Maine Community Health Worker Initiative:
Bibliography – December 2013
Topics Researched/Methods:
The objective of this report is to gain an understanding of current efforts to use community
health workers (CHWs) in a variety of health settings, types of interventions, and program focus.
The report is to be utilized as a resource tool for assessing and integrating community health
workers into the Maine healthcare system as well as illuminating how to accomplish this
effectively and appropriately. The synopses of chosen literature demonstrate characteristics of
CHWs, a wide-range of titles and roles, outcomes, costs of CHW interventions, and examples of
CHW training.
The review is inclusive of all types of studies. Studies from 2000-present were considered
eligible for inclusion and were required to involve participants fulfilling a public health function,
trained and supported in an appropriate way within the context of the intervention. Formal
certification as a CHW was not required. The primary focus (i.e. inclusion criteria) was on the
use and effectiveness of community health workers and examples of integration (of CHWs) into
primary health care teams, including an evaluation of the position in terms of effective delivery,
outcome measures, or financial costs. No outcomes were specifically excluded; preference was
given to quantitative measures of patient outcomes and/or financial effectiveness and savings.
The search strategy concentrated on the electronic databases PubMed and Google Scholar. The
terms used to capture the most relevant research, in various combinations, were “community”,
“outreach”, “health”, “wellness”, “care”, “lay”, “healthcare”, “personal”, “worker”, “specialist”,
“navigator”, “advocate”, “coordinator”, “advisor”, “intervention”, and “reduction”. Related
literature was assessed through citation lists of obtained articles or provided via an online link
through the databases listed above. National agencies and organizations sites were consulted for
publications or reports on CHWs such as the Centers for Disease Control and Prevention (CDC),
American Public Health Association (APHA), Agency for Healthcare Research and Quality
(AHQR) and selected state public health departments. Literature was also obtained through
general internet searches and reviewed websites relevant to CHW roles.
Titles and abstracts retrieved from electronic searches were further screened against the inclusion
criteria stated above, if the abstract matched, the full publication was obtained and
comprehensively reviewed. Studies were ranked according to relevancy and content, while the
highest ranked twenty-six (26) studies appear in the final presentation of literature. Ranking
parameters included studies from states or geographic areas that are comparable in size,
population characteristics, and health circumstances to Maine. Studies highlighted in yellow are
reports determined to be the most applicable to Maine circumstances and useful to understand
ways to integrate CHWs into Maine’s healthcare system.
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Report Summary
What can the Maine CHW Initiative (partners/allies/etc) learn from peer-reviewed
research on CHWs?
Community health worker (CHW) programs that are able to demonstrate cost
effectiveness, sustainability, and improvement of health outcomes commonly focus on at-risk
individuals in their community and high utilizers of health care in terms of emergency
department use for non-emergent issues or unnecessary hospital visits.
High costs and increased health disparities among minority populations or un- and underinsured individuals demonstrates the need for new models of care aimed at addressing these
populations have shown success in improving health equity and other goals.
States with rural and low-population density that are implementing health reform/system
transformation are commonly using models of care that integrate CHWs into patient-centered
medical homes. For these pilot sites, the target population frequently focused on is Medicare
users or people with chronic disease to improve self-management.
CHW programs that focus on developing community accountability and infrastructure to
support healthy living and improve health equity, including working to improve community
advocacy, are components of sustained, successful programs and health reform.
Employing CHWs to add input and assist in the creation of programs are associated with
positive interventions that have minimal barriers to success because CHW input is helpful to
design and adaptation of culturally tailored interventions.
Use of an electronic database for statewide health information exchange between
involved agencies to connect all levels of the care team and enhance patient access is an essential
component to avoid service duplications and assist the success of these new models of care.
Frameworks/intervention that have already been developed (ex. Pathways) and have
demonstrated success in their strategy to implement should be used as resources for program
design or project development.
Professional advisory board recommendations for best practices and strategies of
effective CHW programs are increasingly available and can serve as guideposts for policy
development, program design and curriculum development/adaptation. .
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1. Angus, L., Cheney, C., Clark, S., Gilmer, R., & Wang, E. (2012). The role of nontraditional health workers in Oregon’s health care system: Recommendations for core
competencies and education and training requirements for community health workers,
peer wellness specialists and personal health navigators. Oregon Health Authority.
