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.

INTEGRATION makes sense, but HOW?

This is the second 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 will 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 Focuses on Integration. Maurits van Pelt.

INTEGRATION makes sense, but HOW?

Recognizing the cost effectiveness of the Peer Educator Networks (P.E.N.), the Cambodian Ministry of Health recently approached MoPoTsyo to have the benign neoplastic P.E.N. become more integrated into Cambodia’s primary health care system. This could increase MoPoTyso sustainability by getting government network costs not yet recovered through revenues generated from service provided to members, as well as lead to better access to medical services for patients outside the scope of the Networks. However, what does such integration mean in practice?

Challenge 1: Can peer educators carry out new tasks?
Access to additional medical services can be critical in an environment where diabetic peer educators are untrained and unqualified to provide services outside their own chronic disease. It should be noted these educators are not community health workers and may easily overlook signs of other health problems that need priority attention. Consequently, much of the added value of Peer Educators will be lost if peer educators delay proper care instead of facilitating it.

Challenge 2: Linking various programs at the lowest is hard to do.
Patients often require horizontal functional linkages at the lowest levels of the health system with the National Mother- and Child Health, Neonatal Health program and Communicable Disease program. Unfortunately, many low income countries are notorious for problems with linking these kinds of different programs. However, these turf wars are mainly waged at the top of the program silos where policies are set for allocating resources. Fortunately, at the point of service delivery, patients and staff have different worries and offer little or no resistance to a more integrated approach provided the right conditions are in place.

Challenge 3: The current system may not have the capacity to satisfy consumer needs.
When preceding this integration, service capacity and availability can be a severe constraint. In other words, it makes no sense to train people in doing something if the conditions are not in place for delivery. For example, there are many barriers that delay seeking of professional care: transportation costs are relatively high and trust in public health services is generally low. If a peer educator recommends a patient to go for medical consultation many patients simply will not follow the advice because of real or perceived barriers.

MoPoTsyo’s approach to the challenges: Let’s pilot test at implementation level
Solutions for these technical challenges must be found that work in the local context. With the decentralization of the health system under way, it is likely that these horizontal and diagonal linkages are best piloted at the implementation level. After all, "how to brew the best soup collaboratively and steadily over time as it must be eaten locally". As an example, MoPoTsyo has an opportunity to strengthen the system’s ability to target subsidies to individuals and households who are most vulnerable in order to help them adhere better to prescribed treatment and cope better with the cost of their chronic illness. A voucher system is being piloted in the urban slums starting in July 2011 and can be rolled out to 4 provinces in the 4th trimester of 2011 if the results prove satisfactory. However, a broad regulatory framework for the operational district level is now required that captures the Peer Educator Network to become incorporated under the primary health care system. This can shift specific management tasks to local health authorities in exchange for proper rewards for their extra work and added responsibilities without clipping the wings of the Peer Educator Networks.

Peer Support: Developing a Niche and Demonstrating Value

This will be the first of a three part series of guest blogs based on writings provided by Maurits van Pelt, Director of MoPo Tsyo Patient Information Centre in Cambodia. Collectively these writings will 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 Non-Government Organization (NGO). Part 1 focuses on developing a Niche and Demonstrating value. Maurits van Pelt.

Program Outline
The NGO MoPo Tsyo Patient Information Centre ‘s office is located in the capital Phnom Penh. It organizes capacity building of diabetes patients to become peer educators. Once these trained patients have passed the peer educator exam, they return to their communities and begin to run MoPoTsyo Patient Information Centres from their own home using basic equipment and materials supplied to them by the NGO based on their activity reports.

The urban slums and rural Cambodia are characterized by high poverty rates and extremely limited resources to sustain a chronic disease care system.

The Peer Educators promote lifestyle changes and teach diabetes and high blood pressure self-management. The diabetic educators have learned to manage diabetes themselves and are familiar with the typical ups and downs of diabetes self-management helping them communicate effectively with the people they are supposed to assist. They are trained to provide screening services, home visits, run education courses and help navigate the complex, confusing and often costly disease management system and services. The Peer Educators (khmer “Mit Abrom Mit”) create personal contact and bring understanding to the disease. They remain motivated through social financial innovations of the patient educator networks. Their efforts provide social and emotional support that combine with the innovations to provide success stories such as 87% patient member annual retention average over the past 5 years in the urban slum areas, improved knowledge, self-care skills & lifestyle, and significantly reduced costs to the participating patients. Regular re-assessments show that levels of Blood glucose and blood pressure remain significantly reduced compared to these values at time of registration into the network among the majority of the patients who are in peer educator follow-up.

