Community Health Workers Community Health Workers in an Evolving Technology Environment In low-resource settings, Community Health Workers (CHWs) are frontline providers who serve to bridge formal health systems with communities by working to improve the accessibility, acceptability and quality of health services. CHWs, often recruited from the disadvantaged communities they serve, frequently function as an extension of the health care team serving in a variety of different capacities. These include conducting home visits, screen for disease/illness and health risks, assist patients in finding and getting care, and educate and provide counseling or referrals for further care. Early adoption of CHWs in the global health arena particularly in developing countries has fueled the application of community health workers with safety net populations in the United States since the 1980s. According to the Centers for Medicare and Medicaid Services (CMS), nearly all state Medicaid programs now rely on CHW programs for outreach, screening and education efforts. The Patient Protection and Affordable Care Act’s (ACA) new models of primary care and population health interventions recognizes CHWs as integral members of the health workforce to deliver care at a lower cost, with more efficiency and added attention to the social determinants of health that often impede health improvement. The growing shortage of health care providers, particularly clinicians from underrepresented minority populations, has a multiplier effect on the use of CHWs in provision of care to rural and inner city populations of the U.S. The evolving technology environment is also driving the ongoing transformation of the current healthcare system to a learning health system, as envisioned by the Institute of Medicine (IOM). IOM’s recent report: “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America” outlines the future learning health system as having the capability to rapidly capture and disseminate new knowledge of health care delivery to patients and care providers. CHWs will be empowered by intelligence in the cloud that provides personalized solutions for each patient served by a CHW. Assisted by learning health system, CHWs will be able to more effectively conduct patient education, preventive screening and chronic disease management in their communities. The use of technology in health care delivery and patient engagement has given rise to new opportunities for health improvement that support the Institute for Health Improvement’s Triple Aim objectives of: • Improving the patient experience of care (including quality and satisfaction); • Improving the health of populations; and • Reducing the per capita cost of health care
Pacific and Southwest RHEC
Health information technology (HIT) such as electronic health records, personal health records and e-prescribing have advanced care coordination and management within the health care industry. More recent developments in e-health tools such as online communities and personal health tools have helped to place the consumer/patient at the center of their own health care. One of most broad scale developments of technology in health care is in the use of mobile technologies or mHealth to support health improvement in areas such as reducing child mortality, improving maternal health, combating malaria, HIV/AIDS and other diseases of particular importance in developing countries. Diverse stakeholders including technology developers, governments, health providers, nonprofits and health plans have come together to create a growing mHealth industry that has enormous ramifications for the Triple Aim. As mobile use continues to grow and access expands even in more remote and poor areas, mHealth is being heralded by leaders in the U.S. and across the globe as means for specifically strengthening the capacity of CHWs to make greater and stronger impact. To harness the mobile revolution, Dr. Thomas Kalil, Deputy Director of Technology and Innovation at the White House Office of Science and Technology Policy, advocates for the US to include in its development agenda the expansion of mobile services abroad to promote advancements such as safe drinking water, new vaccines, point of care diagnostics, and improved crops. Director Kalil further argues that mobile technology can improve public health by increasing the effectiveness of community health workers to improve public health data collection, patient diagnostics, and encouraging patients to adopt behaviors to improve health and well-being. Matched up against the six goals of CMS’ quality strategy, strengthening the capacity of CHWs to employ mHealth and other emerging technologies offer remedies for fragmented care and patient care management. Taken individually, gains in each of the goal areas have the potential to manifest as follows: Goal 1: Make care safer by reducing harm caused in the delivery of care. Ability of CHWs to engage in mobile data collection, point of care decision support, and case management enhance diagnosis and treatment and increase access to timely care; thereby reducing harm from wait times and lack of patient data. The addition of mHealth and patient monitoring systems allows for faster transmission of patient information that in turn can result in more timely referrals and transports to health facilities and support better adherence to treatment protocols. Goal 2: Strengthen person and family engagement as partners in their care. Under new delivery structures such as patient centered medical homes or accountable care organizations, the new frontier to be crossed is patient engagement. In other words, consumers have to perceive the information as relevant enough to take on the necessary changes being asked by their care providers. The trust and relationships established by CHWs with the families and communities they serve are paramount to the value and efficacy of this work. CHWs offer “point-of-care” support that greatly enhances patient and family engagement in health care delivery. According to Dr. Judith Hibbard at the University of Oregon and pioneer of the Patient Activation Measure, health information technology activates patients by meeting them where they are. In the hands of CHWs, tools such as mHealth strengthen the partnership between patients and the care team.