“NTHW report, OR”
 Report developed by the Oregon Health Policy Board (OHPB) and their NonTraditional Health Worker (NTHW) subcommittee to define the roles of NTHWs,
show evidence of cost-savings and the effectiveness of this type of service
delivery. In 2011, the Oregon Legislature passed legislation to develop a system
that will deliver health care and services to Oregonians though a coordinated care
organization model. This legislation mandated development of NTHW force.
Community health workers, peer wellness specialists and personal health
navigators all fall under the title of the NTHW. They discuss their
recommendations for NTHW roles, competencies, and education/training
requirements for others.
2. Ashburner, J. M., Gamba, G., Oo, S., & Richter, J. M. (2009). A culturally tailored
navigator program for colorectal cancer screening in a community health center: a
randomized, controlled trial. Journal of General Internal Medicine, 24(2), 211-217.
“Cancer screening RCT, MA”
 Evaluates a culturally tailored intervention to increase colorectal cancer (CRC)
screening rates among low-income, non-English speaking patients. Focused on
patients from the Massachusetts General Hospital Chelsea HealthCare Center, 5279 years of age overdue for CRC screening and compared intervention to usual
care group. Intervention patients received educational material with an
introductory letter followed by phone or in-person contact by a CHW who helped
to created individually tailored interventions. Intervention patients were more
likely to undergo CRC screening than control patients.
3. Beckham, S., Bradley, S., Washburn, A., & Taumua, T. (2008). Diabetes management:
utilizing community health workers in a Hawaiian/Samoan population. Journal of Health
Care for the Poor and Underserved, 19(2), 416-427.
“CHW, Diabetes mgmt, Hawaii”
 Examines effectiveness of CHWs on diabetes management among population of
primarily Native Hawaiian and Samoan ethnic minority on the island of O’ahu in
the State of Hawaii through the Wakiki Health Center. CHWs provided diabetes
self-management education and referrals to registered dietitians if requested or
determined to be needed. Compared HbA1c readings of participants with diabetes
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with and without CHW intervention. Study participants had a 2.2 mean reduction
in HbA1c compared with .2 mean reduction in control group. CHWs were
evaluated as having a positive impact on diabetes management.
4. Brownstein,NJ, Hirsch, GR, Rosenthal, Rush, C. Community Health Workers“101” for
Primary Care Providers and Other Stakeholders in Health Care Systems. (2011). Journal
of Ambulatory Care Management, 34(3), 210–220.

Article is primer for ambulatory care providers and other stakeholders interested in both
learning more about CHWs but also how to successfully integrate CHWs into multidisciplinary care teams. A literature review of the efficacy of the CHW model is provided
along with an overview of unique contributions and characteristics of the CHW model
across preventive screenings, health education, care management and health mediation.
The PCMH expectations of patient engagement, cultural competency, continuity in
communications and more direct connections to the community all parallel the strengths
of CHWs . The article introduces essential considerations for primary care practiioners
interested in utilizing a CHW on their team basic guidance on recruitment, supervision,
and working environment.
5. Bryan LGH Medical Center: ED Connections(2009). Urgent Matters.
Hospital partnership offers pathways-based case management program, leading to
enhanced access to appropriate care for the uninsured.(2013). AHRQ Health Care
Innovations Exchange.
“Lincoln ED Connections - pathways model results”
“Lincoln ED Connections Summary, NE”
 Lincoln ED Connections is a case management program focused on helping
uninsured and underinsured people with a history of using the emergency
department for nonemergent issues in Lincoln, Nebraska. These individuals are at
high risk for poor health outcomes due to untreated or undertreated chronic
conditions. The program uses case managers with support from a database and
tracking system to enhance patient access to medical homes where they can
receive regular health care, and other community resources to address barriers to
care. This program enhanced health access to appropriate care, individual health
functioning, and a significant decline in emergency department use and cost for
nonemergent conditions. In the first 3 years of the program, the two sponsoring
hospital reported a 67% decline in ED costs related to nonemergent care, savings
have enabled the hospitals to continue funding the program even after initial grant
funding ran out.
