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.