HD8 - Interim Report on the Status, Impact, and Utilization of Community Health Workers


Executive Summary:
BACKGROUND ON COMMUNITY HEALTH WORKERS

Introduction

Across the United States and Virginia, the community health worker (CHW) is emerging as a vital link between communities and health care providers. CHWs may work under a variety of titles but typically work almost exclusively in community settings. They serve as connectors between individuals and health and human service providers to promote health among groups that have traditionally lacked access to adequate health and human resources.

As community members, CHWs function effectively within a community’s culture, language, and value system. The formation of the CHW-client relationship establishes trust between the CHW and the client. It is this trust that serves as a foundation for the successful dissemination of information and service delivery. As a trusted voice, CHWs are in a unique position to reach otherwise marginalized or vulnerable populations.

Characteristics of Virginia Community Health Workers and their Places of Employment

Community health workers are persons with varying degrees of training and education who provide a variety of services within health and human service delivery systems. A Centers for Disease Control study found that the average CHW receives forty hours or fewer of initial training, and 2-4 hours of in-service training per month. (*1) This training is often focused on a specific topic or issue. (*2)

CHWs work for a wide range of programs and reach a variety of populations. Such programs include those addressing infant and child health, family services, women’s and reproductive health, nutrition, smoking prevention, HIV/AIDS, breast and cervical cancer early detection, elderly health and respite care, mental health, and substance abuse. Programs serve both males and females and the range of ethnic groups that comprise Virginia’s population. Most programs are delivered through community-based agencies and local health departments, and are funded with federal and state monies. However, approximately one-third of programs are funded by local government agencies, non-profit organizations and private foundations.

Core Roles of Community Health Workers

The 1998 National Community Health Advisor (NCHA) Study provided descriptions of the core skills, roles, and major issues that confront CHWs throughout the U.S. (*3) The NCHA Study identified seven core roles that characterize the work of CHWs in the United States. (*4) These roles also accurately describe the work of Virginia CHWs. The core roles are:

1. Providing cultural mediation between communities and health and social service systems
2. Providing culturally appropriate health education and information
3. Assuring access to needed services
4. Providing informal counseling and social support
5. Advocating for individual and community needs
6. Providing direct services
7. Building individual and community capacity

Community Health Workers as Bridging Cultural and Linguistic Barriers to Health Care Services

Because they are often members of the communities they serve, CHWs engender trust with their clients. Using this trust, outreach and educational services provided by CHWs belonging to underserved and limited English proficient (LEP) communities have shown remarkable effectiveness in linking individuals with health and human service providers, insurance coverage and sources of continuous, appropriate health care. (*5)

In its 2004 "Report of Acclimation of Virginia’s Foreign Born Population," the Joint Legislative Audit and Review Commission (JLARC) indicated that “by all accounts, the language barrier is the most common challenge faced by Virginia’s foreign-born residents. Ethnic leaders reported that the language barrier not only causes difficulty in communicating, but may deter non-English speakers from seeking needed services or assistance.” (*6) The JLARC report also noted that in urban areas of Virginia, community-based organizations, and other non-profit or charitable entities are a vital resource to the foreign-born. (*7) CHWs that are trained to provide interpretation in health care settings for limited English proficient (LEP) persons through the Northern Virginia Area Health Education Center are one example of CHW programs providing model services to LEP populations.

Community Health Workers as Connectors to Services

CHWs serve as connectors between services and the people who need them. In this role, CHWs make referrals to health and human services, serve as a motivator for people to seek care and support, provide transportation to health and human service appointments and services, and often follow-up with individuals to ensure that they have received the care they sought or are following the course of care that has been prescribed for them. (*8)

Working in communities where formal services are often not available, CHWs serve as a complement to services delivered by “formal” health and human service professionals (physicians, nurses, social workers, etc.) to provide more comprehensive and supportive care.