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Bibliography – December 2013
6. Community Health Access Project. (2001). Pathways: Building a Community Outcome
Production Model. Unpublished manuscript.
“Pathways Potential”
 Describes the Community Health Access Project (CHAP) in Richland County,
Ohio and its efforts in their mission to improve health and social outcomes
through the support of community health care workers. CHAP focused on two
neighborhoods with unusually high rates of low birth weight (LBW) babies. CHW
reached out to at-risk individuals through home-visits to provide information on
the program, then followed with development of a personal care plan and linked
the participants with other care coordinators. CHW received salaries and benefits.
The low birth weight rate in the two targeted areas fell significantly after program
implementation and was reported as very promising.
 CHAP uses the Pathways Model, a strategy to track and improve measureable
changes as the CHWs help their clients through the system in dealing with
specific health and social problems. Pathways is a pre-designed program
framework that uses community health workers, nurses, and social workers as
care coordinators to connect the at-risk individuals to a care team and produce a
healthy outcome. The program has 3 overarching principles of identifying those at
greatest risk, treat using health care and social service resources, then measuring
outcomes and evaluating benchmarks. It also focuses on avoiding service
duplication through the use of a “Community Hub” or network of related agencies
that are involved in providing the health care to the target population. The report
shows beginning results of studies utilizing the Pathways model, one being to
reduce low birth weight rates in babies, across the state of Ohio.
7. Community health workers: A review of program evolution, evidence on effectiveness and
value, and status of workforce development in new england(2013). Institute for Clinical
and Economic Review.
“CEPAC CHW Final Report”
 Literature review and report on current CHW utilization in New England and an
assessment of their effectiveness, quality, and recommendations for the future of
the workforce. The report summarizes evidence of CHW program impact on
health outcomes and costs to identify successful components of this type of
intervention. It examines budgetary impact of CHW programs and provides
insight from policy experts on best practices.
8. Diaz, J. (2012). Social return on investment: Community health workers in cancer
outreach. Saint Paul, Minnesota: Wilder Research.
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Maine Community Health Worker Initiative:
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
“CHW investment return report”
A toolkit developed by the American Cancer Society: Midwest division that
discusses the return on investment in community health workers in cancer
outreach. The goal of this economic analysis is to place economic outcomes
generated by CHWs in a cost benefit framework for measuring the Return on
Investment (ROI) of this type of intervention. The report supports that the work of
CHWs in cancer outreach may reduce mortality rates; and low mortality rates
imply more years of productive health. Also, CHWs provide the education and
guidance to allow individuals to use the health care system more efficiently. The
investment in CHWs produces changes in health behaviors with substantial
economic value for society.
9. Dickson, L., & Yahna, R. M. (2012). Report on community health worker programs.
Center for Rural Health.
“CRH Report on CHW prog”
 The Center for Rural Health’s review of current CHW programs and certification
techniques in Minnesota, Massachusetts, New Mexico, New York, Colorado,
Washington, and Wisconsin. Each section covers the status of CHW programs in
the state, the title used to describe the position, the settings where CHW work,
assessment tools, state policy on reimbursement for services, the leading interest
group that developed initial programs, if there is any formal training or
certification, and if there is an established curriculum.
10. Felix, H. C., Mays, G. P., Stewart, M. K., Cottoms, N., & Olson, M. (2011). Medicaid
savings resulted when community health workers matched those with needs to home and
community care. Health Affairs, 30(7), 1366-1374.
“Medicaid savings with CHW, AK”
 This journal article highlights the Arkansas Community Connector Program,
which uses specially trained community health workers and the Tri-County Rural
Health Network to identify people in three disadvantaged counties to connect
them with Medicaid home and community-based support. Results have been a
23.8% average reduction in annual Medicaid spending per participant from 20052008. Net three-year savings to Arkansas Medicaid program equaled $2.619
million.
11. Katula, J. A., Vitolins, M. Z., Morgan, T. M., Lawlor, M. S., Blackwell, C. S., Isom, S.
P., ... & Goff Jr, D. C. (2013). The Healthy Living Partnerships to Prevent Diabetes
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Bibliography – December 2013
Study: 2-year outcomes of a randomized controlled trial.American Journal of Preventive
Medicine, 44(4), S324-S332.
