How to Build Sustainable Community Health Programs in the United States

Henry's doctor gave him clear advice: check your blood sugar and take your insulin every day, not just when you feel bad. Exercise, at least thirty minutes a day, four days per week. Stop eating foods high in sugars and fats, and replace them with vegetables and protein. Perfectly straightforward — but Henry won't follow any of it.

For starters, he doesn't really know what insulin is or what it does for him, but he does know how much it costs: about $40 every time he fills the prescription, even with his insurance. As for the exercise, he'd be happy to, but it's not as simple as going for a jog around the block. Ever since his neighbor got mugged outside his building last year, Henry hasn't felt safe going out on his own. The diet change is also a lost cause, because Henry can't really cook for himself — it's easier to grab takeout from the many cheap restaurants on his block, and who really knows what goes into that food?

Henry's doctor would love to solve these problems for him, but she has neither the time nor the expertise to do so.

Instead, the gap between medical advice and the patient's ability to comply can be filled by another type of professional: a community health worker (CHW). Defined by the American Public Health Association as "a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served," CHWs have been shown to positively impact health outcomes in low-resource communities around the world.

For patients like Henry, a CHW can fill many of the gaps that separate clinical advice from the realities of his daily life. They can serve as educators, explaining the relationship between diabetes, blood sugar, high-sugar foods, and insulin in a way patients understand. They can link patients to community supports like neighborhood exercise groups or food pantries that provide health-conscious meals. Perhaps most importantly, because they come from the same communities as the patients they serve, CHWs can be powerful motivators and cheerleaders, helping patients find both the will and the way to overcoming their health challenges.

While CHWs have been present in the U.S. since the 1960s, they've struggled to become a core feature of our health care system, in large part because the American fee-for-service payment model for care doesn't incentivize the types of preventive or maintenance supports that CHWs often provide. In recent years, however, the U.S. has increasingly moved toward a new type of health care payment system where hospitals and other care providers are held financially accountable for the health outcomes of the patients they serve, broadly referred to as "population health." This transition is creating new financial incentives to address long-persisting disparities in health outcomes among low-income communities, communities of color, and other marginalized groups. As a result, interest in creating and supporting CHW programs has grown tremendously, as providers and payors look for cost-effective solutions to persistently poor health outcomes.

Despite evidence of their efficacy, the proliferation of CHW programs in the U.S. over the last decade has failed to achieve sustainability: making sure programs are designed and financed to reliably provide services over the long term. In an effort to address this core challenge, the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai in partnership with the Office of the U.N. Secretary General's Special Envoy for Health in Agenda 2030 and for Malaria assembled a Task Force of global and domestic experts and frontline leaders to develop a framework for sustainable, effective CHW programs in the U.S.

The goal of the Task Force has been to provide local leaders across the U.S. with a guide to creating a program capable of meeting the needs of the communities they serve. The framework is laid out in a newly published Report, which includes key principles for program design and guidance for developing a business case for CHWs. In order to put these principles into action, the Report also includes a plan to pilot a sustainable CHW program in Newark, New Jersey, through a partnership among key stakeholders in the city who participated in the Task Force, including state government, a public hospital, insurer, and community advocates.

Key Principles for Sustainable Community Health Programs

To identify key principles for sustainable, effective CHW programs, the Task Force began by looking abroad to successful programs as diverse as Brazil's Family Health Program, India's Accredited Social Health Activists (ASHAs), and Ethiopia's Health Extension Program. The group then worked to adapt lessons from these geographies to fit the unique social and financial context of the U.S. health care system.

