Peer support as “being there” with proper training can save lives

Some of our recent blogs have focused on state and national level policies regarding peer supporters and community health workers (CHWs). Although understanding these policies is a critical factor in successfully implementing peer support programs, it is difficult to illustrate the individual level benefits such programs can have when discussing state or federal guidelines. A recent article on the UNICEF website  by Madeleine Logan does an excellent job highlighting the impact two CHWs have had on their community.

In 2008 the UNICEF-funded Community Case Management program in coordination with the Ghana Health Service visited the community of Kpalsako and offered to train two local volunteers to treat children sick with malaria and diarrhea. The community selected two members to receive training to be Community Based Agents (CBA). The members selected were then trained to treat children between 6 months and 5 years old and educate the community about positive health and hygiene practices. In 2010 the CBA’s received training in treating pneumonia as part of ongoing support for the program. CBA’s were also given medication to treat the community children including malaria medication, amoxicillin syrup for pneumonia, and zinc tablets and oral rehydration salts to treat diarrhea. Finally, the CBAs were trained to refer sick children to the nearest community health center if their symptoms do not improve, but offer a critical tie to health care for the community because the center is an hour walk away on foot.

In addition to the strong personal narratives contained in the article , the impact of this program was reflected in the number of malaria cases in the community with an estimated drop from 15 to 5 cases per month in children since the CBAs were trained. The program has been successful in communities outside of Kpalsako as Ghana Health Service National Child Health Coordinator Isabella Sagoe-Moses notes CBAs have brought health care to those most in need. It is estimated that the programs community volunteers treated approximately 83,000 cases of malaria and 17,000 cases of diarrhea in the three northern regions of Ghana in 2010.

While this blog will continue to focus on research projects, funding opportunities, key findings in peer support and many other topics we continue to recognize the importance of highlighting the success of peer support programs around the globe of all sizes. Success stories are regularly highlighted on our Facebook Page and we invite our readers to share their own stories and findings for future blog posts.

Peer Supporters Play Prominent Role in Recent CMS Innovation Funding

In November 2011 the Centers for Medicare and Medicaid Services (CMS) announced the Health Care Innovation Challenge program that would award up to $1 billion in grants for efforts to improve care and lower costs for patients with public coverage. On May 1st, The Office of Health and Human Services announced the first 26 recipients of these grants totaling $122.6 million. Many of these projects are of particular interest to those working with community health workers and in the field of peer support. This blog takes a brief look at some of the innovative ways recipients have proposed incorporating peer support in their grants:

The Center for Health Care Services in San Antonio Texas was awarded $4,557,969 for work with homeless adults in San Antonio with severe mental illness or co-occurring mental illness and substance abuse disorders, at risk for chronic physical diseases. Their intervention will integrate health care into behavioral health clinics. A multi-disciplinary care team will coordinate behavioral, primary, and tertiary health care for patients that are primarily Medicaid beneficiaries or eligible for Medicaid to improve their capacity to self-manage, reducing emergency room admissions, hospital admissions, and lowering costs, while improving health and quality of life and with estimated savings of $5 million over 3 years. The program will train workers to provide peer support to generate readiness for change, build motivation, and sustain compliance.

The Courage center in Minnesota received $1,767,667 to test a community-based medical home model to serve adults with disabilities and other complex health conditions. The intervention will coordinate and improve access to primary and specialty care, increase adherence to care, and empower participants to better manage their own health. Over 50 Independent Living Skills Specialists, Peer Leaders, and other health professionals will be trained with enhanced skills to fulfill the medical home mission. This community-based and patient-centered approach is expected to reduce avoidable hospitalizations, lower cost, and improve the quality of care for this vulnerable group of people with an estimated savings of over $2 million over the three year award.

Duke University, in conjunction with the University of Michigan National Center for Geospatial Medicine, Durham County Health Department , Cabarrus Health Alliance (Cabarrus County, NC), Mississippi Public Health Institute, Marshall University, and Mingo County Diabetes Coalition (Mingo County, WV) received $9,773,499 for its plan to reduce death and disability from Type 2 diabetes mellitus among fifty-seven thousand people in four Southeastern counties who are underserved and at-risk populations in the Southeast. The program will use informatics systems that stratify patients and neighborhoods by risk, target communities in need of higher-intensity interventions, and serve as the basis for decision support and real-time monitoring of interventions. Local home care teams will provide patient-centered coordinated care to improve outcomes and lower cost — expecting to reduce hospital and emergency room admissions and reduce through preventive care the need for amputations, dialysis, and cardiac procedures with estimated savings of over $20 million. Over the three-year period, this collaborative program will train an estimated 88 health care workers and create an estimated 31 new jobs. These workers include new types of health workers including information officers, health integrators, and community health workers, who will use novel technologies to facilitate communication, education, and care delivery.

