To improve population health, health care organizations must reach outside their walls and engage patients in the context of their daily lives. Doing so requires seeing past traditional medical pathways defined by physiology or genetics and delving deeper into social factors that form the fabric of patients’ lives — for example, employment, housing, and social support. Thoughtful health care organizations are looking to community health workers (CHWs) — individuals from local communities who, because of shared experience and established relationships, can see and sometimes act on social issues that are invisible to outsiders. Because of their reach and low cost, CHWs are increasingly common.
Yet CHW programs are heterogeneous in their approach and effectiveness. Saying that “community health workers are effective” is like saying “movies are good.” Some are; others aren’t. The key question is not whether community health workers are effective, but how we can make them as effective as possible.
Here, we describe what we believe to be the core components of effectiveness based on our review of the literature and our experience with developing IMPaCT, a standardized CHW model that has been shown, in multiple randomized trials, to improve mental health and quality of care as well as to improve chronic disease control while reducing hospitalization. We also share lessons from the technical assistance that we have provided to more than 1,000 CHW programs across the country.
A Human Resource Innovation
CHW programs are fundamentally a human resource innovation and are only as good as the people hired for the job. Understanding who is — and is not — a community health worker is a prerequisite for strategic hiring. Community health workers share demographic characteristics with their patients (e.g., income, race, education, language). They are also natural helpers in that they are innately empathic and altruistic. Therefore, the term community health worker is not exactly synonymous with the terms navigator, health coach, care coordinator, or case manager. CHWs can perform these roles, but they also have a unique identity beyond these functions that allows them to build trust with patients.
Finding these natural helpers requires nontraditional recruitment strategies, such as posting jobs at local volunteer organizations rather than just on employment websites. We have conducted behavioral interviews involving theoretical case scenarios to identify job applicants who are good listeners and appear empathic. For instance, an interviewer might role-play with an applicant, acting the part of a combative patient who fails to show up for a scheduled doctor appointment. The interviewer evaluates the applicant’s ability to listen, to build trust, and to address the root causes of the missed appointment without becoming frustrated, dismissive, or pushy.
Most health systems do not approach hiring in this manner, but such unconventional practices can pay rich dividends. Published reports on other CHW programs have demonstrated annual turnover rates of as high as 50%, which can be costly and disruptive; ours has been 1.7%.
Not Just Training
Successful programs incorporate training at all levels (i.e., for program leaders, supervisors, and community health workers) and continue to focus on training over time. Effective training involves the use of standardized skill checks to engage adult learners and to ensure mastery of interpersonal techniques (e.g., motivational interviewing, active listening, respecting boundaries, etc.). Many states are exploring the idea of requiring community health workers to receive standardized training and certification before they are eligible for reimbursement.
This approach seems to be an intuitive way of streamlining the quality of CHW programs; however, there is some concern that it may create barriers to entry for low-income community members who might be best suited for the job. Another risk is that this approach incorrectly assumes that a focus on training is sufficient for optimizing the effectiveness of CHW programs. Experts have suggested that training, while necessary, is only one aspect of building high-quality programs, which also rely on sound hiring practices, supervision, and standardized workflows.
Going Beyond Appointments and Referrals
Many of our client organizations use community health workers solely to reinforce conventional medical care — for example, by providing patients with health education, improving medication adherence, or encouraging attendance at medical visits. These organizations may be overlooking CHWs’ greatest value: the ability to provide creative, patient-centered social support. In the IMPaCT model, CHWs tailor their interventions based on patient-driven action plans, which may have little to do with medical care. For example, our CHWs may exercise with patients at a local YMCA, set up conversations between estranged family members, or restore joy for traumatized patients through fun activities such as bowling.
Indeed, our work has demonstrated that socially mediated approaches can be as effective as conventional medical pathways for improving hard clinical outcomes (e.g., glycosylated hemoglobin levels or hospital readmission rates). This practice of focusing upstream has unshackled CHWs from classical disease-specific care-management models that have historically limited their range.
This adaptable approach also offers advantages over the traditional approach whereby patients are screened and referred to existing social services. First, a limited number of formal services (e.g., public housing) are available, and high-risk patients often will have already exhausted these resources. A more flexible approach allows community health workers to leverage patient, family, and grassroots resources. For instance, if public housing is not available, a community health worker might help a patient to find inexpensive rooms for rent or reconnect with a family member who could provide a place to stay. Second, many patients may have problems such as low self-esteem or loneliness that are not easily solved by resource referrals. Finally, many marginalized patients feel dehumanized by constantly cycling through referral systems.
Because CHW interventions can be so personal and intensive, pre-specifying the duration of the intervention can help to set expectations and facilitate advance planning for the end of the relationship. Programs without a fixed ending, in which patients graduate when they are ready, run the risk of creating perverse incentives, whereby patients who demonstrate improvement lose access to their support person as a result of their progress. This approach also causes operational difficulty in managing CHW caseloads. In contrast, successful programs focus on identifying long-term support systems — drop-in groups, church, family, or neighbors — that patients can lean on once intensive CHW support ends.
Setting the Stage for a Community Health Worker Program
Perhaps persuaded by the intuitive appeal of CHW programs, organizations are often tempted to “just try it.” As a result, health care leaders who would never think of casually undertaking a complex task such as designing a chemotherapeutic regimen on their own can find themselves hastily launching a CHW program. While false steps in the construction of such a program will not express themselves in the dramatic and immediate ways that would be observed in a case of botched chemotherapy, building a CHW program without sufficient planning and infrastructure has risks.
One of the biggest infrastructural problems that we see is inadequate supervision. Community health workers are often placed under the supervision of busy nurses or doctors. This strategy, although expedient, can be ineffective. Clinicians may have competing responsibilities or may not understand this unique workforce, treating them like medical assistants or telephone case managers.
Similar challenges have been described in association with large-scale global programs, in which supervisors are typically primary care nurses who lack understanding of the role of the community health worker. In one study, 48% of CHWs in Zambia’s primary health system reported that supervision — provided by health center staff without regularity or structure — was of no benefit to them. Global experts have recommended that CHWs should receive structured supervision from individuals with a social work or public health background (including former CHWs).
In addition to supervision, there are myriad structural questions that program builders often fail to anticipate: What is the right balance between time spent in clinic as opposed to the community? How can CHWs be kept safe in neighborhoods with high crime activity? How should supervisors track performance to identify early signs of burnout? Prior to launch, program leaders should sit down with frontline staff to develop detailed, easy-to-read operational manuals that address these practical questions.
Community Health Workers Boom or Bust
Community health workers are not new. China’s “barefoot doctors” and their Russian equivalents, the feldshers, are examples of CHWs from the past century. CHW programs go through boom and bust cycles: they become popular for predictable reasons, and, perhaps more importantly, they fail for predictable reasons.
Yet the same remediable mistakes keep recurring, perhaps because low-tech programs create the illusion of being simple or because organizations tend to reinvent these programs from scratch rather than adapting evidence-based programs. Unlike launching a new cancer drug, these programs are relatively easy to pilot. But organizations should not confuse how easy these programs are to start with how easy they are to design and manage well.
We are currently in a boom cycle for CHW programs, and this boom is generating best practices that can advance the field. In order to prevent the bust cycle and translate this wave of enthusiasm into real and lasting change, we need to learn from experience and approach these programs with the rigor and discipline that they deserve.