Member of Care Delivery Team Model

In this model, community health workers (CHWs) may collaborate with or work alongside medical professionals on a clinical care team. The Community Preventive Services Task Force (CPSTF) has determined there is strong evidence to support the integration of CHWs on clinical care teams. Research has demonstrated the effectiveness of engaging CHWs to promote and increase cancer screenings, prevent cardiovascular disease, and prevent and manage diabetes. The CPSTF also recommends interventions that engage CHWs in a team-based care model to improve blood pressure and cholesterol to prevent cardiovascular disease.

CHWs may work in a variety of practice settings, such as Federally Qualified Health Centers (FQHCs), Rural Health Clinics, primary care offices, dental practices, and pharmacies. CHWs may also work with medical professionals to conduct home visits. In this model, the members of the care delivery team will differ across practice settings.

When collaborating with medical professionals, CHWs may offer a number of different services including:

• Take vital signs
• Body mass index calculations
• Disease screenings
• First aid care
• Medication counseling
• Chronic disease self-management
• Patient navigation to increase access to healthcare services
• Other basic services

CHW programs using this model may also integrate a more holistic approach or a medical home model. Within a medical home, CHWs may work alongside a care team comprised of physicians, nurse practitioners, and allied health workers to deliver a range of services, including navigation, outreach, education, or referrals.

Examples of Rural Member of Care Delivery Team Models

• CHW Program of the Northeastern Vermont Regional Hospital Service Area integrates CHWs as part of a diverse team of healthcare professionals, including physicians, nurses, behavioral health specialists, chronic care coordinators, and dietitians. The CHWs provide services that align with other CHW models, including meeting with patients, linking them to services, and enrolling them in insurance.
• In the Prevention through Care Navigation Outreach Program, CHWs provide biometric screenings, assess and refer clients to services, and provide peer support to increase coordinated care in rural Colorado.
• A CHW-Based Chronic Care Management (CCM) program for patients with high health care costs was implemented in three Central Appalachian states. The program enrolled patients with diabetes, heart disease, and chronic obstructive pulmonary disease. CHWs worked with a mid-level provider and a nurse. CHWs conducted home visits and helped patients with their self-management goals, medications, and other social needs. Patients in the program had better outcomes and the program had an annual cost savings of $384,000.
• The Spectrum Health Core Health Program is a 12-month program for underserved populations with chronic diseases in rural Michigan. Nurses and CHWs work together to conduct home visits to help patients manage their chronic disease. A 2018 study of the Core Health Program in two hospitals in rural Michigan showed improved health outcomes and a positive return on investment (ROI).

Implementation Considerations

When seeking to integrate CHWs into healthcare teams, it is essential to create a clear plan. This includes identifying the specific role of the CHW and how their role relates to the other members of the care team. Other implementation considerations for this model are described below.

Integration

Programs may experience barriers integrating CHWs into the care delivery team. Some providers may be less willing to work with CHWs, particularly if they do not recognize the value of CHWs to the care delivery team. Further, CHWs must be sure to maintain their ties with the communities they serve. Successful integration relies on communication and collaboration. One strategy for achieving this is by co-locating CHWs and members of the care delivery team.

Funding

A major consideration for implementing this model is identifying a funding source. Funding for incorporation of CHWs into care-based teams can come from grants, but increasingly, states are implementing reimbursement for CHWs in medical settings. In some states, reimbursement for CHW services is provided by Medicaid programs. In other states, public health plans have begun reimbursing for CHW services or using teams of in-house CHWs. Healthcare providers may also develop other internal financing strategies to support CHWs. For more information on funding, see Funding and Sustainability Strategies.

Liability

When CHWs offer some direct health services, there can be liability concerns regarding any mistakes or negligence that may occur. In some states, including Virginia, there is a Good Samaritan statute addressing civil liability issues for CHWs. For example, people voluntarily performing certain types of care in good faith are immune from civil liability for acts or omissions resulting from that care. However, if a volunteer or paid CHW is negligent, the organization or employer may still be liable.

Many CHW programs recognize these liability issues but few have formal policies. Programs should explore whether their state has relevant laws to understand the broader context of their activities. Programs should also assess liabilities, including:

• Do CHWs drive their own vehicles to appointments and/or transport patients in their vehicles?
• Is the employer responsible for a CHW who is injured on the job?
• Does the employer's liability change if the CHW is a paid versus volunteer employee?

Organizations hiring CHWs may consider acquiring malpractice insurance and should educate CHWs about their scope of practice and responsibilities.

Program Clearinghouse Examples

• Migrant Health Center, Western Region, Inc.
• Kodiak Island Health Care Foundation (Kodiak CHC)

Resource to Learn More

Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings
Document
Offers healthcare administrators, providers, and others guidance and recommendations when developing CHW programs. Addresses hiring, training, supervision, evaluation, and integration of CHWs into healthcare systems.
Author(s): Kapheim, M. G. & Campbell, J.
Organization(s): Sinai Urban Health Institute
Date: 1/2014

Bringing Community Health Workers into the Mainstream of U.S. Health Care
Document
Focuses on the integration of CHWs into team-based primary care. Identifies promising CHW programs, evidence of CHW effectiveness, and obstacles to their implementation. Offers recommendations for advancing integration.
Author(s): Pittman, M., Sunderland, A., Broderick, A., & Barnett, K.
Organization(s): Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
Date: 2/2015

Community Health Representative Program
Website
Describes activities providing outreach healthcare services and health promotion/disease prevention services to American Indians and Alaska Natives within their communities.
Organization(s): Indian Health Service

A Guide to Implementing a Community Health Worker (CHW) Program in the Context of HIV Care
Document
Identifies CHW best practices from Ryan White HIV/AIDS Program (RWHAP) and state and local CHW association standards. Discusses the key considerations for using CHWs as part of the healthcare team to improve outcomes for people with HIV along the continuum of care: patient engagement, retention in care, adherence to treatment and viral suppression.
Author(s): Rajabiun, S., Falkenberry, H., Downes, A., et al.
Organization(s): Boston University
Date: 2/2020

In Focus: Integrating Community Health Workers into Care Teams
Document
Describes healthcare organizations that have integrated CHWs into multidisciplinary teams.
Author(s): Hostetter, M. & Klein, S.
Organization(s): The Commonwealth Fund
Date: 12/2015

Integrating Community Health Workers into Complex Care Teams: Key Considerations
Document
Discusses the critical elements of maximizing the impact of CHWs within a healthcare setting including recruiting and hiring, training and career advancement, team integration, and support and retention.
Author(s): Lloyd, J. & Thomas-Henkel, C.
Organization(s): Center for Health Care Strategies
Date: 5/2017

Integrating Community Health Workers into Health Care Teams Without Coopting Them
Document
Describes the potential challenges of integrating CHWs into healthcare teams, including the risks of medicalizing their position or modifying workflows to better suit existing clinical patterns.
Author(s): Garfield, C. & Kangovi, S.
Citation: Health Affairs Blog
Date: 5/2019

Integrating Community Health Workers into State and Local Chronic Disease Prevention Efforts: Program and Financing Considerations
Document
Describes how CHWs can be integrated into clinical chronic disease prevention and health promotion activities, using Washington state's Medicaid Transformation Demonstration Project as an example.
Author(s): Spencer, A.
Organization(s): Center for Health Care Strategies
Date: 2/2018