Joslin Diabetes Center, Inc. received $4,967,276 to expand their “On the Road” program that will send trained community health workers into community settings to help approximately 3000 Medicare and Medicaid beneficiaries and low income/uninsured populations understand their risks and improve health habits for the prevention and management of diabetes. The program will target at risk and underserved populations in New Mexico, Pennsylvania, and Washington, D.C., helping to prevent the development and progression of diabetes and reducing overall costs, avoidable hospitalizations, and the development of chronic co-morbidities.

After our previous blog discussing community health workers in the US workforce and efforts to demonstrate their value to the healthcare system, this round of funding demonstrates the government’s interest in increasing the role of community health workers and peers supporters in the health system. To read about the other award winners please check out http://innovations.cms.gov/initiatives/Innovation-Awards/Project-Profiles.html. The next round of recipients will be announced in June and we will look forward to seeing additional ways for peer supporters and community health workers to be incorporated into improving health across the nation.

Peer Support and Community Health Workers (CHWs) Series:

“ Can CHWs integrated with primary care save cost?”


Community health workers (CHWs) – known by a variety of names such as promotoras and peer supporters – are trusted sources of support that promote health and help people manage diseases. This is the 3rd post of a 3 part blog that takes a closer look at the 3 action steps that can help promote full participation of community health workers (CHWs) in patient-centered primary care and the promotion of Community Wellness provided in a recent article by Balcazar et al.

As discussed previously, there has been an increased recognition of CHWs in the last decade including by the National Institute of Medicine, US department of labor and the Affordable Care Act. This has led to more formal training programs for CHWs as discussed in part 2. However, when investing in training as well as applications for general funding there is a consistent need to demonstrate value. Although the value that CHWs provide in improving access to care and improved health outcomes can not be overstated, there is also a need to demonstrate the cost savings CHWs may have on the healthcare system. With that in mind, this 3rd blog takes a look at selected programs where the return on investment (ROI) and cost saving of CHWs has been demonstrated.

The Arkansas Community Connector program integrated CHWs into long-term care by finding community members in three disadvantaged Arkansas counties and connecting them to Medicaid home and community-based services. In a three year study involving nearly 2000 participants, those connected with CHWs reported a 23.8 percent average reduction in annual Medicaid spending per participant (Felix et al, 2012)

In Colorado, the Denver Health program is the primary healthcare “safety net” for underserved populations in Denver. They employ CHWs that provide a variety of services including community-based screening and health education, assistance with enrollment in publicly funded health plans, referrals, system navigation, and care management (Whitley et al., 2006). Over a 9 month period patients working with CHWs had an increased number of primary care visits and a decrease in urgent and inpatient care. This resulted in a $2.38 ROI for every dollar invested with the CHWs (Whitley et al, 2006). 

In Kentucky, the Kentucky General Assembly authorized the Kentucky Homeplace Program in 1994. This program currently employs 39 CHWs, called family health care advisors, who provided services to 13,000 clients in 2007 across 58 predominately rural counties. The program received 2 million dollars in funding and in 2007 and was estimated to provide $15 to $20 of free or discounted medical services for every dollar invested (Goodwin & Tobler, 2008).

In Maryland, Baltimore CHWs working with diabetes patients on Medicaid achieved a 38% reduction in emergency room visits leading to a 27% drop in Medicaid costs for the patients. It was estimated that each community health worker was responsible for $80,000 to $90,000 dollars in savings by alternating weekly home visits and phone contacts (Fedder et al. 2003).

Although these 4 programs vary greatly in size and scope, they are all important in adding to a growing evidence base suggesting CHWs have the potential to provide substantial cost savings in the health care system. Further documentation of the financial impact of these programs can only serve to strengthen the argument for funding such programs. As CHWs continue to receive more recognition and the opportunity for more standardized training, demonstrating their financial impact will take on increased significance.

Balcazar, H., Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011)

 Fedder, D. O., Chang, R. J., Curry, S., & Nichols, G. (2003). The effectiveness of a community health worker outreach program on healthcare utilization of west baltimore city medicaid patients with diabetes, with or without hypertension. Ethnicity & Disease, 13(1), 22-27.


