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May 15, 2020
Primary Care Transformation Delivery System Reform Medicaid Social Determinants of Health COVID-19
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One day last month, New York City Health and Hospitals community health worker Kasha Caesar got a call from a distraught older woman named Eleanor. Eleanor’s husband was critically ill with COVID-19 and on a ventilator. Eleanor had been told to self-isolate, but she was beside herself with worry about her husband and wanted to go to the hospital. She also confided that she was running low on food. Kasha responded immediately, making calls to local community organizations and setting up a free emergency food delivery. She also held a three-way telephone call with Eleanor and the hospital to connect Eleanor to her husband’s care team for daily updates. Perhaps most importantly, she was a listening ear and a source of emotional support during a stressful time. Eleanor called Kasha a “Godsend that allowed her to make it through this crisis.”
Community health workers like Kasha—trusted individuals from local communities specially hired and trained to support disadvantaged individuals and families—are a critical part of the US COVID-19 response in many areas. Community health workers can help to reopen our economy and restore normalcy in our communities through public health messaging and contact tracing, while also addressing broader social, economic, behavioral, and preventive health needs.
Kasha may sound one-of-a-kind but she belongs to a workforce of about 50,000 individuals across the United States. They are typically employed by community organizations, health systems, or public health departments with grant funding or through limited Medicaid waivers or demonstration projects. A growing body of scientific evidence supports the effectiveness of community health workers to address underlying socioeconomic issues, improve chronic disease control, promote healthy behavior, improve access to care and reduce costly hospitalizations. Several randomized clinical trials of IMPaCT—a standardized model for hiring, training, and deploying community health workers—have demonstrated that community health workers can improve health and the quality of health care, reducing costly hospitalizations. A recent cost analysis from a randomized trial involving Medicaid beneficiaries living in high-poverty neighborhoods and diagnosed with two or more chronic conditions showed that this model saves Medicaid $4,246 per beneficiary. These outcomes and costs savings are likely related to specific program elements including hiring guidelines, structured supervision, manageable caseloads, integration with clinical teams, and a holistic approach to patient support.
Community health workers can help to reopen our economy and restore normalcy in our communities through public health messaging and contact tracing, while also addressing broader social, economic, behavioral, and preventive health needs.
Now experts are recommending that US policymakers such as Congress, the Centers for Medicare & Medicaid Services (CMS), and state departments of health consider payment strategies to rapidly scale up the use of community health workers as part of COVID-response—and incorporate them into our health system long term. To do this effectively, however, CMS and states need standards for the community health worker profession to ensure quality and serve as guardrails for federal funding.
The National Committee for Quality Assurance (NCQA), in partnership with the Penn Center for Community Health Workers, is leading a multi-stakeholder effort to create these evidence-informed standards. NCQA is convening an advisory panel composed of members from organizations like the National Association of Community Health Workers, Kaiser Permanente, and the Johns Hopkins University that is reviewing the global and domestic experience and implementation science on community health workers and developing standards. The advisory board will include a number of grassroots community health workers. In addition, a reactor panel of patients and community health workers will review draft standards and provide feedback.
These standards will address domains that appear to be associated with high-quality programs:
The standards, which should be released by the fall, can ultimately be used by state health departments, Medicare, and Medicaid, as well as private health plans as they are determining which health providers and community-based organizations that employ community health workers to include in their networks. The standards can also be used by community health workers to advocate for themselves.
There are, of course, risks associated with standards development. In health care, the concept of standards is often associated with training, certification, and licensure. This can often evolve into rigid definitions of scope of practice and narrow billing codes for service and episodic reimbursement. Several states that have adopted the approach of certifying community health workers based on their completion of an approved training course; however, a recent evidence review by the Agency for Healthcare Research and Quality suggests that these training-based certifications do little to improve quality. In fact, these certification requirements may have the unintended consequence of weeding out “natural helpers” who may be nervous about standardized testing or unable to afford courses or certification fees.
Critically, the proposed NCQA standards are not focused on how community health workers are trained or intended to generate an itemized scope of practice. Rather the goal is to provide simple, evidence-informed guardrails for the systems in which community health workers function, including hiring of authentic community members and the preservation of holistic, grassroots work practices. We hope that a systems approach developed by an advisory board composed mainly of community health workers will guard against over-professionalization or coopting of the workforce.
It is also our hope that national standards will allow national policymakers, state and local health departments, community-based organizations, and health systems to invest in a cadre of community health workers who not only can stem the tide of COVID-19 but also build a foundation for lasting public health.
Shreya Kangovi, MD, is executive director of the Penn Center for Community Health Workers and Margaret O’Kane is president of the National Committee for Quality Assurance.
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