An example of the connector role of CHWs is the Comprehensive Health Investment Project (CHIP) of Virginia. CHIP, a non-profit organization with eleven regional sites across Virginia is an intensive home-visiting program that helps families establish and maintain relationships between a primary care clinician, the mother, and her baby. CHIP CHWs work in collaboration with a nurse or nurse practitioner and maintain regular (weekly or biweekly) contact with families over a period of months. CHIP clients have demonstrated a 20% improvement rate in immunizations, significant reductions in hospitalization stays and emergency room visits over two years of participation. (*9)

CHWs as Providers of Informal Counseling and Social Support

Conditions of poverty, unemployment, discrimination, and isolation are characteristics of many communities where CHWs work. Clients of CHWs often describe themselves as having difficulty coping with day-to-day events. (*10) There is a volume of literature that has demonstrated the importance of social support in preventing mental health problems and improving physical health outcomes. (*11)

A report released in 2001 by the Surgeon General’s Office Titled "Mental Health: Culture, Race and Ethnicity," found that providers of mental health services often know little about the cultural values and backgrounds of patients they are treating or the traditions of healing and the meaning of illness within their cultures. (*12) According to Dr. Satcher, “if people are going to feel comfortable discussing mental disorders, they have to be talking to someone they trust, and to someone who understands their culture and how things are expressed in their culture”. (*13)

Because of the trust established between CHWs and their clients, CHWs are there to offer their client’s “a shoulder to lean on” when there is no one else.

Community Health Workers as Providers of Direct Services

In the various settings in which they work, CHWs provide a range of direct services. For many CHWs across the nation and in Virginia, this often means helping clients and families meet basic needs. This includes helping persons secure food, clothing, transportation, adequate housing, and employment resources.

Similar to examples of school-teachers reaching into their own pockets to pay for needed supplies for school children, there are few CHWs who have not used their personal resources or time to assist their clients above and beyond their program’s objectives. This happens despite what one Virginia CHW commented upon when she said that she was “one paycheck away from being in the same (poor) financial situation as my client”.

Health care providers often do not know the environments that some of their patients live in and the struggles that they may have just to meet basic needs. In these situations, important medical information and treatment plans will often go unheeded and physical improvement will be minimal or not occur at all. This is often caused by the client’s inability to follow a care protocol or regimen due to the immediacy of their economic, emotional and/or social situation.

In Virginia, programs such as CHIP, Healthy Families, Resource Mothers and AIDS Service Organizations are examples of CHW programs that must work to secure basic needs for their clients so that they are then able to address specific needs related to the goals and objectives of their programs.

Community Health Workers as Builders of Individual and Community Capacity

In many ways the previous six identified CHW roles contribute to the final core role of the CHW - building individual and community capacity. (*14) To reduce gaps in community health, and strengthen public health systems, individual and community strengths and weaknesses need to be identified. Strengths need to be maximized while weaknesses are identified and minimized. Within local health and human service delivery systems, CHWs are often the ones working behind the scenes weaving together community resources to address their client’s needs.

The practical experiences of CHWs provide essential contributions to public health and other health and human service activities that often prove to be models of care delivery or best practices. In this regard, CHWs provide invaluable services by acting as cultural liaisons between health and human service providers and the communities they serve.

INVENTORYING CHW PROGRAMS IN VIRGINIA: STATUS AND CHALLENGES

In its 1996 report titled "The Development of Community Health Advisor Programs Throughout the Commonwealth of Virginia," the Institute for Community Health at Virginia Tech estimated that there were as many as 4,000 Community Health Advisors (CHWs) working in Virginia. (*15) The Virginia Center for Health Outreach database of CHW programs contains over 230 programs.

Challenges in Inventorying Programs

There are several factors that make gathering a complete list of CHW programs in Virginia very challenging. These factors include the following:

Number of Titles. The numbers of official titles used by programs in Virginia for work conducted under the core roles established by the NCHA Study are many and varied. The plethora of titles creates challenges for identifying an accurate number of CHWs.

Paid versus Volunteer CHWs. There are CHWs who work on a volunteer basis in Virginia. These CHWs may work in a variety of community settings. Volunteer CHWs are more likely to rotate in-and-out of work typical of CHWs. Their status and work as a CHW is more likely to not be documented than paid CHWs because they often operate without formal administrative structures.

Lack of Licensure or Certification. Health and human service professionals that must be licensed or certified to practice have accurate databases maintained by state agencies. For CHWs, the lack of formal licensure or certification means that there is no mandated central repository for CHW workforce information.

Funding. CHW funding comes from various sources, including federal, state and local agencies, and private sources such as foundations. This funding has time limits. The instability of funding sources often means that there is significant fluctuation in program staffing levels and their efficacy in meeting the program’s mission.

