Community Health Workers

Value-based pricing, the call for integrated team-based care, and new reimbursement strategies will affect the state's future workforce needs. As North Carolina's health care and public health systems maneuver through this time of transition, there is great need to coordinate those who are addressing all aspects of population health. Part of this discussion must address the role and inclusion of community health workers (CHWs). This term should be applied broadly to include outreach workers and lay health advisors. Like other states, North Carolina has an opportunity to develop this community-based resource as an integral component of the primary and preventive care system.

According to the American Public Health Association, a community health worker can be defined as: A frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. [1]

The impact of CHW services has been recognized and documented for health care concerns such as asthma, hypertension, diabetes, cancer, immunizations, maternal and child health, nutrition, tuberculosis, and HIV/AIDS [2].

In North Carolina, CHWs hold both formal and informal roles within the health care system. The nuanced and contextual skills they exhibit are valuable in reaching individuals and groups who are often unfamiliar with or distrustful of people outside of a given cultural, ethnic, and/or economic community. To assess current CHW programs in the state, the North Carolina Division of Public Health worked with partners in the Department of Health and Human Services and the University of North Carolina at Chapel Hill. The resulting program inventory revealed that some CHW programs have existed for more than 50 years. These programs have assisted members of diverse communities by promoting the use of primary care and follow-up care for prevention and management of disease. They have helped patients keep appointments, boosted adherence with prescribed medications, and educated patients on behavior change.

North Carolina now has the opportunity to catalogue, align, and systematically promote the use of CHWs. Several states are examining this issue and have taken strides in creating a statewide association of CHWs, identifying core competencies, and developing a training and certification process for CHWs. Some states have enacted legislation that has directed these efforts, while other states have been guided by Medicaid expansion.

The North Carolina Division of Public Health is working with many partners—including the North Carolina Area Health Education Centers (AHECs), the Office of Rural Health, the North Carolina Division of Medical Assistance (Medicaid), Community Care of North Carolina, cancer hospitals, and the North Carolina Community Health Center Association—to develop strategies that support CHW services. This stakeholder group has recommended several potential next steps: establish an advisory group with broad representation, including payers, health care providers, and CHWs; integrate CHWs into the health care system to improve cultural competency and understanding of the patient perspective; consider the risks of professionalizing CHWs, including the loss of their connection to communities; develop core competencies and scope of practice for CHWs; examine options for CHW education and certification, such as the North Carolina AHEC program and the community college system; provide flexibility and multiple entry points for certification or credentialing; define the value of CHWs in order to demonstrate return on investment; and measure CHW program effectiveness and impact.

Recent changes to health care laws encourage the use of CHWs to promote positive health behaviors and outcomes. Moreover, Section 5313 of the Patient Protection and Affordable Care Act of 2010 authorizes the Centers for Disease Control and Prevention to consider promoting the use of CHWs through grants to state health departments. This increased support for CHWs provides an opportunity to impact population health, reduce disparities, and engage patients and communities in a new health care delivery model. Enhancing the role of CHWs should be an informed process aimed at maximizing the ability of each worker to cost-effectively improve community health outcomes.

• ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.