The CHW: A Bridge to Address the SDoH

Community Health Workers (CHWs) are emerging as a key piece of the puzzle in efforts to promote population health. They can connect health care systems, public health, and community organizations with community members of greatest need to address social determinants of health (SDoH). Health care disparities have increasingly become primary drivers of the failure of American health care to achieve outcomes that match those of other advanced countries, which in turn, drives the industry to create new solutions.

The Centers for Disease Control defines a CHW as a frontline public health worker, who is a trusted member or has a particularly good understanding of the community served. The CHW serves as a liaison between health and social services and the community member, while facilitating access to services to improve the quality and cultural competence of care.¹

CHWs may be known by other names like promotores de salud, coaches, lay health advisors, community health representatives, peer mentors, or peer navigators, to name a few.

The CHW is not a new concept. Atul Gawande, in his landmark 2011 New Yorker article² “The Hotspotters” spotlighted the innovative work of Rushika Fernandopulle, an internist who developed the Special Care Center in Atlantic City, NJ. Among the Special Care Center innovations were a team of 8 full-time “health coaches” or CHWs. The coaches worked with the doctors but saw their high-risk patients more frequently than the doctors did, at least once every 2 weeks. Their most important attribute was a knack for connecting with sick people, and understanding their difficulties.

Most of the coaches came from their patients’ communities, understood their unique cultures, and spoke their languages. Many had experience with chronic illness in their own families. Few had extensive clinical training, although many had been medical assistants.

I was fortunate to work at AtlantiCare and participate in several daily Special Care Center team huddles. The CHWs provided higher levels of patient education, support, and coordination than could be provided by busier, and often higher-paid professionals. CHWs knew their patients, understood their patients’ cultures and values, and provided high-value care coordination by flexibly meeting their patients’ needs at home, work, and within the health care system itself.

Maternal mortality provides one example of the dramatic gap in outcomes in the United States compared to other countries. This disparity has only worsened over the past 20 years.

Complex factors drive this disparity and include medical issues, access to care, health literacy, implicit racism, and poor continuity of care. Women of color are 2 to over 3 times more likely to experience pregnancy-related mortality compared to white women.⁴

CHWs, a common maternal health care team member in other nations, provide continuity of care for the patient from early pregnancy through delivery and the postpartum period. That postpartum care includes supporting the new mother in caring for her newborn baby within the home and community. The CHW serves as a critical liaison with the health care system. Threats to mother’s and baby’s health can be identified early, with facilitated access to medical care.

The COVID-19 Pandemic and social justice movement have underscored the importance of addressing SDoH in order to advance the health and wellness of our population.⁵

The Centers for Medicare & Medicaid Services is integrating greater attention to health equity across its new models of care, including the ACO REACH model⁶ and the CHART model⁷ that addresses rural health needs.  This focus on addressing SDoH to achieve value-based care will require adoption of cost-effective innovations, such as incorporating CHWs into health care teams.

The growing recognition of the value of CHWs has resulted in better definition and alignment of these efforts, such as through the National Association for Community Health Workers.⁸ Formed in 2019, the Association represents a recent effort to unite CHWs nationally in support of communities to achieve health, equity, and social justice.

References:

1. Community Health Worker Resources. Centers for Disease Control and Prevention. February 9, 2022. Accessed March 18, 2022. https://www.cdc.gov/chronicdisease/center/community-health-worker-resources.html
2. Gawande A. The Hot Spotters: can we lower medical costs by giving the neediest patients better care? January 16, 2011. Accessed March 18, 2022. https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
3. Global Health: High US maternal mortality rate. November 19, 2020. Accessed March 18, 2022. https://www.statista.com/chart/23541/maternal-mortality-developed-countries/
4. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths. September 6, 2019. Accessed March 18, 2022. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html
5. Kaminski M, Skoufalos A. The pandemic exposes clear opportunities for population health in the United States. Popul Health Manag. 2020;23(3) doi:10.1089/pop.2020.0071
6. Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model [fact sheet]. Centers for Medicare & Medicaid Services. February 24, 2022. Accessed March 18, 2022. https://www.cms.gov/newsroom/fact-sheets/accountable-care-organization-aco-realizing-equity-access-and-community-health-reach-model
7. CHART Model. Centers for Medicare & Medicaid Services. Updated March 15, 2022. Accessed March 18, 2022. https://innovation.cms.gov/innovation-models/chart-model
8. National Association of Community Health Workers. Accessed March 18, 2022. https://nachw.org/