In the process of transitioning to patient-centered medical homes (PCMH), many medical practices are finding that community health workers (CHWs) have a valuable role to play in achieving the aims of this service delivery model. In the South Bronx, New York, one medical practice documented the successful integration of CHWs into the PCMH model. The findings, presented here, shed light on the specific roles of CHWs within a health care team and how CHWs fit within the division of care in a PCMH.
Getting the staff on board
In this case study, the managers of the CHW program took an active role in building institutional support for CHW integration. Although there are different models for linking CHWs to primary care, the goal of this particular practice was the full integration of CHWs into the health care team. With this objective in mind, managers created opportunities for clinical staff to learn about CHW roles; through Continuing Medical Education courses, rounds with CHWs, team meetings and all-staff meetings. The authors cite the involvement in monthly clinical team meetings as a key to integrate CHWs into clinical teams. CHWs may fill a broad range of roles, so defining and communicating these roles to staff and management is necessary to promote understanding of how CHWs fit into the care team.
Building staff support is a key step in the successful integration of CHWs into the health care team. One way to make this case is to demonstrate how CHWs improve the patient-centeredness of care. According to the report, CHWs “present detailed patient care narratives focusing on cultural, social, and communication issues”. They can transform the way that health care team members view patients by correcting misunderstandings and providing context for patient behaviors. Health care providers value the ability of CHWs to connect with patients, overcoming the linguistic, cultural, economic, and other barriers that they are unable to transcend.
Choosing the right people to serve as CHWs
Securing the backing of the human resources department was an important factor behind the success of this initiative. By recruiting qualified candidates based on a well-articulated job description and ideal qualities (in this case, “empathic, natural helper, communicator, and experienced in the community culture”), HR helped choose the right people to serve as CHWs. An intentional selection process helps dispel the myth that anyone can be a CHW and build institutional support by demonstrating their effectiveness. Because some qualities are hard to select for, the Bronx initiative required a probationary period of three months to ensure that hired CHWs are a good fit for the program.
Publicize benefits early and often
Initial reports on cost savings were useful in the bid for institutional support. According to the article, “early evidence of the benefits of the CHWs was critical to obtaining organizational, administrative, and team-wide support”. For every dollar invested in the CHW program, the hospital saved $2.30. Publicizing this impressive outcome among administrators and hospital staff helped build support for the CHW program. These improvements helped the clinic attain the additional $250 per member per month enhanced reimbursement rate for care coordination.
Monitoring and Evaluation
Another important part of this initiative is its focus on monitoring and data reporting. The CHW manager monitors and reviews CHWs through weekly time sheets (Figure 1). Additionally, tracking service utilization rates (i.e. hospitalizations and urgent care visits) has allowed the practice to demonstrate substantial improvements. For example, the rate of hospitalization for patients with chronic disease has declined by 12.6% since CHW integration. The practice also reports qualitative evidence of the program’s effectiveness through patient narratives and patient feedback collected from focus group discussions.
Although integrated CHW programs can vary widely, there is much to learn from the Bronx program. The incorporation of CHWs into the care team allowed for the team to better engage patients who experienced the greatest barriers to care. Through full integration with the care team, CHWs helped identify ways in which the care team could become more patient-centered. Thus, it was not simply the addition of the CHW, but the transformative nature of the collaboration between CHWs and other members of the care team, that allowed this practice to improve its outcomes for the most vulnerable patients.
Findley, S., Matos, S., Hicks, A., Chang, J., & Reich, D. (2014). Community Health Worker Integration Into the Health Care Team Accomplishes the Triple Aim in a Patient-Centered Medical Home: A Bronx Tale. The Journal of ambulatory care management, 37(1), 82-91.
Huyen Vu, MSPH
In a recent blog post, our colleague emphasized the importance of patient engagement as “a precursor to successful prevention and chronic disease self-management programs.” Engagement is especially crucial to Internet-based peer support interventions, which suffer from sporadic participation and high dropout rates. Engagement levels drop significantly with time, with less than 20% of patients following an online intervention through to completion.1 The promise of online forums to deliver low-cost peer support to varied and sometimes geographically remote populations can only be realized with continuous quality improvement. To enhance the impact of online support, it is important to understand how communication patterns in this medium influence patient engagement.
