Community Health Workers:

A Health Home Delivery Model for the 21st Century

Health Home is Where The Heart Is

The University of Oklahoma-Tulsa School of Community Medicine & Anne and Henry Zarrow School of Social Work

CHWs Are The Future

CHWs are key to future cost containment in underserved communities (US DHHS, March 2007). March 2007 CHWs were made an official health care profession in 2010 (US Bureau of Labor, 2010).

Overview
1. Who makes a good Community Health Worker (CHW)? 2. How do we find good CHWs? 3. How will CHWs save money while improving care?
Hire for community commitment and train for skill.

Who makes a good Community Health Worker?

Community Health Workers should be: 1.) members of the communities where they work; 2.) selected by the communities; 3.) answerable to the communities for their activities; 4.) supported by the health system but not necessarily a part of the traditional Doc in a Box model; 5.) professionally trained specific to their area of focus.
World Health Organization, Policy Brief, 2007

OHCA CHW Pilot

Establishment of Alternate Non-Emergency Services Providers Lessons learned:
1. 2. 3. 4. 5. 6. Patients slow to modify treatment-seeking behavior. We need pre-determined community-based selection criteria. High turnover limited relationship-building between CHWs and patients. Patient contact in community settings is more effective than the ER. Too much time between ED visit and follow-up contact by CHW. No pre-determined data collection and analysis limited monitoring and evaluation of outcomes.
(OHCA Quarterly Report, 2010)

Maryland CHW Program

ER visits declined by 40%. Medicaid reimbursements declined by 27%. Total annual savings of $262,080 for a population of 117 patients, with improved quality of life (QOL) indicating cost effectiveness (Fedder, 2003). CHWs were selected based on their extensive community experience and residence in the catchment area. Careful attention was paid to the selection process.

Denver Community Health Voices (2003).

An increase in primary and specialty care visits, and a decrease in emergency room visits; A savings of $95,941 annually for a population of 591 patients managed by 2CHWs, reflecting a ROI of 2.28:1; Denvers CHWs are lay people interested in health who are representative of the communities they serve (Whitley, 2011).

Native Sisters Lay Health Advisors Network (2010)

Native Sisters contacts lead to a 42% increase in women receiving mammograms over the control group. Lay health advisers earn up to $15 per hour. Additional costs include automobile insurance and expenses. The program identifies and recruits bilingual and/or bicultural American Indian who have the respect of the community, regularly model healthy behaviors, and possess a passion for helping community members.

Why Did These CHWs Programs Work??

Hiring community members assured a fit between the message and the messengers. Used existing social capital to reduce program costs. The CHWs were seen as trustworthy by their patients and thus were able to communicate meaningfully with them about behavioral change.

Experience Based Expertise

A Lived Experience Based Expertise of the Community:
We say that those referred to by some other analysts as lay experts are just plain experts albeit their expertise has not been recognized by certification; crucially, they are not spread throughout the population, but are found in small specialist groups. Instead of using the oxymoron, we will refer to members of the public who have special technical expertise in virtue of experience that is not recognized by degrees or other certificates as experience-based experts. (Collins and Evans, 2006).

Funding for this program was provided by the Robert Wood Johnson Foundation and the Tulsa Community Foundation

CHW as Educator

Community
Academia de la Salud
Screenings

Health Fairs

Promotora (CHWs)
Apartments
Libraries

Community Agencies

Homes

CHW Worker as case manager/navigator

Geographic Community (73111)

Training
Low acuity ER Patient Low Acuity ER Patient

CHWs
Low acuity ER Patient Low acuity ER Patient Low acuity ER Patient Low acuity ER Patient

A Health Home is Where the Heart Is

An Effective Health Home is not the traditional Doc in a Box model.

Home is a localizable idea and a realization of ideas which starts by bringing some space under control that creates feelings of familiarity and safety (Douglas, 1991).
CHWs provide experience based outreach which is safe and familiar to the patient.

Our Pilot Model: De-branding the ER

OU Medical Resident OU Medical Resident

Facilitator (Social Work)

How do we find these special CHWs?

Community Based Participatory Research (CBPR) - involves members of the target population at every stage of the research process. A collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community and has the aim of combining knowledge with action and achieving social change... Kellogg Foundation, Community Health Scholars Program

North and West Tulsa

Long Term
Every Medical Home has a CHW(s) drawn from target communities. CHWs link up with nurses in the SoonerCare HMP program.

Outcomes
1.) Reduced costs stemming from re-routing

low acuity ED utilizers to health homes. 2.) Economic Development in MUA through stipends for CHWs. 3.) Increased cultural competence within health professionals who interact with CHWs. 4.) Good PR. This model of CHWs fits Oklahomas frontier values of self reliance.

References
Community Health Worker National Workforce Study, United States Department of Health and Human Services (March 2007). Collins, H.M., Evans, R. (2002) The Third Wave of Science Studies: Studies of Experience and Expertise. Social Studies of Science 32:235. Douglas, M. (1991) The Idea of Home: A Kind of Space. Social Research 58(1):287-307. Fedder Denver Health Community Voices (2010). National Community Health Advisor Study (1998). Service C., Salber E. (eds.): Community Health Education: The Lay Health Advisor Approach. Durham, NC, Duke University Health Care System, 1979.