“Diabetes RCT, NC”
 Examines the impact of a 24-month, community-based diabetes prevention
program on fasting blood glucose, insulin, insulin resistance as well as body
weight, waist circumference, and BMI in the second year of follow-up. Study
participants represent the racial composition of the population of Forsyth County,
North Carolina. Compares a lifestyle weight-loss (LWL) program to enhance
usual care condition (UCC) in participants with pre-diabetes. The LWL program
was led by CHWs, and the UCC intervention involved registered dietitians.
Analysis reports that LWL participants experienced greater decreases in outcome
measures enough to conclude the intervention was effective.
12. Krantz, M. J., Coronel, S. M., Whitley, E. M., Dale, R., Yost, J., & Estacio, R. O. (2013).
Effectiveness of a community health worker cardiovascular risk reduction program in
public health and health care settings. American Journal of Public Health, 103(1), e19e27.
“Cardio risk reduction, rural CO”
 Program evaluation of use of CHW to prevent coronary heart disease (CHD) and
improve the risk in public health settings. CHWs provided point-of-service
screening, education, and care coordination to residents in 34 primarily rural
Colorado counties. The results from 2010 to 2011 showed statistically significant
improvements in diet, weight, blood pressure, lipids, and risk score. Conclusions
of the study were that a CHW-based program in health care setting can improve
CHD risk.
13. Krieger, J. W., Takaro, T. K., Song, L., & Weaver, M. (2005). The Seattle-King County
Healthy Homes Project: a randomized, controlled trial of a community health worker
intervention to decrease exposure to indoor asthma triggers. Journal Information, 95(4).
“Asthma RCT, WA, Krieger study”
 Assessed effectiveness of community health worker intervention on reducing
exposure to indoor asthma triggers in King County, Washington. RCT with 1-year
follow up. CHWs provided in-home environmental assessment, education,
support for behavior change, and resources. Participants were assigned to highintensity (7 visits, full resources) or low-intensity (single visit, limited resources).
Pediatric asthma caregiver quality-of-life scores and asthma-related urgent health
services use significantly improved more for the high-intensity group. Actions to
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reduce triggers were greater in the high-intensity group. Projected net-savings per
participant among high-intensity relative to low-intensity group were $189-$721.
14. Lawlor, M. S., Blackwell, C. S., Isom, S. P., Katula, J. A., Vitolins, M. Z., Morgan, T.
M., & Goff Jr, D. C. (2013). Cost of a group translation of the diabetes prevention
program: healthy living partnerships to prevent diabetes.American journal of preventive
medicine, 44(4), S381-S389.
“Cost AYS, Diabetes pvnt, NC”
 Describes associated costs of Healthy Living Partnerships to Prevent Diabetes
(HELP PD) trial, a 24-month RCT testing the impact of a weight loss intervention
using a diabetes educational program focused on blood glucose and body weight.
Delivered by community health workers to prediabetics in Forsyth County, NC.
Measured direct medical cost, direct nonmedical costs, and indirect costs over
study period. Analysis concluded the program was delivered effectively and with
reduced cost.
15. Michael, Y. L., Farquhar, S. A., Wiggins, N., & Green, M. K. (2008). Findings from a
community-based participatory prevention research intervention designed to increase
social capital in Latino and African American communities. Journal of Immigrant and
Minority Health, 10(3), 281-289.
“Power for Health CHW Intervention, OR”
 A participatory research intervention using CHWs and “popular education” to
identify and address health disparities in African American and Latino
communities in Multnomah County, Oregon. Assessment of participant’s social
capital, self-rated health, and depressive symptoms at base-line and end of
intervention are included. Social support and self-rated health improved,
depressive symptoms declined. Popular education is defined by the study as “an
interactive and empowering method of teaching”. CHWs received 80 hours of
initial training, then 80 hours of ongoing training.
16. Minyard, K., & Fund, C. (2007). Lessons from local access initiatives: Contributions and
challenges Commonwealth Fund.
