Community Health Workers
History, Identity, Financing
Creating a Healthy Community
P2 Collaborative of WNY Conference
September 25, 2009
Buffalo, New York
Sergio Matos, CHW
Community Health Worker Network of NYC - Executive Director
Columbia University - Director for CHW Development
COMMUNITY HEALTH WORKER
NETWORK OF NYC
We want freedom...
We want justice and peace...
We want completely free healthcare for all people...
We want decent housing for all people...
We want education that teaches us our history and our
role in present-day society...
We want land, housing, education, food and clothing...
We want the power to determine the destiny of our
communities...
We want opportunity and full employment...
We want an immediate end to all wars of aggression...
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Overview
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CHW history
CHWs in the US
The CHW identity
CHW effectiveness
The future of CHWs
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHW – A tradition
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Health Promoters in Latin America
Village Health Workers in Mexico, Africa, Indonesia and
Europe
Feldshers in Russia
Barefoot Doctors in China
Community Activists in NGOs, CBOs and FBOs
Community Health Representatives in Native American
Nations
Neighborhood Health Representatives in U.S.
Note: CHWs is not a medical model. It is a social
concept that has always been a piece of society.
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Background
World Health Organization, 1978
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Primary health care approach adopted as most effective way to
achieve health for all - Prevent illness & promote health
Names CHWs as integral member of healthcare teams
Guiding Principles
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Accessibility, public participation, health promotion, intersectoral
cooperation
World Health Organization, 1987
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Providing sophisticated hospitals and highly trained staff is not the
most efficient way to improve health
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Guiding principle to utilize CHWs
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Support communities to identify their own capacities and health needs
Help people solve their own health problems
Extend health services to where people live and work
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHWs in the U.S.
1960s - Community Health Representatives - NACHR
1970s - Neighborhood Health Representatives in Unites States
1978 - Community Health Workers - WHO
1998 - Community Health Advisers – National Community Health
Advisor Study
2002 - American Public Health Association Supports CHWs
2004 - Institute of Medicine Supports CHW (Unequal Treatment)
2005 - WHO 3-by-5 Initiative demands tens of thousands of CHWs
2009 - Executive Office of President of the U.S. publishes 2010
Standard Occupational Classification to include unique CHW
classification (soc 21-1094)
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Community realities CHWs find
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Mistrust of healthcare system
Fear of government, police and authority
Terror of Homeland Security
Poverty & economic insecurity
Experience that personal information is
shared – informed consent
Past experience with healthcare system
Note: These social and psychosocial pressures have health
consequences that then present in the medical setting – but
have no medical solution.
COMMUNITY HEALTH WORKER
NETWORK OF NYC
What do CHWs do?
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Respond to individuals, family & community
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Create change
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Promote liberation through education & organizing
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Promote development, freedom and independence
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Develop social networks and supports
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Organize communities
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Advocate for justice and equality
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Improve maturity of institutions
COMMUNITY HEALTH WORKER
NETWORK OF NYC
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Too many titles
Case Worker, Community Follow-up Worker, Community Health
Advocate, Community Health Adviser, Community Health Aide,
Community Health Outreach Worker, Community Health Rep.,
Community Health Specialist, Community Health Worker, Counselor,
Eligibility Worker, Family Health Promoter, Family Support Worker,
Health Advisor, Health Facilitator, Health Information Specialist, Health
Promoter, Health Liaison, Health Specialist, Outreach Worker, Outreach
Specialist, Patient Navigator, Peer Counselor, Peer Educator, Peer
Health Advisor, Peer Health Educator, Peer Worker, Promotor(a), Public
Health Aide, Public Service Aide, Social Worker Assistant, Addiction
Treatment Specialist, HIV/AIDS Educator, HIV Disclosure Counselor,
Mental Health Aide, Nutrition Assistant, Pre-Perinatal Health Specialist,
Volunteer, Women’s Health Specialist
Addiction Treatment Specialist, HIV/AIDS Educator, HIV/STD Prevention
Counselor, HIV Risk Assessment/Disclosure Counselor, Mental Health
Aide, Nutrition Assistant, Pre-Perinatal Health Specialist, Women’s
Health Specialist
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHW organizing
Community Health Worker Network of NYC
 An independent professional association of
CHWs.
 Mission – To establish a CHW identity and
assume leadership of policy and practice
issues relevant to our field.
 Non-member organization
 CHW-led governance structure
 Evolved a policy and training focus
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHWs are…
Community Health Workers are trusted
members of the communities they serve
and function as frontline health and social
service providers and community
organizers.
Community Health Workers function within the
cultural, linguistic, social, spiritual and economic
value systems of the community.
*Endorsed by The Community Health Worker Network of NYC
COMMUNITY HEALTH WORKER
NETWORK OF NYC
National CHW definition
Community Health Workers (CHWs) are frontline public health
workers who are trusted members of and/or have an unusually
close understanding of the community served. This trusting
relationship enables CHWs to serve as a liaison/link/intermediary
between health/social services and the community to facilitate
access to services and improve the quality and cultural
competence of service delivery. CHWs build individual and
community capacity by increasing health knowledge and selfsufficiency through a range of activities such as outreach,
community education, informal counseling, social support and
advocacy.
- Endorsed by American Public Health Association, 2008
- Submitted to US Dept of Labor, 2008
- Adopted by Community Health Worker Network of NYC, 2008
COMMUNITY HEALTH WORKER
NETWORK OF NYC
How do CHWs function?
