Community Health Worker Integration: Best Practices and Lessons Learned from Hypertension Self-Management
Community Health Workers as Part of the Hypertension Self-Management Care Team
Nearly 30 percent of adults in the United States have hypertension, which places them at a greater risk for heart disease and stroke, the first and fifth leading causes of death.[i][ii] Infrequent provider interactions are insufficient to adequately support behavior change among clients self-managing chronic diseases like hypertension. Evidence suggests that community health workers (CHWs) working alongside clients and providers can serve as key intermediaries to help improve disease outcomes and lifestyle changes, especially among underserved populations that often experience health disparities. Historically, CHWs have not been part of health care teams; however, a focus on the triple aim and acknowledgement from the health care system has increased attention on promoting CHWs as partners to provide support to health care teams in the prevention, management, and control of chronic disease.
Specifically, CHW studies have demonstrated support for CHWs as interventionists in self-management of hypertension.[iii],[iv] In 2014, a national sample of over 200 CHWs were surveyed about their roles in hypertension self-management and reported working alongside nurses (50%), medical doctors (46%), health educators (32%), social workers (30%), and pharmacists (17%). The most frequently reported responsibilities in hypertension self-management were educating clients on a healthy diet (84%) or low-sodium diet (79%), helping clients understand they should not stop taking their medicines without talking to their doctor (74%), and assisting clients with keeping doctor’s appointments (73%). The Community Preventive Services Task Force recommends interventions that engage CHWs in team-based care models, specifically to improve clients’ health behaviors.[v] Despite strong evidence for CHWs working in hypertension self-management efforts, CHWs still need appropriate support to complete their work. Previous studies have demonstrated a lack of understanding of the CHW’s role, which creates a barrier to integration. For example, one CHW from the 2014 survey reported, “I am put in the office and I’m given a list, but we don’t thrive that way because… we’re from the community. It takes a lot of backing up, informing the immediate staff that I work with, so they know how to utilize me, making sure that they’re on board and being more supportive and including me in the health care plan instead of leaving me just as an option in an office.”[vi]
Elements of Successful Programs: Integration Techniques
The following information offers field-driven, CHW-endorsed best practices for integrating CHWs who are working with clients on self-management efforts. These suggestions are derived from the literature and an online survey and telephone interviews conducted with CHWs in 2014. The focus of the survey and interviews was to understand CHW roles in hypertension self-management, training competencies for delivering hypertension self-management education, and organizational characteristics and best practices for successful integration into health care teams. Survey respondents (n=160) were mostly female (88%) and had a high school diploma or higher. About half were Hispanic/Latino (45%), 36% were African American, 26% were non-Hispanic White, and the mean age was 43.1 years. Respondents described their roles as flexible and multifaceted but always client-driven. Specifically, they described communicating with both clients and providers, often elaborating on suggestions from the provider and educating clients on the benefits of healthy lifestyles, reinforcing providers’ instructions, and providing support for clients. Respondents also helped people receive necessary services through client advocacy and connecting clients to referral programs. Although the CHWs who participated in these surveys and interviews generally felt supported in their work, they noted a few specific suggestions to improve integration into their program:
- Focus on recruiting CHWs with the qualities necessary to fill CHW positions (e.g., relationship with the community, empathy).[vii] This includes posting a clear job description, communication with the HR staff to create a job posting, and using appropriate interview techniques to assess CHW qualities (e.g., role play, scenarios).
- Provide clear guidelines and competency-based initial training and ongoing training for CHWs and other team members to improve integration into care teams.
- Consider how to best assess CHW performance, client satisfaction, system integration or changes, and contributions that CHWs make to prevention, treatment, and self-management of clients.[viii]
- Build institutional practices with the health care system or organization that last throughout the program’s lifetime and provide ongoing support for data collection, monitoring, and feedback to ensure success and update/modify the program as needed.