“Lessons/review of CHW Programs”
 Report on five case studies of community health initiatives that all seek to
improve access and coverage for the most at-risk population to be uninsured. The
report identifies success factors, barriers, and challenges that occur when trying to
replicate community health initiatives. They also discuss policy implication and
general contributions of the various case studies.
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17. Mirambeau, A. M., Wang, G., Ruggles, L., & Dunet, D. O. (2013). A Cost Analysis of a
Community Health Worker Program in Rural Vermont. Journal of Community Health, 18.
“Cost Report, NP&CHW Program, Rural VT”
 Program cost assessment of Community Connections team focused on improving
quality of life in a rural service area in northeast Vermont. The program is the
regional hospital’s pilot community health team program model. The analysis
determines how much funding the public health system will need to set up and
operate similar programs. Focuses on personnel and operations, no effectiveness
conclusions, only numbers on total program costs.
18. Nielsen, M., Langner, B., Zema, C., Hacker, T., & Grundy, P. (2012). Benefits of
Implementing the Primary Care Patient-Centered Medical Home.Washington: PatientCentered Primary Care Collaborative.
“PCMH National Report”
 National survey and report on cost savings and impact of the Patient Centered
Medical Home (PCMH) model. This model is being used by a number of states
that incorporate the CHW position into its framework for patient outreach and
navigation. The paper reviews data from PCMH initiative nationwide, provides a
summary of new and updates results from the past two years, including cost and
quality outcome data. It also defines the features of a PCMH and shows data to
demonstrate these features and how they contribute to lower costs, improved care,
and better health outcomes. The findings in this report demonstrate how the
PCMH model improves health outcomes, enhances patient and provider
experience of care, and reduces the expensive, unnecessary hospital and
emergency department utilization.
19. Paskett, E., Tatum, C., Rushing, J., Michielutte, R., Bell, R., Foley, K. L., ... & Reeves,
K. (2006). Randomized trial of an intervention to improve mammography utilization
among a triracial rural population of women. Journal of the National Cancer
Institute, 98(17), 1226-1237.
“LHA Mamm Prev, rural NC”
 Use of lay health advisor (LHA) intervention based on behavioral theory, to
assess and improve mammography utilization among a tri-racial, rural, lowincome population in Robeson County, North Carolina. Rates of mammography
use were compared after 12-14 months, and base-line and follow up surveys were
used to obtain information on demographics, risk factors, barriers, beliefs, and
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knowledge about mammography. Women in the LHA group had higher
mammography use and were more likely to have better belief scores and reduced
barriers to follow-up.
20. Redding, M. Michigan Pathways Project Links Ex-Prisoners to Medical Services,
Contributing to a Decline in Recidivism.
Michigan Prisoner ReEntry Initiative Progress Report(2010). . Lansing, Michigan:
Public Policy Associates, Inc.
“MI Prisoner CHP – AHRQInnovationsExchange”
“MI Prisoner Reentry In_2010_Progress_Report”
 A statewide initiative across all Michigan counties with the aim to help newly
released prisoners access services that facilitate successful reentry into the
community and decline recidivism rates. Community health workers link newly
released prisoners to medical homes, help access needed medications and primary
or specialty care, as well as ensure to obtain medical records on release from
prison. These are done through prison “in-reach” sessions about twice a week and
a meeting with a medical navigator to conduct a personal health assessment. The
program appears to have contributed to a significant decline in recidivism rates
(46% to 20%), provided more than 1,700 individuals with access to medical
services, and improves parole success rates. There is an assumed positive return
on this investment since the program appears to be highly cost-effective.
(Spending on prisons declined $293 million annually). Use of pathways model.
21. Schlenker, T. L., Baxmann, R., McAvoy, P., Bartkowski, J., & Murphy, A. (2001).
Primary prevention of childhood lead poisoning through community outreach. Wisconsin
Medical Journal, 100(8), 48-54.
“Lead Outreach, WI”
 The Community Lead Outreach Project (CLOP) attempts to identify children 6
months to 6 years old with elevated blood lead levels (BLL) within the service
area of a community health center near the south side of Milwaukee, Wisconsin.
A team of community outreach workers led by a nurse-coordinator visit families
in their homes over a 4-year period to provide environmental assessments, lead
poisoning prevention, repair hazards and draw blood samples. Average BLLs
declined by 24% over 2 years, the program is evaluated as successful.
