context required to help find the root cause of chronic illness in a community, and then develop interventions to address that cause.
“One person fitting that health profile may only have access to fast food on his way to a minimum-wage job. Another person might not have the will to get out of bed because he lost his son to violence. Another might not be able to afford his medication.”
An increasing amount of data is showing the value of community health worker programs in addressing social determinants. IMPaCT, which provides standardized, scalable community health worker programs to 50 organizations (including health systems) in 18 states, recently quantified the value of its work in two studies.
One, a randomized clinical trial, recruited low-income, underinsured or publicly insured patients who had been diagnosed with two or more chronic diseases. The results, published in JAMA Internal Medicine in October 2018, showed that patients in the intervention group were more likely to report the highest quality of care. They also reduced total days in the hospital by 69 percent after six months and 65 percent after nine months. Patients in the intervention group also had lower odds of repeat hospitalizations.
The second, an analysis published in HealthAffairs in February, showed that every dollar invested in a standardized community health worker intervention would return $2.47 to an average Medicaid payer within the fiscal year. “We believe this to be the first ROI analysis of its kind with regard to community health worker programs,” Feldstein says.
Building Blocks for Successful Community Health Worker Programs
The most effective community health worker programs are evidence based, with workers drawing real-life experiences from people within the population a health system serves. To build a successful program, Feldstein recommends these best practices:
1. Don’t make assumptions.
Data may show where the greatest needs exist in a community, but the boots-on-the-ground support of community health workers will uncover hidden truths. “Here in West Philadelphia, we had community health workers go right to our local soup kitchens and ask people about their experience with health care,” Feldstein says. “Their answers helped us understand exactly where our community health workers should focus their work.”
2. Hire the right people.
Discussing health care is a sensitive topic, and many community members may not respond unless they’re approached by someone who looks, acts, and talks like them. “Ideally, community health workers should be people who know the community, speak their language, and share their experiences,” Feldstein says.
Feldstein finds that the most successful community health workers also fit a specific personality type. “They’re natural helpers and great listeners who know how to empathize with others,” she says.
3. Give them the right questions.
Community health workers will meet patients one-on-one and perform a social needs assessment. This requires the touch of a skilled interviewer who knows exactly what to ask — and how to ask it to get a response. Needs assessments should go beyond a patient’s physical health conditions. “The goal is to understand who the patient is,” Feldstein says.
Questions such as Where did you grow up? What was that experience like for you? What makes you most proud? provide the context to help form a more complete picture of a person and, in turn, a community at large.
How Community Health Workers May Impact COVID-19
With COVID-19 cases rising again in the U.S. this summer — and a second wave anticipated this fall — health systems will continue to face numerous challenges. Community health workers can play an integral role in a health system’s pandemic response.
“Many of the issues brought forth by the pandemic — social isolation, stress, higher unemployment rates, financial strain, deferred preventive care — are in a community health worker’s wheelhouse,” Feldstein says.
In communities at high risk for COVID-19, community health workers within health systems can work with community organizations to provide education and psychosocial support. Such interventions can also allow health systems and community health workers to address longer-term fallout from the pandemic.
In lower-risk communities, Feldstein sees community health workers playing a role as surge tracers who may perform light-touch contact tracing. These surge tracers would then refer individuals to a health system’s more experienced community health workers only as needed. Payment for surge tracers could come from government stimulus funds.
No matter the trajectory of COVID-19, health systems will feel the pandemic’s effects for months and years to come. Community health worker programs are an option that may help health systems devise a more local response to the pandemic, reduce disparities in care, improve care for people with chronic disease, and be better stewards of their population’s overall well-being.
Kyle Hardner is a professional writer, editor, and ghostwriter with 20 years of experience in the health care, technology, and B2B fields.