Community Health Workers Playing a Bigger Role in Health Care

by Candi Helseth

Orlando Gonzalez can sometimes be seen atop a ladder in fruit orchards near Okanogan, Wash., instructing farmworkers about ladder safety. Gonzalez also regularly speaks to area farmworkers about safety and health-related topics such as heat stroke, high blood pressure and HIV in his capacity as the health outreach coordinator at Family Health Centers (FHC), a federally qualified health center covering 5,268 square miles that include Okanogan County, the nation’s fourth largest migrant employment county.

Family Health Centers

Orlando Gonzalez (kneeling) and Miguel Carrera, (l), both with Family Health Centers in Okanogan County, Wash., talk to orchard workers about health and safety issues.

In her work with Okanogan County Public Health (OCPH), Gonzalez’s wife, Keila, accompanies a public health nurse on home visits, where she educates mothers about nutrition and family care while the nurse provides professional services. Like her husband, she is fluent in Spanish and English. The couple’s Hispanic heritage and bilingualism are primary qualifications for their jobs as community health workers (CHWs). These lay workers, whose commonality lies in their familiarity with the community they serve, are a growing force in health care delivery.

“Providing culturally and linguistically appropriate health care to Latino patients is an ongoing challenge for local health care providers because the community has a different language, and may have cultural beliefs that affect willingness to access care,” explained FHC Chief Operations Officer Heather Findlay. “We have employed CHWs and promotores (Hispanic lay health workers) to bridge the gap between health care professionals and the Latino community since 1985.”

Common CHW duties may include interpretation and translation services, health education and informal guidance, helping people access care, being an advocate for health needs, and limited direct services such as first aid and blood pressure screenings, according to the Health Resources and Services Administration (HRSA). CHWs most often work with disadvantaged and/or minority populations and/or in rural or isolated areas where acute health care shortages exist.

“Several studies have recognized that community health workers can significantly improve quality and expand efficiency of the existing work force,” said Ed Salsberg, HRSA National Center for Health Workforce Analysis director. “When you think about rural communities and the potential for people from that community to be part of an outreach team that interfaces with community and medical professionals, there is great opportunity to improve effectiveness and change lifestyles, especially in areas of prevention. These are people the community already knows and trusts and they are valuable in getting the messages across.”

Salsberg noted that a wide range of workers, titles and functions actually fall under the role of community health workers. CHW titles and definitions vary from state to state and even within organizations. At FHC, CHWs are full-time employees responsible for outreach education, program enrollment and data collection. The on-call promotores assist with various health education efforts. In the summer, Orlando said, they go to the orchards to teach farm worker families about topics such as preventing heat stress when working in the fields. When winter comes, education may be targeted at other safety issues such as driving safely in the area where many roads become completely blocked by snow.

“A lot of what we do is preventive medicine,” Orlando explained. “We try to keep them healthier and safer so they’re not coming into the ER and clinic for help after something has already happened.”

FHC, along with co-partners Mid-Valley Hospital and OCPH, expanded CHW services in 2006 with funds from a three-year Rural Health Care Services Outreach Grant awarded by the Office of Rural Health Policy (ORHP). Grantees increased public education and health care presence at community events, produced and distributed informational brochures, and developed Spanish-language radio health education spots. They documented several successful outcomes in response to established goals, such as reaching 1,239 seasonal farm workers with no previous exposure to services and increasing by 10 percent the number of women entering prenatal care in their first trimester. FHC continues the programs with other funding.

Growing recognition of CHWs

CHWs can contribute significantly to improvements in community members’ access to, adherence to and continuity of care, as well as reducing health care costs, according to the American Public Health Association (APHA).

Keila Gonzalez

Keila Gonzalez visits with mother Maribel Morales and daughter Angela B Morales. Gonzalez, a bilingual CHW with Okanogan County Public Health, provides provides nutritional and childcare education to local families.

“CHWs and other trained non-physician health providers (lay nurses, EMTs) are often more available in rural communities than physicians or advanced practice nurses,” said APHA Executive Director Dr. Georges Benjamin. “Under proper supervision, they can provide the diagnostic examinations, basic tests or in many cases common core procedures essential to assuring high quality care.”