22. Schwartz, R., Powell, L., & Keifer, M. (2013). Family-Based Risk Reduction of Obesity
and Metabolic Syndrome: An Overview and Outcomes of the Idaho Partnership for
Hispanic Health. Journal of Health Care for the Poor and Underserved, 24(2), 129-144.
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
“Obesity Prvt prog, rural ID”
Details approach in rural Idaho using promotores as lay health outreach workers
to promote healthy eating and exercise behavior in the Hispanic community, to try
and reduce the risks of metabolic syndrome among these families as well as
increase community support and infrastructure for healthy living. Report included
statistically significant reductions in weight, BMI, metabolic syndrome risk, A1c,
glucose, blood pressure, and cholesterol from pre- to post-intervention and one
year follow up.
23. Spencer, M. S., Rosland, A. M., Kieffer, E. C., Sinco, B. R., Valerio, M., Palmisano, G.,
& Heisler, M. (2011). Effectiveness of a community health worker intervention among
African American and Latino adults with type 2 diabetes: a randomized controlled
trial. American Journal of Public Health,101(12), 2253.
“Diabetes RCT, Detroit, MI”
 Assessment of CHW intervention to improve glycemic controls among African
American and Latino adults in Detroit, Michigan, recruited from two health
systems. CHWs provided participants with diabetes self-management education
and regular home visits, and accompanied them to a clinic visit during the 6month intervention period. The intervention group’s mean HbA1c value
improved while the control group stayed the same. Intervention participants also
had improved self-reported diabetes and understanding compared with control
group. CHW teams are effective in their team roles in culturally appropriate
health care delivery.
24. Support for community health workers to increase health access and to reduce health
inequities(2009). (APHA Policy Statement. Washington, DC: American Public Health
Association.
“APHA support CHW development”
 Define CHW roles and responsibilities, and the unique position they have in a
community. Recognizes the need to provide training or certification and notes on
the body of research that indicates the effectiveness of CHWs in improving
quality of care and individual health outcomes. Recommends the development of
states integrating CHWs into the health system.
25. Tillman, T., Gilmer, R., & Foster, A. (2011). Utilizing doulas to improve birth outcomes
for underserved women in oregon. Portland, Oregon: Oregon Health Authority.
“Doula Report on improving birth outcomes, OR”
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
Defines the responsibilities of doulas, who are certified professionals that provide
personal, non-medical support to women and families throughout a woman’s
pregnancy, childbirth, and postpartum experience. Oregon Health Authority
recognize a pattern of disparities in birth outcomes between women of color and
the white Non-Latino population, and based on research, doulas have been an
effective strategy in reducing birth outcome inequities. Summary of current
models that utilize doulas to address inequitable birth outcomes are included.
Concludes that integrating doulas into Oregon’s health system may result in
healthier births for women and children, while also mitigating long term costs
associated with poor birth outcomes.
26. Vermont Blueprint for Health 2012 Annual Report(2013). . Williston, VT: Department of
Vermont Health Access.
Bielaszka-DuVernay, C. (2011). Vermont’s blueprint for medical homes, community
health teams, and better health at lower cost. Health Affairs, 30(3), 383-386.
“VT Blueprint for Health 2012 Report” and
“Report on Blueprint efforts, VT”
 Shows the impact of Vermont’s health care reform program upon utilization and
associated costs of health care and the uptake of education and patient activity.
Describes cumulative growth trends of the number of participating primary care
practices in this program, the character and reach of Vermont Community Health
Teams, and the implementation of support services for the elderly and disabled
Medicare beneficiaries. Highlights one service area to demonstrate their success
with the new model of care. Vermont Blueprint is a statewide public-private
health initiative that focuses on universal coverage, a delivery system built on
medical homes and community health teams, emphasis of prevention, statewide
health information exchange, and an evaluation infrastructure to support ongoing
improvement with quality and cost effectiveness as guiding principles. The
Blueprint strives to achieve sustainable health reform centered on the needs of
patients and families. Key innovations are utilizing community health teams work
with primary care providers, patient centered medical homes, and a central health
registry that captures all patient data.
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