Accelerating Best Practices in Peer Support Around the World

Institute of Medicine Discussion Paper on Community Health Workers

Clayton Velicer, MPH

In the past month, we’ve seen an increase in news coverage of Community Health Workers (CHWs) as they take on bigger roles in the US healthcare system. A feature in Modern Healthcare highlighted successful CHWs programs in Minnesota, New Mexico and Pennsylvania. Meanwhile, Florida became the latest state to establish certification for CHWs.

On February 4th, the Institute of Medicine (IOM) released a discussion paper on CHWs. In this blog, we take a look at the benefits and implementation challenges outlined in this paper.

Community Health Workers Save Costs

The authors of the IOM paper cite that CHWs save costs for providers. For example, CHWs produced a return on investment of 4:1 when working with children with asthma and a return on investment of 3:1 for Medicaid enrollees with unmet long-term care needs.

According to the authors, if the cost savings for CHWs were the “results for a clinical trial for a drug, we would likely see pressure for fast tracking through the FDA.” Yet, despite the scientific evidence and recognition from the IOM, ACA, and Department of Labor, CHWs programs have not been widely replicated or brought into the mainstream of U.S. healthcare delivery.

For more evidence, take a look at our blog on CHWs showing significant savings for CHWs integrated into long-term care in Arkansas, working with diabetes patients on Medicaid in Maryland, and providing community-screenings and health education in Colorado.

Challenges in Implementation

Limited professional recognition

The authors attribute this to a couple of factors. First, the term “community health worker” is used interchangeably with other titles including promotora, navigator and health outreach worker. These many different titles are sometimes driven by the different sources of categorical funding supporting CHW work. A second issue for recognition is a lack of specificity in roles. CHWs often have overlap with other members of the care team, such as medical assistants. The authors state that providers have concerns about ensuring quality of care and avoiding duplication of services.

Lack of data to make the business case

The IOM discussion paper points out that individual clinics are different from hospitals and insurance providers in the amount of data they have. Specifically, they do not have the analytic capacity or access to cost of care data to properly evaluate the impact of CHW services.


A large percentage of CHW positions are supported through grants. These grants provide funding for a specific amount of time but leave programs unable to sustain themselves after funding concludes. As a result of the above mentioned limited professional recognition and lack of data, it is difficult to secure CHW payment through more reliable mechanisms.

Lack of knowledge of best practices

While there is an increasing evidence base for the effectiveness of CHWs, there is currently no “go to” resource to track and disseminate findings.

The specific questions that the paper raises are “how should CHWs engage with patients vis-a-vis other members of the care team? How will they be incorporated into routine care processes? How should they be evaluated and supervised? What level of patient data should they be allowed to access, and what data should they contribute to the medical record?”

Moving Forward

In this next blog, we will share the IOM discussion paper’s suggestions for resolving these challenges and recommendations for the future. In addition, we will incorporate findings from a recent research paper by Islam and colleagues on integrating CHWs under the Affordable Care Act.

We are very grateful for the increased recognition that CHWs are receiving in the U.S. healthcare system. Discussion papers like the one released by the IOM are essential for furthering the conversation. Coverage of CHWs in the general media also helps inform the general public and medical professionals of the capabilities of CHWs. We encourage you to engage and become involved in this very important discussion.


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