Awareness and Integration. Often there is a lack of integration of CHWs into existing health and human service delivery systems and institutions. This occurs as a result of a lack of awareness of the role of CHWs and the employment of CHWs using a title other than “community health worker”. Where integration does exist, the contributions of the CHW are often not well recognized.

DEVELOPING A STANDARD DESIGNATION FOR VIRGINIA CHWs

Background

The capacity of CHWs to improve access to health and human services, especially for Virginia's most vulnerable populations is great. Supporting this belief are numerous groups, organizations, and programs across Virginia that recognize the value of CHWs and have worked to increase the visibility of the CHW role in health and human service delivery.

Despite these commitments, there is recognition that a barrier to maximizing the value of CHWs is that so many CHWs nationally and in Virginia work under a variety of titles. Many outreach workers in Virginia are unfamiliar with the title of "community health worker."

The limited understanding of the CHW role by other health and human service professionals can sometimes cause CHWs to be pushed beyond their training and, perhaps more significantly, at other times to be underutilized. This can, in part, be traced to the lack of a standard designation for persons performing one or more of the core roles of CHWs.

A Standard Designation for Virginia Community Health Workers

Based upon the work of the Study Resolution Committee, CHWs, and CHW program supervisors in Virginia, the following description of CHWs working across Virginia is offered:

A Community Health Worker applies his or her unique understanding of the experience, language and culture of the populations he or she serves to promote healthy living and to help people take greater control over their health and their lives. CHWs are trained to work in a variety of community settings, partnering in the delivery of health and human services to carry out one or more of the following roles:

• Providing culturally appropriate health education and information

• Linking people to the services they need

• Providing direct services*, including informal counseling & social support

• Advocating for individual and community needs, including identification of gaps and existing strengths and actively building individual and community capacity

*Direct services may include providing transportation, purchasing food on behalf of clients, other activities associated with basic needs, taking blood pressures, temperatures, monitoring blood sugar levels, measuring heights and weights, and teaching self-screening measures such as breast self-examinations. Direct services may also include instruction on constructive problem-solving decision-making and planning.

RECOMMENDATION. In partnership with the Department of Human Resource Managements, James Madison University and the Community Health Worker Study Resolution Committee should review the Direct Services Career Group Description to ensure that Community Health Workers are appropriately identified as a health care support occupation and defined in accordance with the Committee's findings.

EVALUATING THE EFFICACY OF COMMUNITY HEALTH WORKERS

Background

In order to fully understand and communicate the value and impact that CHWs have on the population they serve and health and human service systems, many organizations conduct evaluations of their CHW programs. These evaluations are used to demonstrate various aspects of a given program, including its procedures, its strengths and weaknesses, its cost-effectiveness, and how it affects individuals and the community where services are delivered.

The information collected and analyzed in CHW program evaluations can serve many purposes. Often, evaluations serve as feedback regarding a specific program and assist administrators in determining whether or not programs should be continued, expanded, reduced, or discontinued.

Two types of evaluations are primarily used for CHWs and their programs - process evaluation and outcome evaluation.

• Process evaluations analyze how a given program operates and identifies aspects of that program that can be improved. Process evaluation considers what was done, when it was done, who did it, how often it was done, to whom it was done, and how well it was done. (*16)

• Outcome evaluations determine both the short-term and long-term impact and value that a program has had. In the case of CHWs, they often consider the number of individuals enrolled in a given program, the health status of those individuals, and how those individuals have changed over the duration of the program. (*17)

Both of these types of evaluations are useful in examining CHWs and CHW programs. Process evaluations are beneficial in providing an overall picture of a program’s status and in examining internal strengths and weaknesses related to administration, techniques, personnel, and other aspects of a program. Outcome evaluations are beneficial in determining the external strengths and weaknesses of a program, primarily by analyzing the impact and value that a program brings to the community that it serves.

Following are several descriptions of evaluations utilized by selected Virginia programs that employ CHWs. Where available, outcome information is described.

The AIDS/HIV Services Group uses prevention educators to provide HIV/AIDS education and support services to nearly 8,000 individuals in central Virginia. In 2003, these educators worked with individuals in Charlottesville, Waynesboro, and Staunton, and in Albemarle, Fluvanna, Nelson, Greene, Louisa and Buckingham counties. ASG received a substantial federal grant in 2002 which allowed it to expand its education outreach programs and hire additional CHWs to serve as educators. As ASG has expanded its education programs, it has evaluated its impact on HIV incidence as compared to statewide data using information gathered by the Virginia Department of Health. In Charlottesville, for example, the number of new cases of HIV dropped from twelve in 2001, to nine in 2002, and to three in 2003. This is a 67% decline in incidence, compared to a statewide rate of 20%.