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Trust & Respect
Shared Life Experiences
Understanding & Empathy
Compassion
Creativity/Resourcefulness
Empowerment Approach vs. Service Delivery
Self-reliance, Self-sufficiency
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHW roles — a continuum
Service
Functions
Development
Functions
2° and 3° Care
1° Care
Mobilizing community members
to seek services
Mobilizing community members
to create healthy community
Narrow Disease Focus
Holistic, ecological approach
Extenders of health care system
Community change agents
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Challenge of priorities
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHW effectiveness
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Reduce ER visits & preventable hospitalizations
Increase primary care and well care visits
Reduce cost of chronic disease care – asthma,
diabetes, CVD, HIV/AIDS
Improve pre- and perinatal care & birth outcomes
Reduce health disparities – immunizations in NYC
Increase health insurance enrollment
Positive effect in interventions – STDs, Smoking
cessation, Violence, Teen pregnancy
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Evidence-base on CHWs
Davis et al 2007: CHWs can focus on the “how” of diabetes
management, yet we do not document sufficiently exactly what
CHW do with patients.
Norris et al. 2006: CHWs are effective as team members to promote
improvements in participant knowledge and behavior, but many
gaps in knowledge about the best setting/niche for their
contributions to the care of persons with diabetes. Too few studies
document health outcomes. Only 8 RCTs, and only 2 with strong
designs.
Babamoto KS et al. 2009: Improving diabetes care and health
measures among Hispanics using community health workers:
results from a randomized controlled trial. Health Educ Behav.
Gary TL et al. 2004: A randomized controlled trial of the effects of
nurse case manager and community health worker team
interventions in urban African-Americans with type 2 diabetes.
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Evidence-base on CHW
effectiveness
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Swider 2002: CHWs improve access to care, but few studies
and inclusive results regarding health literacy, behavior
change, and selected health outcomes. Need for clarity and
documentation of role of CHWs.
Nemcek and Sabatier 2003: Quality of Care indicators key
to assessing CHW effectiveness. Emphasis has been on
health care utilization, risk reduction, and patient education,
less on health outcomes.
Lewin 2005: Very few RCTs, but these show effectiveness of
CHW to improve outcomes for selected problems
(immunization, maternal/infant care). Need for more RCTs.
CDC
Ongoing RCTs in NYC
COMMUNITY HEALTH WORKER
NETWORK OF NYC
CHWs improving health care
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CHWs are trusted by the people they serve
Access to truthful and accurate information – improve institutions
Relationship guided by client priorities
Improve access to and use of routine medical care services
Improve client recruitment and retention
Improve cultural and linguistic appropriateness of health care
systems and services
Facilitate improved communication with providers – honest
accurate information
Assistance navigating complicated Tx regimens
Provide education about health promotion & disease
prevention/management
Promote healthier lifestyle behaviors - diet, activity, monitoring
Build social support and positive reinforcement among family and
friends
COMMUNITY HEALTH WORKER
NETWORK OF NYC
System challenges
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Healthcare is a commodity – influenced by market forces
Business case - investing entity realizes a financial return on its
investment in a reasonable timeframe.
Social case - healthcare providers are mainly seeking to provide
good care for their patients
Challenges
 Data collected influenced by business values
 Benefits of your investment might be enjoyed by another entity
(externalitity)
 Payoffs on investment may occur far in the future – not
benefiting the innovator
 Investment may reduce need for future services – reduces your
revenues
COMMUNITY HEALTH WORKER
NETWORK OF NYC
The challenge of assessing
CHW effectiveness
Albert Einstein - "Not everything that can be counted counts, and not
everything that counts can be counted."
CHWs address social and psycho-social determinants of
health
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Not valued in business modeling
Focus on evidence base & clinical outcomes
Externality
ROI might not be timely enough
CHW contributions are both qualitative and quantitative
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Effect on utilization of healthcare services
Effect on improving cultural and linguistic utility of healthcare
services
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Establishing CHW in NYS
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Establishing CHW in NYS
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Build broad statewide coalition of CHWs and
stakeholders with CHW leadership
Develop consensus identity and definition
Establish scope of practice
Develop appropriate credential process
Reach consensus on potential training standards
Build the CHW business case
Conduct advocacy
Develop stable sustainable financing models
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Lessons Learned
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Recognize, respect and value CHW unique roles in healthcare
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Organize CHWs at local, regional and national levels
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Support CHW leadership of policy and practice issues –
credentialing, training, scope of practice, financing
Embrace CHW self-determination – maintain identity & traditions
Provide appropriate training content and training pedagogy – core
skills plus specialty areas – NYC study
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Involve CHWs in all aspects of program development- planning,
implementation, training, supervision, management and evaluation
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Recognize, value and respect CHWs as members of a practice
8.
Resist the urge to make CHWs like “Us”
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Questions & Comments
COMMUNITY HEALTH WORKER
NETWORK OF NYC
We want freedom...
We want opportunity and full employment...
We want completely free healthcare for all people…
We want decent housing for all people...
We want education that teaches us our history and our role in present-day
society...
We want land, housing, education, food and clothing…
We want justice and peace…
We want the power to determine the destiny of our communities...
We want an immediate end to all wars of aggression...
Excerpts from the Ten Point Program, 1966
The Black Panther Party – a community-based, nonprofit research, education, and advocacy center
dedicated to fostering progressive social change.
COMMUNITY HEALTH WORKER
NETWORK OF NYC
Contact Information
Sergio Matos, CHW
Executive Director
Community Health Worker Network of NYC
sergio@chwnetwork.org
917-653-9699
Director for CHW Training and Development
Columbia University – Mailman School of Public Health
Heilbrunn Department for Population and Family Health
sm2845@columbia.edu
212-304-6415
COMMUNITY HEALTH WORKER
NETWORK OF NYC