Felix, H. C., Mays, G. P., Stewart, M. K., Cottoms, N., & Olson, M. (2012). The care span: Medicaid savings resulted when community health workers matched those with needs to home and community care. Health Affairs (Project Hope), 30(7), 1366-1374. doi:10.1377/hlthaff.2011.0150

Goodwin K., Tobler L. (2008). Community health workers. Issue Brief of the National Conference of State Legislators, 1–11

Whitley, E. M., Everhart, R. M., & Wright, R. A. (2006). Measuring return on investment of outreach by community health workers. Journal of Health Care for the Poor and Underserved, 17(1 Suppl), 6-15. doi:10.1353/hpu.2006.0015

Peer Support and Community Health Workers (CHWs) Series:

“ How are CHWs licensed and trained?”
This is the 2nd post of a 3 part blog that takes a closer look at the 3 action steps that can help promote full participation of community health workers (CHWs) in patient-centered primary care and the promotion of Community Wellness provided in a recent article by Balcazar et al.

As discussed previously, there has been an increased recognition of CHWs in the last decade including by the National Institute of Medicine, US department of labor and the Affordable Care Act. However, this increased recognition has also led to increasing attention to the licensing and training of CHWs.

Consequently, the US Health and Human Services Health Resources and Services Administration (HRSA) office released a toolkit in August of 2011 that included a discussion of training for CHWs (HRSA, 2011). This toolkit noted that there is no current standardized training curriculum for CHWs and that the content and focus of these training programs can vary greatly from community to community.

However, HRSA noted that at a more broad level many programs have developed on-the-job training programs that have been adapted from existing materials from the Centers for Disease Control and Prevention. Common components of these trainings include “cultural competence, patient intake and assessment, protocol delivery, screening recommendations, risk factors, insurance eligibility and enrollment, communication skills, health promotion, and disease prevention and management”(HRSA, 2011).

Furthermore, calls for more standardized training and licensing led to some state level policies for certification being established beginning in the 1990’s. The successes of these training and certification programs have allowed them to serve as case studies for other states to ultimately have CHWs incorporation into standard training and licensing programs and more integrated in the healthcare system as a whole. For example, Texas developed a state level certification program and in 1999 passed legislation requiring CHW program in health and human services to hire state-certified CHWs when possible (Rosenthal et al., 2011). More recently the Massachusetts Department of Public Health conducted a comprehensive statewide study of community health workers and recommended a community health worker “professional identity” campaign. This campaign included expanded training programs for workers and their supervisors as well as statewide certification (Office of Community Health Workers, 2012). The state currently offers CHW training at community colleges and is moving toward state level certification (HRSA, 2011).

Perhaps the most critical integration has taken place in Minnesota where an organization called the Community Health Worker Alliance has worked with a statewide stakeholder coalition to develop CHW training as well as a statewide credit-based curriculum. This alliance led to the state passing legislation in 2007 that approved hourly reimbursement of community health worker services under Medicaid (Rosenthal, 2011)

Thus, although there is much progress to be made in CHW occupational regulation, including the development of training and certification programs in many states (Balcazar, 2011), the progress that has been made training and licensing CHWs in the states of Texas, Massachusetts and Minnesota offers promise.

Through interactions with programs from around the world, the interests in training and certifying peer supporters like the case for CHWs in the U.S. are universal. Often these discussions raise issues related to program sustainability and quality control for “service delivery” which both are critical to effective peer support. Notably, Peers for Progress and a few Network Members are going to present at the upcoming annual Society of Behavioral Medicine (New Orleans, Louisiana, USA; April 11-14, 2012) . The presentations will help address some of these issues (see below).

· A seminar on peer supporter training, ensuring competencies, and intervention tracking by Tang et al.
· A symposium on impacts of “organizational home” on sustainability of peer support programs by Boothroyd et al.
· A symposium on implementation differences and underlying commonalities of peer support by Oldenburg et al.

You can click here to glance what these presentations will feature. Also stay tuned for more follow up discussions on CHWs, peer supporter training, program sustainability and more programmatic challenges.

References
Balcazar, H., Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L. (2011).
Community health workers can be a public health force for change in the united states: Three actions for a new paradigm. American Journal of Public Health, 101(12), 2199-2203. doi:10.2105/AJPH.2011.300386

Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., et al. (2011). Community health workers: Part of the solution. Health Affairs (Project Hope), 29(7), 1338-1342. doi:10.1377/hlthaff.2010.0081

Office of Community Health Workers Boston (MA): Massachusetts Department of Public Health; c2012 [cited 2012 March 9]. Available from: http://www.mass.gov/dph/communityhealthworkers

U.S. Department of Health and Human Services, Health Resources, and Services Administration (2011). Community Health Workers Evidence-Based Models Toolbox. HRSA Office of Rural Health Policy. Retrieved March 9, 2012, from http://bhpr.hrsa.gov/healthworkforce/chw/default.htm.