The Community Health Education Development (CHED) Program targets rural counties in Virginia’s Middle Peninsula to increase access to and use of existing health care services. This program was initially launched in three counties: Westmoreland, Caroline, and Essex. It was subsequently expanded to Northumberland, Lancaster, and Richmond counties. CHED performed an annual SWOT (strengths, weaknesses, opportunities, threats) analysis through both the developmental and implementation phases of the program and also gathered demographic information and data on community screening activities. The SWOT analysis covers program activities, outcomes, community benefits, and administrative aspects of the statewide CHED Program.

Comprehensive Health Investment Project (CHIP) of Virginia targets vulnerable children and their families with the goal of improving children’s health and promoting wellness. This program supports a network of eleven community-based home visiting programs in the following localities and regions: Arlington, Greater Richmond, Greater Williamsburg, Norfolk, Chesapeake, Portsmouth, Petersburg, Jefferson Area, Roanoke Valley, New River Valley, and Southwest Virginia. CHIP offers four categories of services: screening, assessment, and planning; education and support; follow-up; and referral and outreach. Examples of CHIP outcome measures included:

• Increased employment rate among mothers (23% to 33%)
• Increased use of family planning methods increased from 54% to 68%
• Increased number of children enrolled in Medicaid and/or FAMIS Plus (70% to 81%)
• Decreased number of low birth weight baby (17.8% as compared to 7.0%) for women who enrolled in CHIP at least 4 months prior to giving birth

Expanded Foods & Nutrition Education Program (EFNEP) is a program that focuses on nutrition education and attempts to provide individuals with knowledge, skills, attitudes, and behaviors essential to a nutritionally sound diet. Virginia EFNEP operates in 26 counties and cities throughout the state, seven of which are urban and 19 are primarily rural. The program targets low-income families with young children and low-income youth. The program’s economic efficiency over one year was calculated through a cost-benefit ratio comparing the amount of money spent on the program to the potential savings from the program. The analysis determined that in 1996, the Virginia program resulted in benefits totaling $18,223,980 and costs totaling $1,713,081. The program had a benefit to cost ratio of $10.64 to $1.00, and an internal rate of return of 16.41%.

Healthy Families provides home visiting services to families in Virginia and has an overall goal of reducing risk factors for child abuse and neglect by positively impacting pregnancy outcomes, child health, parenting practices, and child development. Healthy Families (HF) collects outcome data from its clients using a standardized database and compares this data to statewide outcome goals and objectives. The 2004 Healthy Families Virginia Statewide Report focused on infant and child health outcomes and found that among program enrollees, 88% of babies were within the healthy birth weight range as opposed to the 77% statewide rate. Additionally, 85% of the children enrolled in programs received all of their scheduled immunizations while the Virginia average was only 64.8%. The child abuse and neglect rate among families enrolled in Healthy Families program is .97% (<1%) while the child abuse and neglect rate among families with characteristics similar to families enrolled in HF is 4.7%. Another outcome goal of HF programs is reducing subsequent births among enrolled teenage mothers. Approximately 94% of teenage mothers do not have additional births for at least two years after enrolling in the program.

Resource Mothers is a program directed at teenage parents focusing on enhanced birth outcomes, promotion of a stable home environment, and help establishing connections to existing support services within the community. Resource Mothers collects data regarding birth outcomes, subsequent pregnancies, and visits and support sessions within the program. In 2004, teenage participants in Resource Mothers had a repeat pregnancy rate of 6.1%, significantly lower than the state average of 20%. The low birth weight rate among Resource Mothers participants was 9.03 (2004) per 1000 live births while the statewide rate was 10.6 (2002) per 1000 live births. The Resource Mothers report included information from 25 sites serving 87 localities throughout Virginia.

Challenges in Evaluating CHWs

Although each CHW program operates somewhat differently, there are general challenges to evaluating CHWs that would likely impact any program attempting to conduct an evaluation. These challenges stem from the following reasons:

Lack of funding. Many programs that employ CHWs lack sufficient funding to develop and implement an accurate evaluation program.