History
In 2005 the first MoPoTsyo project started in Phnom Penh’s slum areas as a “knowledge provider” and was not intended to become involved in medical service provision as there were already 2 charities running medical services for people with diabetes in the area. As a result, MoPoTsyo was able to concentrate on a core mission of finding and helping diabetes patients in the slums that wanted to learn diabetes self management. After a few years the charities ran out of money and ended their projects. Consequently, the prices of medical services quickly rose to unaffordable prices for MoPoTsyo members. This development put MoPoTsyo in the dilemma of deciding whether to continue working in advocacy for the lowering of prices from existing professional medical services providers or to expand the scopes of its own action and begin to organize services.

In many development sectors this is a common dilemma. Many initiatives experience ups and downs forcing organizations like MoPoTsyo to develop community action plans to try and support a marginalized community. With the closing of the two charities patients now needed affordable medical services. Consequently, it was decided to organize delivery of services for its members by selecting interested public and private partners to work with the peer educators.

Working toward to a sustainable model with impact
With a well organized group and agenda MoPoTsyo educators were able to take advantage of their resources and make an impact on multiple obstacles in the community that had previously seemed insurmountable. The peer educators were able to make many positive changes by negotiating at the local level and introducing change in a gentle low key fashion. In these negotiations MoPoTsyo utilized a system approach by establishing a proper regulatory framework and governance at multiple levels. By negotiating and drawing up contracts with its partners from the public and private sector, a set of transparent rules of engagement have been formulated that provisionally fill the policy gap. Besides clarifying relevant practical issues, this creates accountability among those who engage to abide by the rules. Local engagement and support are very strong as a result of the chosen approach. It seems inconceivable to achieve similar ownership if a top down service supply driven approach were suddenly adopted to benefit from perceived cost efficiencies. If given the chance, MoPoTsyo will continue to scale-up by supporting the existing Peer Educator Networks to replicate in response to demand from patients willing and able to take an active role.

As a result of this low key practical approach by familiar faces there were no turf wars between peer educators, local health centers and referral hospitals located within the operational districts that serve a population of 100,000 to 200,000 residents. After 5 years, the peer educator networks have shown to be a cost effective and affordable strategy to change and adapt health system relationships among local stakeholders into a more productive and more collaborative health market: One that can meet a great unmet health need for a population that would otherwise have remained excluded from a continuum of care.

Coming up
Next month, I will share more about integration of Patient Educator Networks (peer support) into the primary care system in Cambodia and scaling up our program.

Bridging the Gap: Students and Professionals in Peer Support

By Clayton Velicer,
UNC MPH Candidate 2012,
Health Behavior and Health Education

As Peers for Progress continues to collaborate with peer support programs around the globe there is an increased opportunity for students to become involved and gain valuable work experience in peer support and establish connections with PFP partners. At the University of North Carolina the MPH program affords its’ student this opportunity by having a practicum requirement in the summer between the first and second years of the program. This practicum can be either 200, 300 or 400 hours of work experience in the field that allows a student to set up a series of deliverables for the organization and North Carolina by creating a learning contract in the spring. This past summer Peers for Progress sent 6 students to projects including sites in China, Mexico and Australia for their practicum projects.

I was one of these students and spent 3 months working for the Australasian Peers for Progress Diabetes Project at Monash University in Melbourne Australia. This blog will briefly share some of my experiences with this project and allow other Peers for Progress partners the opportunity to read about the kinds of activities students can become involved in at placements in future years.

After arriving in Melbourne in May I was quickly caught up to speed on the project through a series of meetings with the program director and members of the research team. I was provided copies of all education materials included in the intervention, trained on physical data collection methods such as taking blood pressure and measuring waist circumference and informed of developments with the project to date. I then accompanied a member of our research team to the community intervention and control sites throughout Victoria and assisted in collecting the physical data and 6 month questionnaires. This provided a unique experience unavailable in my previous education training to interact with the peer leaders and participants of an ongoing multilevel intervention directly at a community basis.

At the same time my program’s training in qualitative methods provided me with background experience and knowledge for transcribing and coding interviews and focus groups. This allowed me to take on a personal project for the program with the teleconferences that had occurred between the peer leaders and the research teams as a means of ongoing support for the first six months of the study. My presence on site allowed me the time to transcribe and code 15 transcripts and examine the kinds of support that had been delivered during these calls. The summary of this analysis is a paper on ongoing support for peer supporters currently being drafted fostering ongoing collaboration between the University of North Carolina and the University of Monash in Melbourne. An abstract for this paper has also been submitted for poster presentation at the Society of Behavioral Medicine in the Spring of 2012.
Overall I have found the experience to be involved in a peer support project as a researcher while still a student to be an extremely rewarding experience that has allowed me to develop my professional network and become a larger part of Peers for Progress. I would encourage Peer Support Programs to think of ways they can build similar relationships with students to establish future mutually rewarding experiences.