Peer Support and Community Health Workers (CHWs) Series:

“People with similar life experience”- A closer look at the unique role of CHWs and its implications for peer support

A recent article by Balcazar and colleagues discussed how community health workers known as CHWs can be a public health force for change in the United States (Balcazar et al., 20011). This article provided 3 action steps from CHWs that can help promote full participation in patient-centered primary care and the promotion of Community Wellness. Check out our previous blog posting highlighting this article. This has prompted a 3 part blog that will take a look at each one of these steps.

The first step is to Advocate for Inclusion of CHW Perspectives by promoting “awareness and appreciation of the uniqueness of CHWs and support their roles in bringing community perspectives and priorities into the process of improving health care systems.” This raises some interesting questions about CHWs including their history, where they work, how they are currently recognized and what unique skills they offer.

A review of the commentary by Balcazar and others helps answer these critical questions. CHWs have been around for more 60 years to increase engagement between community members and the US healthcare system (Balcazar et al., 20011). The federal government first endorsed their use for expanded health access for underserved populations in the 1960’s (Nemcek & Sabatier, 2003). They work in a variety of settings including individual and family services, social advocacy organizations, outpatient care centers, education programs, other ambulatory health care services and physicians’ offices (Brownstein et al., 2011). In 2003 the Institute of Medicine recommended that CHWs serve as members of health care teams, to improve the health of underserved communities (Rosenthal et al. 2011). The US Department of Labor recommended an occupational classification for community health workers in 2009 (Office of Management and Budget, 2008) and they were subsequently included in a provision of the 2010 National Health Reform Law (Rosenthal et al. 2011).

Throughout this time period different terms have been used to describe workers under the umbrella of the term CHW including outreach workers, promotores(as) de salud, community health representatives, and patient navigators (Rosenthal et al. 2010). In a more formal definition the American Public Health Association defined CHWs as “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. . . between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery” (Balcazar, 2011).

This definition underscores the unique role CHWs have compared to other health workers. As a result of their role in the community CHWs have commonalities of life experience with patients. This allows them to establish a trust and rapport that can elicit honest responses about patient’s symptoms and comprehension of health communications from their providers (Gilkey et al, 2011). Furthermore, this allows CHWs to communicate with other members of the healthcare system to ensure patient’s care is sensitive to cultural factors and community issues. This can impact issues of adherence to medications or healthy lifestyle recommendations (Balzacar et al 2011). CHWs can utilize these strengths through their involvement with community-based primary care services and community based participatory research to strengthen the health system and coordinate with other health professionals, health care administrators, and policymakers (Balzacar et al. 2011).

By looking into the roles and functions of CHWs, what would be the implications for peer support and its strategies? Here are two examples-
Effective peer support fundamentally relies on people with similar experience, who are therefore able to build a trusting relationship with those they serve. So think broadly in terms of identifying characteristics of peer supporters.
It is critical that peer support strategies help strengthen linkages to the resources both in communities and health care system.

We welcome you to share with us your thoughts on CHWs and peer support!

The second blog of this series will move forward with this definition in mind and discuss Balzacar’s second action step, promoting CHW’s integration into the work force.

The role of Community Health Workers (CHWs) in the United States is moving forward – A recent commentary by Hector Balcazar et al.

Part of the Peer Support and Community Health Workers (CHWs) Series.

Community health workers (CHWs) – known by a variety of names such as promotoras and peer supporters – are trusted sources of support that promote health and help people manage diseases. A recent commentary by Hector Balcazar and colleagues discussed the increasing official recognition of Community Health Workers (CHWs) in the United States. More importantly, the authors suggested 3 potential action steps for strengthening their roles and enabling them to become collaborative leaders in the health care system:
· Action Step 1: Promoting awareness and uniqueness of CHWs
· Action Step 2: Integrating CHWs into healthcare delivery and programs
· Action Step 3: Implementing a national agenda for CHW evaluation research and sustainability

Here we would like to share a few interesting key points by the authors.

Point 1: The true strength of CHWs does not lie in their understanding of clinical care and health systems, but rather their ability to relate to members of the community and their shared life commonalities.
The ‘‘experience-based expertise” allows CHWs to establish a level of trust and communication with patients that can result in more candid responses about symptoms and their understanding of communication from providers. Also, because of CHWs’ direct personal understanding of community beliefs, cultures, norms and behaviors they have a different relationship with patients than other professions such as nursing or social work. This is a strength that should be appreciated and CHWs should not be judged by the same values we use for clinical disciplines.