Lack of resources. Many programs that utilize the services of CHWs are limited in the amount of personnel that they can hire. Many programs do not have the capability to sufficiently train their employees to conduct and prepare evaluation reports.

Characteristics of the program and its services. Many of the services that CHWs provide to their clients are not quantifiable and the impact of these services is not easily measured or recorded. Additionally, CHWs offer many intangible benefits to their clients specifically through education and counseling.

Characteristics of the population served by the program. Individuals who receive services provided by CHWs are often a transient population and enter or leave programs due to changes in location, employment, financial status, or family status.

PROPOSED OVERVIEW OF YEAR TWO OF STUDY

James Madison University, in collaboration with the Study Resolution Committee, requests the opportunity to address the remaining directives outlined in HJR 195 in a report to be submitted to the Governor and the General Assembly no later than the first day of the 2006 Session of the Virginia General Assembly.
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(*1) Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Adult and Community Health. Community Health Advisors/Workers, Selected Annotations and Programs in the United States, Volume III, at xiv (1998).
(*2) S.A. Brown and C.L. Hanis, A Community-Based, Culturally Sensitive Education & Group-Support Intervention for Mexican Americans with NIDDM: A Pilot Study of Efficacy, 21(3) The Diabetes Educator 203 (May – June 1995).
(*3) University of Arizona, The Final Report of the National Community Health Advisor Study, 27-28 (1998).
(*4) Id. at 11-14.
(*5) Joint Legislative Audit & Review Commission. Acclimation of Virginia’s Foreign-Born Population: House Document No.9, at 33 (2004).; see also L.R. Bone et al., Emergency Department Detection & Follow-up of High Blood Pressure: Use & Effectiveness of Community Health Workers,7(1) Am. J. Emer. Med. 16 (1989).; J.F.C. Fund et al., Effect of a Cancer Screening Intervention Conducted by Lay Health Workers Among Inner-City Women, 13(1) Am. J. Prev. Med. S51-57 (1997).; D.O. Fedder et al., The Effectiveness of a Community Health Worker Outreach Program on Healthcare Utilization of West Baltimore City Medicaid Patients with Diabetes, With or Without Hypertension, 13 Ethnicity & Disease 22 (Winter 2003).; D.L. Olds et al., Long-Term Effects of Home Visitation on Maternal Life Course & Child Abuse and Neglect: Fifteen Year Follow-up of a Randomized Trial, 278(8) J. Am. Med. Assoc. 637 (1997).
(*6) Acclimation of Virginia’s Foreign-Born Population, supra note 5 at 33.
(*7) Id. at 16.
(*8) The Final Report of the National Community Health Advisor Study, supra note 3, at 27-28.
(*9) CHIP is a non-profit organization with eleven regional sites across Virginia; See also P.A. Boelens et al., An Approach to Reducing Infant Mortality Rate Through the Utilization of Lay Home Visitors, 37(10) J. Miss. State Med. Assoc. 379 (1999); H. Kitzman et al., Effect of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes, Childhood Injuries, and Repeated Childbearing, A Randomized Controlled Trial, 278(8) J. Am. Med. Assoc. 644 (1997); C. Barnes-Boyd et al., Promoting Infant Health Through Home Visiting by a Nurse-Managed Community Worker Team, 18(4) Public Health Nursing 225 (2001).; M. L. Poland et al., Development of a Paraprofessional Home Visiting Program for Low-Income Mothers and Infants, 7(4) Am. J. Prev. Med. 204 (1991).
(*10) The Final Report of the National Community Health Advisor Study, supra note 3, at 29.
(*11) Id.
(*12) Erica Goode, Minorities are Lacking Mental Health Care, Study Says, Kansas City.Com, Nov. 8, 2004, at http://kcstar.com/item/pages/printer.pat ,local/3accecdb.826.html.
(*13) Id.
(*14) The Final Report of the National Community Health Advisor Study, supra note 3, at 32-34.
(*15) Virginia Center for Health Outreach at James Madison University, Grant Application for Special Initiative Funding submitted to the Office of Rural Health Policy, Health Resources Services Administration, Department of Health and Human Services 1 (2001).
(*16) The Final Report of the National Community Health Advisor Study, supra note 3, at 51-52.
(*17) Id.