Characteristics of People that Use Online Forums
People who participate in online support-groups are generally classified as posters, lurkers (common terminology, no negative connotations intended) and non-users, corresponding to varying levels of engagement in a particular online intervention.2 Posters actively participate in online peer support groups, while non-users rarely seek support from the virtual community. Lurkers are participants who read and follow posts, but seldom or never publicly contribute to the online forums.
Han et al. suggest that different engagement patterns in online breast cancer support groups are associated with patients’ socio-demographic characteristics and psychological factors.3 For example, Causasians are far more likely to be active in online support groups than African Americans, spending more time and producing greater volumes of writing. Posters were more likely to live alone than lurkers. Noticeably, high levels of depression and low competence in health information were correlated with high levels of engagement in online support groups. Patients who perceived their cancer condition as serious and did not otherwise receive much offline social support from family and friends tended to post and exchange messages more actively to solicit informational and emotional support.
Finding Patterns in Online Forum Posts
Researchers from Carnegie Mellon University analyzed the contents of over 31,000 messages in an online breast cancer support group to study factors that prompt participation and determine the most-discussed issues on the forum.4 As expected, patients sought more (or less) help and comfort from the online medical support community when they faced more (or fewer) stressful events in their illness. Specifically, patients had a stronger motivation to join the discussion and seek informational and emotional support when they experienced a major disease event such as diagnosis, chemotherapy, or recurrence of the cancer. Many patients joined the support community shortly after their cancer events occurred. Chemotherapy and diagnosis were the most significant events that prompted participation in the online support groups.
Not surprisingly, patients participate in discussion topics that are most relevant to their current cancer development stage. Accordingly, chemotherapy, diagnosis, reconstruction and mastectomy were the most often discussed topics in the forum. The topic of chemotherapy was dominated by messages related to hair loss/appearance and spirituality, indicating that patients seek emotional support to help cope with the side effects of treatment.
Characteristics of Effective Online Messages
Responsiveness to messages in an online peer support group is a key indicator of group cohesion, and it can motivate lurkers and non-users to become more active members of the online community. Lewallen et al. defined responsiveness as “having received [at least] one reply from another participant.”5 By analyzing 12-weeks of messages on an online forum for cancer survivors with significant distress, Lewallen et al. found that greater message length, less use of second-person pronouns (e.g., you, your, yourself), and less use of positive emotion words were significantly associated with group members’ responsiveness.
Peers were more likely to respond to longer messages than those with lower word counts. The researchers explained that participants were more responsive to those who seemed open to share details of their personal experiences in the forum. Longer messages also represent greater investment in the group, and provide more details about the authors for discussion. Interestingly, participants were less likely to reply to posts containing a greater proportion of second-person pronouns. Examples included “I hope things get better for you” and “I find myself thinking of you often and what you are going through.” The explanation proposed was that these messages did not provide necessary space or specifics to encourage further communication exchange, though they contain some emotional comfort to message receivers. In addition, group members preferred to respond to messages containing less positive emotion (e.g., “I don’t feel well today”) than positive emotion (e.g. “I feel better today”), which may be understood by peers that the member has less need for support.
As one in four Internet users with a chronic condition seek others who might share similar health concerns, online peer support interventions have a significant role in improving patients’ health.6 Understanding patterns of online communication as well as barriers to engagement, is critical to maintaining active, effective, and sustainable peer support groups. Importantly, Internet-based interventions for patients with cancer or other chronic conditions should be developed using a patient-based approach that considers participants’ opinions, preferences, and communication characteristics. When patients’ needs and psychological determinants of engagement are fully understood, the interventions can be tailored to enhance patient engagement and maximize the benefits of online support groups.
- Gorlick A., Bantum E.O. & Owen J.E (2013). Internet-based interventions for cancer-related distress: Exploring the experience of those whose needs are not met. Psycho-Oncology.
- Han J.Y., Kim J.H., Shim M., McTavish F.M. & Gustafson D.H. (2012). Social and psychological determinants of levels of engagement with an online breast cancer support group: Posters, lurkers, and nonusers. Journal of Health Communication, 17:365–371
- Han J.Y., Hou J. & Kim E. (2014). Lurking as an active participation process: A longitudinal investigation of engagement with an online cancer support group. Health Communication.