Ultimately, the Task Force identified eight essential design principles:

1. Prioritize the patient at the center of care. The program, operational, and financial models must be designed to meet the clinical and social needs of the patients being served.
2. Reflect community needs in every aspect of design. Community engagement and leadership of CHW programs is essential to ensure trust.
3. Follow clearly defined, evidence-based protocols to meet patient needs. Not all CHW-based care models are equally effective: programs should use evidence-based protocols, like those developed by the Penn Center for Community Health Workers, whenever possible.
4. Build strong systems to support the service provided by CHWs. Well-designed operational infrastructures such as easy-to-follow care protocols, defined management structures, and user-friendly data systems make it easier for CHWs to serve patients.
5. Select and develop a high-quality workforce. Hiring and training should focus on interpersonal skills, such as empathetic listening. To retain high-quality staff, CHWs should have clear paths to career development and be compensated commensurately with the importance of their work.
6. Make CHWs an integrated part of the full care team. As an essential component of primary care, CHWs should participate in care planning and have strong bi-directional communications with clinical staff.
7. Align programmatic, operational, and financial models. There is no single right design for CHW programs; rather, financial, operational, and programmatic systems must be co-designed to work cohesively.
8. Be a strong partner to health systems. Although CHWs are ultimately representatives of the community they serve, the ability to provide reliable, high-quality service in partnership with provider systems is essential to achieving sustainable funding.

Crafting the Business Case for Community Health Programs

Because financial sustainability has historically been the single greatest barrier to CHW programs in the U.S., the Task Force also zeroed in on the challenge of developing a business case for CHWs. Even as some CHW programs have achieved returns on investment as high as $4.80 for each dollar spent, ensuring sustainable funding requires demonstrating and capturing value for investors. The Task Force recommends CHW program leaders begin by answering these five questions:

1. What is the work being done by the CHW-based care model? Each CHW program will perform slightly different work as it is designed to meet the needs of the patients being served.
2. What are the essential programmatic components needed to support this model? Again, the specifics of each program—including training models, operational needs, and integration with primary care teams—will look different depending on the community served.
3. How does this model create value? Well-designed CHW programs can improve health outcomes, increase access to clinical care, or reduce costs; many achieve all three at once.
4. To whom does that value accrue, and how? Depending on the impact of the program, the value of that impact may accrue to different actors. For example, while insurers benefit financially from patients utilizing fewer clinical services overall, hospitals can benefit when utilization simply shifts from the emergency room to a primary care clinic.
5. How does that value translate into investment? Understanding the paths through which value is created creates opportunities to build matching financial arrangements.

Taking Action in Newark, New Jersey and Beyond

Because a core goal of the Task Force was to put these principles into action, stakeholders from both public and private entities in Newark, New Jersey were brought into the Task Force to develop a pilot CHW program. The goal is to test the design of a program to be jointly funded by the state, a major insurance company, and a safety-net provider for effectiveness and sustainability. As a city with both a history of engaging communities in health, including through a CHW program at the Rutgers University School of Nursing, and a population suffering high rates of unmanaged chronic disease and lack of access to care, Newark represents an ideal opportunity to model the development of a sustainable CHW program.

The first essential step in developing the pilot was to bring together local stakeholders. In a partnership catalyzed by their work on the Task Force, Horizon Blue Cross Blue Shield, the state's largest health insurer, is joining forces with Newark Beth Israel Medical Center, the Greater Newark Health Care Coalition, Rutgers University School of Nursing, and the New Jersey Department of Labor. This unique collaboration will enable the development of a program with a strong business case to ensure sustainability while also keeping the needs of individual patients and communities at the center of the conversation.

While the pilot will start small, with five CHWs trained by the Department of Labor working with the community in and around Newark Beth Israel Medical Center, the Task Force is excited to watch its development over the coming years. The success of the program will be focused on two key outcomes: reduced hospital readmissions for patients with chronic conditions, and improved outpatient behavioral health appointment attendance for patients with mental illness. Beginning in 2017, Horizon Blue Cross Blue Shield will take the lead on evaluating the impact of these five CHWs over a 12-month period.

In fact, collaborative implementation of CHW programs in places like Newark is exactly what we hope this Report will inspire. While the specific needs of every community differ, the guiding principles elaborated in the Report serve as a starting point for local leaders to think through the design of a program able to meet those needs over the long term.

There has never been a better moment for communities in the U.S. to engage this work. We're experiencing a moment of great opportunity to positively impact the health of historically neglected communities through more effective care models like CHWs that close the gap between the clinic and the community. To take advantage of this moment, we urge local leaders to develop strategically designed CHW programs capable of closing that gap for generations to come.

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