Urban institute- CareWorks: The Community Health Worker Project

Urban Institute    
 contact:   publicaffairs@urban.org     Publications Office at (202) 261-5687

CareWorks: The Community Health Worker Project

Prevention, wellness, and management of chronic conditions are attracting policymakers’ attention as solutions to the problems of growing costs and demands in US health care. Growing appreciation for how nonclinical services can help creates an important opportunity for community health workers (CHWs) to contribute and expand their numbers. CHWs are laypeople whose close connections with communities, health care knowledge, and interpersonal skills enable them to provide strategic education and other supports, especially in underserved communities. Effectively targeted CHWs can help people manage chronic conditions, coordinate services, and guide at-risk patients through the complexities of health services, including insurance enrollment. They can also help address social determinants of health at a neighborhood or community level, connecting clients to social and family services. In short, they create bridges between those in need and those who provide or pay for needed services, often going beyond clinical care. CHWs are also versatile. They can readily work with health care teams, other service providers, health insurers, or public health practitioners.

This project assesses how CHWs can help achieve better care, better health, and lower costs—the key goals of reform—and what action steps can further integrate CHWs into evolving health care and public health. This series of papers, funded by the Rockefeller Foundation, is based on relevant literature and interviews of both experts and practitioners.


Urban Institute—contact publicaffairs@urban.org     Publications Office at (202) 261-5687

Integrating Community Health Workers into a Reformed Health Care System
by Randall R. Bovbjerg, Lauren Eyster, Barbara Ormond, Theresa Anderson, and Elizabeth Richardson

This capstone brief summarizes opportunities and challenges for CHWs in the ACA era. The act recognizes CHWs as an important health profession, but how well CHWs will achieve their potential to improve health, services, and efficiency remains unclear because permanent financing structures are only beginning to evolve. Moreover, for CHWs to meet growing demand for services, their training must emphasize valued skills and personal attributes, and CHWs must meet the needs of employers. This paper highlights the roles, training, and evaluation of CHWs under health reform and assesses strategies for further growth.Read more

The Evolution, Expansion, and Effectiveness of Community Health Workers
Lauren Eyster, Theresa Anderson, and Christin Durham
The CHW profession has increased in visibility over the past decade, but still lacks widespread support for its integration into the US health care system. Lessons from CHWs’ current contributions to health care are important to understand as the ACA’s implementation continues. This research report describes CHWs’ current achievements, traditional barriers to their employment, and the need for new business models to support valuable CHW services. Read more

Opportunities for Community Health Workers in the Era of Health Reform
Randall R. Bovbjerg, Lauren Eyster, Barbara Ormond, Theresa Anderson, and Elizabeth Richardson
The ACA and other health reform efforts have expanded insurance coverage and focused on improving both health and health services while constraining health spending. This reform has created a watershed era for the CHW profession to expand its contributions. Working with insurers, CHWs can increase enrollment and help high-risk patients utilize care more appropriately. Working with health providers, CHWs can help improve practitioner-patient communication, effectuate referrals across levels of care, and improve management of chronic conditions between office visits. Working with public health and other professionals, CHWs can educate communities and build bridges to nonclinical services. This paper assesses the opportunities for and impediments to increased CHW employment under reform. It also analyzes changing roles for CHWs, as in insurance enrollment, access to services, and support for public health and prevention. Read more

Promising Approaches to Integrating Community Health Workers into Health Systems: Four Case Studies
Lauren Eyster and Randall R. Bovbjerg, editors
Interest is growing in the CHW profession among US policymakers and industry stakeholders, but little has been documented both about the scope of practice, supervision, and professional standards implemented by states and employers of CHWs, and about how CHWs are financed. Understanding these matters is important to show the value of CHWs and to help integrate them into health care as well as public health and social services. This research report presents case studies from Texas, Minnesota, North Carolina, and Ohio that draw lessons from different approaches to credentialing CHWs and delivering CHW services. Read more

Case Studies:
The Texas Community Health Worker Certification System. Texas created the first state certification program for CHWs. This legislative success for CHWs showed the importance of advocates, employers, and payers in enacting, designing, and operating such credentialing. Yet growth in employment lagged. More recently, state leaders have reconsidered how to best support, educate, and oversee CHWs in the interests of educators, employers, patients, and CHWs themselves.
The Minnesota Community Health Worker Training Program.Minnesota spent years compiling research evidence and stakeholder opinions before enacting legislation both to credential and to pay for CHW services. The effort was spearheaded by a partnership between the health services and education industries. Together, they helped achieve both state legislation and federal approval for some Medicaid payment for CHW services.
CHW Initiatives in Health Care and Public Health in Durham, North Carolina. Duke Medicine is this region’s largest health care employer and has integrated CHWs into many of its programs. Thought leaders see CHW services are important for caring for chronic conditions, high utilizers of hospital services, and underserved populations. They are also exploring community outreach for prevention of important health conditions as identified by a community participatory process. The approach often emphasizes CHWs’ ability to help offset their costs through savings from prevention and education, either for Medicaid managed care or, for Duke, as a safety net provider of free and reduced-fee services. Beyond that, Duke’s integrated system seeks to learn how to thrive in a future that emphasizes accountability for whole populations. Duke is investigating ways to replicate its model in other communities.
The Pathways/Community HUB Model and Ohio Certification of CHWs.The Community Health Access Project (CHAP) addresses community health through its pathway model of coordinated care. In this model, community hubs connect payers with CHW care managers, who educate at-risk clients and connect them with clinical, behavioral, or social services. Each pathway plan’s success is measured by a patient-specific outcome, such as enrollment in an effective insurance plan or the healthy delivery of a baby, and CHWs earn more for good results. CHAP has had early successes, state leaders are supporting expansion to other regions, and there has been national interest as well. The CHAP model features in some projects funded by the federal Center for Medicare and Medicaid Innovation.