The Value of Community Health Workers
by Anna Broadwater
In the middle of a 12-hour shift, I found myself arguing with Mr. Jones about using his call light again. I was a nurse on a hospital unit and Mr. Jones’ name would show up on my admissions pager at least once per month. I knew his family, his history and his hobbies—more than I normally knew about my patients. He was a stubborn, independent old man and he refused help of any kind. At the hospital he refused to use his call light, scaring and frustrating the nursing team. At home he refused help, causing him to fall and injure himself. His endless cycle of hospital admissions continued. I educated him on safety and he yelled at me to leave him alone until we were both blue in the face. We were at a stalemate.
This is where the current healthcare system fails its patients: healthcare providers aren’t able to see the full picture. All I saw was a defiant man trying to make my shift more difficult, and all Mr. Jones saw was a young nurse trying to tell him what to do. The solution? Community health workers.
Community health workers (CHWs) serve as the bridge between the healthcare system and public services sector, forming a connection that doesn’t otherwise exist. Was Mr. Jones refusing help because of a cultural norm I didn’t understand? Did he see asking for help as a sign of weakness? Or was it something else entirely? CHWs answer these questions, supporting and building relationships with their patients using soft skills like empathy and shared life experiences. A CHW might have helped Mr. Jones’ healthcare team by communicating that he feared losing his dog if he accepted treatment at home. A CHW might have helped Mr. Jones by reassuring him that he would be able to keep his dog if he received care at home. The importance of CHWs forming relationships and building trust rooted in shared life and cultural experiences cannot be overemphasized.
The healthcare system has not utilized CHWs at scale because historically there has been no way for to pay for them. The United States pays for healthcare through a fee-for-service (FFS) payment model. Under the FFS model, the provider gets paid for every test, procedure, consult, and service that they deliver. This incentivizes providers to increase the quantity of services, thereby increasing their income, rather than focusing on the quality of care they are delivering. While most of the healthcare system still operates under this FFS model, there is a promising shift underway to a new model.
Value-based payments incentivize the delivery of higher-quality care for patients at a lower cost, and value-based models have grown in size and popularity since Congress passed the Affordable Care Act. Instead of providers being reimbursed for every service provided, they receive a capitated rate to care for a patient over a period of time. The provider receives the difference between the total cost of caring for each patient and the patient’s capitated payment. The focus then becomes providing high-quality care to keep patients healthy so that they require fewer healthcare services.
Transitioning away from incentivizing quantity to incentivizing value opens the door to greater deployment of nonclinical team members, such as CHWs. In an FFS model, there was no way to bill for the services provided by nonclinical team members. Now, under a value-based model, the provider is getting paid per patient instead of per service and providers can invest in CHW interventions. This keeps patients like Mr. Jones safe in his home and out of the hospital. With value-based payments, the potential of CHWs as members of the interdisciplinary healthcare team can finally be realized.
Despite CHWs’ enormous potential in a value-based environment, there is not yet a scalable CHW model that healthcare systems can easily replicate. Currently, Penn has a growing CHW division focused on conducting research into their effectiveness and disseminating toolkits for other healthcare systems to replicate. To ensure that the full potential of CHWs is realized, more pilots and research into developing scalable models are critical. The healthcare system must also embrace the potential changes coming—the opportunity to improve the care and quality of life for all the Mr. Jones’ out there cannot be overlooked.
Anna Broadwater is a second-year MPP candidate at Duke’s Sanford School of Public Policy, focusing on health policy and improving care delivery.