APHA now has a CHW Section, which grew out of a Special Primary Interest Group originally formed in 1970. Formation of the Section reflects the growing recognition of CHWs in the health care workforce. According to the APHA Policy Statement Database, “A growing body of research indicates the effectiveness of CHWs in improving the quality of care and individual health outcomes.”

The APHA document also states that, although CHWs are “uniquely positioned to address issues of health care access, quality, cost, and disparities, comprehensive policy and practice changes are needed at all levels.”

Providing training

No national standard exists for CHW training or professional certification and most CHWs receive on-the-job training tailored to the specific program with which the CHWs are hired to work, according to APHA, which has called for a standardized training program that will ensure CHWs have basic qualification levels and are capable of meeting standardized core competencies.

“We’ve found that little attention may be paid to the core skills necessary for effective outreach; outreach skills are assumed. Instead, attention is largely focused on the specific disease or topic,” said Susan L. Mayfield-Johnson, director of the University of Southern Mississippi Center for Sustainable Health Outreach (CSHO). “CHWs may have familiarity with and compassion for the population being served but we’ve learned how important it is that they also have essential training in core skill areas such as communication skills, time management and setting personal boundaries—as well as training in core competencies and chronic disease management.”

CSHO demonstration programs have trained more than 900 CHWs since 1999 and CSHO has documented decreases in morbidity among populations receiving services, Mayfield-Johnson said. USM has developed numerous programs, using CHWs in primary capacities, to provide certain services in Mississippi Delta communities and federally qualified health centers.

GOTCHA Program

Community health workers with the GOTCHA program regularly hold health fairs where they provide professional guidance and free health screenings. They recently offered glucose screening and monitoring at this fair in Greenville.

In one program co-sponsored by CSHO, GOTCHA (Getting on Target with Community Health Advisors), CHWs provide information, professional guidance, and specific free services to address and curb heart disease and stroke. To participate in GOTCHA, CHWs first were required to complete core skills training. Subsequent training modules qualified them to go beyond the role of providing education to being able to perform certain procedures out in the communities, such as doing digital blood pressures for hypertension and glucose screenings for diabetes. An ongoing evaluation system requires CHWs to demonstrate understanding and abilities in competency and chronic disease management.

Education is particularly important in changing lifestyles because the history and culture of the Delta region contributes to many negative health behaviors, Mayfield-Johnson said. Another program begun 10 years ago demonstrates the ability CHWs can have in positively impacting those behaviors, she said, pointing to the Deep South Network for Cancer Control (DSNCC). The program, a collaborative effort between USM and the University of Alabama at Birmingham, targets four regions. Two are urban and two are poor, rural areas: the Delta region and the Black Belt of Alabama.

Ten years ago no infrastructure in the Delta addressed cancer disparities, health and wellness, according to Mayfield-Johnson. DSNCC partnered with 40 churches to implement a plan for 11 Delta sites. Using CHWs as primary facilitators in these communities, DSNCC ultimately decreased cancer health disparities by 40 percent, according to CSHO data. Success stories included CHWs and volunteers getting plantation owners to donate land to develop three walking trails and more than 500 people participating in the WALK plan. Church members reported substantial weight losses and positive changes in eating and lifestyle habits.

“As community members, these workers are able to integrate health information about prevention of disease and the health system into the community’s culture, language and value systems,” Mayfield-Johnson said.

Health care future includes CHWs

Salsberg said CHW numbers appear to continue to grow. The addition last year of CHWs to the Bureau of Labor Statistics’ list of standard occupations should result in improved data and trends information, he added.

Ensuring reimbursement for CHW services from Medicaid, Medicare, the Department of Defense and Veteran’s Administration is critical, Benjamin said. “Private insurers usually follow the federal reimbursement models at some point. There is a provision in the new health reform law that creates a role for CHWs in the Standard Occupational Classification. The law also seeks to expand the role and strengthen financial support for CHWs, as modeled by two states (see Community Health Workers: Part Of The Solution [No longer available online]) that have already initiated policies to reimburse CHWs under Medicaid.”

In Mississippi and elsewhere, CHWs will play an increasing role. “We have a saying at CHSO,” Mayfield-Johnson said. “ If the problem is in the community, the solutions are in the community.’ Community health workers are solutions in many communities and we believe they will continue to be so even more in the future.”


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