Point 2: CHWs can have a very critical role in a PCMH model because of their close ties the community, cultural awareness and ability to facilitate communication between providers and patients.
Current efforts to restructure the delivery of primary care include proposals for a patient-centered medical home (PCMH) model. Through existing relationships and community ties, CHWs link people to services and other resources in ways that often enhance both comprehensive and culturally sensitive care which a PCMH aims to address. Also, CHWs bring patience, persistence, empathy, and respect to their relationships which may help the community accept the PCMH model as more than just a realignment of the same old players.

Point 3: CHWs can help beyond case finding and referrals.
In addition to their regularly recognized role in case finding and referrals, CHWs can assist in health education, providing support, coaching and follow-up, particularly in the management of chronic conditions, which health care providers may not be aware of. It is also noted that CHWs can play roles outside the health care system such as integration to other settings that address health including schools, faith-based organizations, parks and recreation, and community-based nonprofits such as the YMCA. This can help address the social determinants of health and use social support to help combat some of the stigma and social isolation that can exasperate existing disease and mental illness.

Point 4: We need a different approach to evaluate and document the impacts of CHWs.
Balcazar and colleagues argue current research methods may be too narrowly focused on clinical interventions or randomized control trials and are limited in their ability to capture complex systems and community changes providing insufficient evidence to help shape policy and program planning. By placing more emphasis on qualitative and ecological approaches to research on community health, CHWs may prove more effective at capturing the proposed themes of social justice and equality. A national agenda drafted in 2007 recommended several steps to accomplish this goal including more community based participatory research (CBPR), using interdisciplinary methods that are both qualitative and quantitative, translating findings to practice to meet needs of policy makers and the development of standard metrics and methods.

Point 5: Changes need to be made to improve sustainability of the CHW workforce.
It is noted that changes should include workforce development strategies such as on-the-job training and career development, occupational regulation, such as establishing standards for training and certification at the state and national level and the creation of guidelines for common research and evaluation measures. Policies surrounding financing are of particular interest because 70-80% of paid CHW positions come from soft money sources such as grants and contracts as opposed to a consistent funding stream.

To summarize, echoed by the Institute of Medicine (IOM), CHWs are playing an increasingly critical role in the US health care system, but it is important to recognize their unique skills, understand the best way to integrate their services and focus on sustainability to maximize their potential.

We invite you to read this commentary and share your thoughts.

Scaling up

This is the final post of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPoTsyo Patient Information Centre in Cambodia. Collectively these writings provide a roadmap for scaling up peer educator networks and developing sustainability for what is now still an intervention organized and facilitated by a Cambodian NGO. Part 1 focused on developing a Niche and Demonstrating value. Part 2 Focused on Integration. Part 3 focuses on the scaling up process.

Why do many organizations fail to scale up interventions?
There have been many attempts to scale up interventions in the health sector by engaging with the community that have not been successful. The reasons for these failures in low resource contexts are multiple and complex (Bloom & Ainsworth, 2010). Often times there is not a lasting community engagement even when resources are made available because training is either too short or handed down as a set of technical instructions from the service supply side to community representatives without appropriate explanation. A top-down inflexible package that is neither adapted nor responsive to the needs of the local community can be delivered but the results will frequently disappoint.

MoPo Tsyo’s approaches to scaling up
MoPoTsyo’s has experienced successful growth thus far by focusing on replication and selecting candidates from new areas to receive extensive training. These candidates travel and stay several weeks in places where they can learn and interact with others that have been successful. This experience helps prepare candidates for travel to places where there is a need for training and supervision of others.

Once networks are mature, selected members play a key role in helping to create other networks. Some of them grow to become managers and are involved in organization, negotiation and representation. The organization at the central level lets members grow and take on more responsibility but also adds people with special skills that cannot be found among the staff. Continuous learning and standardization is achieved through a centralization of information at the NGO’s relatively small office in Phnom Penh. There are no plans to establish physical infrastructure in the provinces outside the existing public health infrastructure. The organization is aiming to coordinate and finance its growth by intensifying its partnership with the existing public health care system where it can without losing quality, effectiveness, efficiency and responsiveness.


Bibliography

Bloom, G., & Ainsworth, P. (2010). Beyond Scaling Up: pathways to universal access to health services. Sussex UK. Retrieved from http:\\www.steps-centre.org\publications.