- Provide strong, supportive supervision of new CHWs by a more experienced CHW.[ix]
- Provide CHWs access to the Electronic Health Records (EHR) in order to support the bi-directional flow of knowledge and resources between the provider and CHW team. This helps CHWs become more fully integrated into the care team. Specific EHR templates can be used (e.g., structured questionnaires, auto-generated templates).[x]
- Prepare staff for CHW integration by educating health care staff, administrators, and payers about CHWs and their roles to help establish acceptance of CHWs and their unique contributions to the health care team. This includes communicating early and often throughout the implementation process to ensure continued success throughout the life of the program and facilitate full integration of CHWs into organizational culture. Consider involving program champions who will advocate for CHWs.[xi]
- Results show that there is a statistically significant correlation between the number of CHWs in an organization and the level of satisfaction with the way they are integrated into a health care team, suggesting stronger institutional support and understanding of their work as well as peer support.[xii]
- Consider opportunities for CHWs to partner in unique community settings such as collaborating with community pharmacists, especially in challenging locations or among high-risk populations.
- Build career ladders within the organization to help legitimize CHW roles and improve workforce development (e.g., provide supervisory responsibilities).
Lessons Learned: Key Take-Aways
Findings from the literature indicate CHWs play an integral role in chronic disease self- management, especially for hypertension. CHWs can be exceptional partners for providers and programs seeking to improve their clients’ self-management skills or to expand their reach into community-based settings. By understanding the CHW’s roles in hypertension self-management, health care professionals can better integrate CHWs into health care teams, which allows for improved opportunities to effectively address barriers to clients’ prevention and management of hypertension. Specifically, allowing CHWs to be part of interventions that activate clients to participate in their own care and improve their self-management behaviors is important for the prevention and treatment of heart disease and stroke. Supportive supervision, clear communication, and collaboration among CHWs, other team members, clients, and community resources will improve the CHW’s ability to integrate into health care teams and allow them to contribute to improving population health and chronic disease prevention, treatment, and management.
[i] Centers for Disease Control and Prevention. High blood pressure frequently asked questions (FAQs); 2014. Retrieved from http://www.cdc.gov/bloodpressure/faqs.htm.
[ii] Yoon, S. S., Burt, V., Louis, T., & Carroll, M. D. Hypertension among adults in the United States, 2009–2010. NCHS Data Brief 2012;107(107):1–8. PubMed
[iii] Brownstein, J. N., Bone, L. R., Dennison, C. R., Hill, M. N., Kim, M. T., & Levine, D. M. (2005). Community Health Workers as Interventionists in the Prevention and Control of Heart Disease and Stroke. American Journal of Preventive Medicine, 29(s81): 128-133.
[iv] Brownstein, J.N., Chowdhurry, F.M., Norris, S. L., Horsley, T., Jack, L., Zhang, X., & Sauerfield, D. (2007). Effectiveness of Community Health Workers in the Care of People with Hypertension. American Journal of Preventive Medicine, 32(5): 435-447.
[v] Retrieved from https://www.thecommunityguide.org/findings/cardiovascular-disease-prevention-and-control-interventions-engaging-community-health
[vi] Allen, C. G., Escoffery, C., Satsangi, A., & Brownstein, J. N. (2015). Strategies to Improve the Integration of Community Health Workers into Health Care Teams: A Little Fish in a Big Pond. Preventing Chronic Disease, 12(E154): 1-10.
[vii] 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 Patient-Centered Medical Home: A Bronx Tale. Journal of Ambulatory Care Management, 37(1): 82-91.
[viii] Retrieved from http://chw.upenn.edu/tools
[ix] Retrieved from http://www.mchip.net/sites/default/files/mchipfiles/09_CHW_Supervision.pdf
[x] Johnson, S., Gunn, V. L. (2015). Community Health Workers as a Component of the Health Care Team. Pediatric Clinical of North America, 62: 1313-1328.
[xi] Allen, C.G., Brownstein, J.N., Jayapaul-Philip, B., Matos, S., & Mirambeau, A. (2015). Strengthening the Effectiveness of State-Level Community Health Worker Initiatives Through Ambulatory Care Partnerships. Journal of Ambulatory Care Management, 38(3): 254-262.
[xii] Allen, C. G., Escoffery, C., Satsangi, A., & Brownstein, J.N. (2015). Strategies to Improve the Integration of Community Health Workers into Health Care Teams: A Little Fish in a Big Pond. Preventing Chronic Disease, 12(E154): 1-10.
Keywords: Evaluation, Metrics, Programs, Promotores