Goal 3: Promote effective communication and coordination of care. CHWs can use mHealth and other technologies to organize their work, track patient visits, access health protocols, and collect and access data that can result in more appropriate allocation of resources due to enhanced communications and coordination across care teams including reducing language barriers for populations who are limited English language speakers. Goal 4: Promote effective prevention and treatment of chronic disease. CHWs often work to support compliance with prevention and treatment plans such as adherence to taking asthma medications or antibiotics. Personalized text messages to remind patients about appointments or to share health education messages to pregnant women, diabetes patients about nutrition and physical activity can effectively promote healthy practices that prevent illness and/or manage chronic disease. Goal 5: Work with communities to promote healthy living. Often serving as part of the safety net team, CHWs have access to a wide range of information that can be evaluated to determine health improvements that have the potential to impact populations of people in addition to individual health. CHWs often rely on their lived experience to deliver the place-based, culturally competent care in the communities they serve. Part of this lived experience is the understanding the importance of addressing social and environmental conditions that often impede health improvement efforts. Using health technology to monitor, share, and strategize for social determinants of health can influence community and population health. Goal 6: Make care affordable. The financial incentives and feasibility of this work in the US becomes even more compelling as conversations about payment reform to improve care and reduce costs continue. CHWs and their use of health technologies enhances patient engagement, streamlines communications and care coordination, improves time and quality of diagnoses and treatment, contributes to public health data, and enhances the consumer’s experience in health care. Each of these outcomes makes care not only more accessible but more affordable as well by strengthening the systems for care delivery. Case examples Text4Baby, launched in 2010, capitalizes on the fact that in the US, 90% of women have a cell phone and texting with increasing frequency. As the first free national mobile health service in the nation, Text4Baby sends pregnant women and new mothers text messages with health care reminders about prenatal vitamins, infant immunizations, nutrition, as well as connects them to public clinics and other prenatal and infant care services. Content for text messages was produced by National Healthy Mothers, Healthy Babies Coalition in coordination with CDC to ensure accurate and evidence based content. Findings from a 2015 evaluation of Text4Baby program can be found here: http://www.hrsa.gov/healthit/txt4tots/text4babysummary.pdf Care Navigator, developed by BluePrint Healthcare IT, allows community health workers to maximize their role in the community and as part of the care team by creating a platform that enables real time, team-based care coordination and communication. The Care Navigator strengthens the communication between patient and provider and reinforces
behaviors and strategies for health improvement based on a patient’s assessed needs. http://www.blueprinthit.com/care-navigator CommCare, developed by researchers from the University of Washington and the University of California at Berkeley, is a mobile phone-based software that aids CHWs in a variety of tasks including screening for illnesses such as TB and malaria, providing accurate information on family planning and safe drinking water, reminding patients about follow-up visits, and keeping track of new births or deaths. Emerging educational applications of CommCare will also enable CHWs to engage in refresher courses and continuing education to support continued effectiveness of CHWs. https://www.commcarehq.org/home/ New mobile information technologies are increasingly being developed and piloted with CHWs. While inherently appealing because of their ability to connect community and health care systems, more efforts are needed to assess and document the nature of this work to improve health outcomes. In particular, researchers call out four key strategies to improving the delivery of health services by CHWs through use of mHealth tools including: 1) process improvement and technology development, 2) standards and guidelines, 3) education and training, and 4) leadership and management. A stronger focus on impact evaluation would accelerate the evidence base needed to guide health policy and program implementation. References and Additional Resources 1. Community Health Workers and Mobile Technology: A Systematic Review of the Literature, Rebecca Braun, Caricia Catalani, Julian Wimbush, Dennis Israelski, PLOS (Public Library of Science) One, June 2013, Vol 8, Issue 6, www.plosone.org. 2. Mobile Technology and Community Health Workers, Unite for Sight, 2010, http://www.uniteforsight.org. 3. Harnessing the Mobile Revolution, Kalil Thomas, New Policy Institute, 2008. 4. Mobile health evaluation methods: the Text4Baby case study. Evans, W.D., Abroms, L.C., Poropatich, R., Nielsen, P.E., Wallace, J.L., Journal of Health Communication: International Perspectives, 17(sup1):22-29, 2012. 5. Community Health Workers in California: Sharpening our Focus on Strategies to Expand Engagement, California Health Workforce Alliance, January 2015. https://www.phi.org/uploads/application/files/2rapr38zarzdgvycgqnizf7o8ftv03ie3mdnioede1ou6s1cv3.pdf 6. Enhancing Community Health Worker Performance with Mobile Technology, Dennis M. Israelski, M.D., Innovative Support to Emergencies Diseases and Disasters (InSTEDD), http://instedd.org/news-media presentations, 2015. 7. Best Care at Lower Cost: The Path to Continuously Lerning Health Care in America, Mark Smith, Robert Saunders, Leigh Stuckhardt, and J. Michael McGinnis, Editors, Institute of Medicine, The National Academy Press, www.nap.edu, 2013.