- Wen M. & Rose C.P. (2012). Understanding participant behavior trajectories in online health support group using automatic extraction methods. GROUP ’12 Proceedings of the 17th ACM international conference on Supporting group work.
- Lewallen, A.C., Owen J.E., Bantum E.O., & Stanton A.L. (2014). How language affects peer responsiveness in an online cancer support group: Implications for treatment design and facilitation. Psycho-Oncology.
- Fox S. (2011). Peer-to-peer healthcare. Pew Research Center, Pew Internet & American Life Project.
Laura Guzman-Corrales, MPH candidate
Improving Health in Afghanistan with the Help of CHWs
Improved access to basic health services can have dramatic effects on life expectancy and other health indicators in global and domestic contexts. In Afghanistan, the expansion of health care infrastructure in the past 10 years has led to significant improvements in life expectancy. Recent reports attribute most of these gains to reductions in infant and child mortality. These reductions have been achieved through large-scale vaccination campaigns and the establishment of more clinics and hospitals to provide primary care services, especially for women and children.
Along with the expansion of basic health services, Community Health Workers (CHWs) have been another critical resource in improving health, especially in the most rural areas of the country. CHWs help the Ministry of Public Health communicate messages about the benefits of using new clinic and hospital services, with special attention to pregnant women. Many women have unattended home births, but the CHW program hopes to teach women the benefits of prenatal care and delivering in clinics, hospitals, or with the help of a trained midwife. They also distribute neonatal kits for women to have safer at-home births. The health education they provide targets the entire household, especially mothers-in-law, to address harmful cultural practices, such as feeding infants tea instead of breastfeeding.
CHWs are a valuable informational resource for rural women who have limited knowledge of and experience with a formal health care system and the many services it can provide to them and their families. Despite the importance and effectiveness of CHW-provided health education programs, there is a growing concern about the long-term sustainability of these efforts. Foreign aid to Afghanistan is getting cut in the coming years as coalition troops are withdrawn from the region. Already, CHWs have lost the support of large NGOs like Save the Children. USAID, a major funder of health programs, is slated to halve their current level of aid to Afghanistan. While CHWs are continuing much of their educational work, they have fewer tangible resources, such as neonatal kits, to offer women beyond informational support.
Strategies for Sustaining Global Health Programs
So the question remains, how can these hard-won gains be sustained given limited long-term funding and technical support from international funders?
Below are some possible considerations in planning and implementing CHW programs, as well as other health programs, that may promote their sustainability.
Involve local stakeholders. Foreign donors have funded much of the improvements in the health care system of Afghanistan and the CHW program; however, much of this money has been funneled through the Afghani Ministry of Public Health and local NGOs. This ensures that local actors have contributed to the program process from the planning to the implementation phase with the goal of aligning programs with local values and systems.
Develop local technical capacity. A related benefit of involving local stakeholders is the sharing of knowledge between large international donor NGOs and local, community based organizations. This allows the smaller, local organizations to develop the technical capacity to provide services without the direct involvement of an international NGO. For example, the Ministry of Public Health has developed the capacity to plan and monitor the CHW program as a result of this partnership.
Empower CHWs to continue their work. In addition to content specific trainings about health, CHWs should receive training to develop professional capacities, like leadership and community organizing skills. Promoting leadership can empower CHWs to continue their work even without the formal support and funding of international NGOs.
Cross-cutting Implications for Domestic Contexts
These are just three considerations for sustaining global health programs. Many of these considerations are not exclusive to the global context. Sustaining CHW programs domestically presents similar challenges. Often, CHW programs are not reimbursable by insurance unlike other health services, so clinics, hospitals, and community organizations have to seek outside funding to support these efforts. Grants are often short-term, so programs struggle to plan for the medium and long-term future.
Some of the above steps can also be used to sustain these efforts. For example, similar to global programs, domestic programs should think about how to involve several local actors in program planning and implementation phases. This can help maximize resources and avoid duplication of CHW programs in the same community. For more information about the health programs in Afghanistan and issues of sustainability in a global context, refer to the resources listed below.