"The widespread incorporation of CHWs into the health delivery system offers unparalleled opportunities to improve the delivery of preventive and primary care to America's diverse communities."
-Pew Health Professions Commission, 1994

Over the last 25 years a body of research and writing has been built up on the role of Community Health Workers in primary and community health care in the US. While some are informal program descriptions, others are well-designed controlled research studies (see two-volume set of abstracts Community Health Advisors, CDC). The purpose of this round-up is to give a summary of some of the most interesting studies on CHWs, those which show the power of the role of CHWs.

This research points toward a great potential for CHWs to play an expanded role in the US health care system, particularly in the areas of chronic disease management, patient navigation/utilization, prevention work and the provision of "enabling services" such as medical and cultural translation, linkages to non-medical social services, etc. Because CHWs do not work in isolation, but as members of community and primary health care teams, this research fits into the wider context of research on primary and public health care delivery.

It is clear from the record that there has never been a sustained line of research on role and effectiveness of CHWs in primary and community health care. While very interesting, the work is episodic and has a certain static quality: Many of the same issues being investigated in 1970 have not advanced a quarter-century later. For example, a fascinating 1970 research study on CHW work in pediatric upper respiratory infections hangs in the air, with no follow-up and no effort to apply and replicate the findings (Cauffman 1970, below).

The notes are organized in the following sections:

1. Overview/Literature Review
2. Chronic Disease Management
3. Patient Navigation/Utilizatio
4. Prevention Work/Perinatal
5. Other

I. Literature Review: Overview of CHW Potential

28 studies cited by Witmer et. al., show that CHWs can:

• Teach concepts of primary and secondary prevention and improve access to prenatal care: 6 studies.
  
• Link hard-to-reach patients to needed services: 3 studies.
  
• Increase access to preventive care to Medicaid Kaiser enrollees: 2 studies.
  
• Facilitate appointment-keeping: 8 studies.
  
• Increase compliance with prescribed regimens: 5 studies.
  
• Improve screening and early intervention in cancer (1), immunization (1), infant mortality and low birth weight (4), hypertension control (1), smoking cessation (3). Prevent unnecessary reliance on costly emergency department and specialty services: (3)

The review was sponsored by the Pew Health Professions Commission.

CHWs: Integral Members of the Health Care Workforce, AJPH, August 1995, Vol. 85, No. 8, p 1055-1056.

II. Chronic Disease Management

Hypertension Control in Baltimore

This is a synthesis of a multi-pronged 15-year intervention in an inner-city African American community. It involved targeted screening and detection of high blood pressure (including peer outreach in churches and CHWs stationed in emergency rooms); continuing community health worker training, and interventions using the media, area food markets and fast-food restaurants to promote healthy lifestyles. A very significant element of the program was community ownership of the community-based activities through a partnership between the East Baltimore Heart, Body and Soul Program, and Johns Hopkins University.

In the initial five-year phase, the rate of control of hypertension in the intervention group doubled from 38% to 79%, with a 35% decrease in hospitalization and 65% decrease in mortality from uncontrolled hypertension. In the second eight-year phase, control of hypertension among men rose from a baseline of 12% to 40% (p. 321).

Levine D, Becker D, Bone L. Narrowing the Gap in Health Status of Minority Populations: A Community-Academic Medical Center Partnership. Am J. Prev Med 1992;8(5) 1992.

CHWs were used to screen for hypertension, provide risk reduction counseling, carry out telephone preappointment reminders; and recontact no-shows. They worked in an inner city adult emergency room at Johns Hopkins Hospital.

Study results indicate that CHWs can improve appointment keeping as well as assist in screening and counseling for chronic conditions within the ER. Results of preappointment reminders by CHWs showed a 19% improvement in appointment keeping. With a sample of patients who had failed to return for a follow-up visit, CHW contact showed an overall improvement rate of 7%.

Emergency Department Detection and Follow-up of High Blood Pressure, Bone, LR et al, Am J Emer Med, 7(1): 16-20, Jan. 1989. Cited in Community Health Advisors, Vol. I, CDC, 1994, p. 75.

Hypertension Control in Mississippi

Researchers describe the use of community members as hypertension health counselors in a five-county poor rural area in central Mississippi. Briefly-trained counselors: 1) managed individual hypertensive clients; 2) organized high blood pressure management self-help groups; 3) performed community activities such as blood pressure screenings and dissemination of health education materials.

After 12 months, 5 counselors were managing 211 hypertensive clients, with over 90% having achieved a controlled blood pressure (no pre/post data provided). Over the one-year period, 1300 individuals were identified who were recently or previously diagnosed hypertensives who subsequently entered the medical care system for treatment.

Frate DA, et. al, Selection, Training and Utilization of Health Counselors in the Management of High Blood Pressure, Urban Health 12(5): 52-54, May 1983. Cited in Cited in Community Health Advisors, Vol. I, Sept. 1994, CDC, p. 78-79.

Hypertension and Diabetes Control in Previously-Hospitalized Patients, University of Baltimore

The University of Baltimore developed a CHW Outreach Program, targeting medical assistance patients with diabetes and/or hypertension who had been hospitalized in the preceding 12 months. Briefly-trained community health volunteers followed 10 patients, visiting each patient twice a month, calling the patient on alternate weeks, providing information about other referrals and helping patients deal with Medical Assistance. The workers helped patients keep regular appointments, follow their doctor's treatment advice/diets, monitor glucose, and recognize early warning signs of serious illness.

Fedder CO. CHW Outreach Program, U. of Maryland, 1991, abstracted in Cited in Community Health Advisors, Vol. I, Sept. 1994, CDC, p. 81-82.

Diabetes Control in Remote Native American Communities, IHS

Community Health Representatives were employed and trained by Indian Health Service to work with public health nurses in monitoring people with diabetes on remote southwestern Arizona reservations. The two CHRs coordinated diabetes field clinics, being responsible for organizing transportation, equipment and supplies. They also led group teaching sessions and food demonstrations, did intake and organized treatment. They assisted with patient flow, performed foot checks, and acted as interpreters. They carried out home visits and organized community agencies.

Landen JB, CHRs: The Vital Link in Native American Health Care, IHS Primary Care Provider 17(7): 101-102, July 1992. Cited in Community Health Advisors, Vol. I, Sept. 1994, CDC, p. 81.

Pediatric Asthma Control

In a large intervention study, a subset of 140 school-age inner-city African-American children with asthma were enrolled in a program of home visits by CHWs. The purpose was to obtain medical information and to teach basic asthma education to families. Results showed that appropriately recruited and trained CHWs are effective in obtaining useful medical information and in providing basic asthma education in the home.

Butz, AM, et. al, Use of CHWs with Inner-City Children Who Have Asthma. Clinical Pediatrics, 33(3):135-141, March 1994. cited in Community Health Advisors, Vol. I, Sept. 1994, CDC, p. 147.

III. Patient Navigation/Utilization

Preventing Unnecessary Emergency Room Use in New York

Inappropriate use of emergency rooms (ERs) is a major financial drain on health systems. With 120,000 visits in 1991, the Presbyterian Hospital is the second largest emergency department in New York State. The leading medical problems for which parents bring their child to the emergency room are colds, ear infections and throat infections (UHF 1994 p. 14) Of the total annual visits to the pediatric emergency room at Presbyterian Hospital, 80% were for nonemergent conditions. In the adult emergency department, 40% of the visits were nonemergent. At the same time, Presbyterian's primary care clinics were underutilized, and reported a broken appointment rate of 50% among first-time patients.

Presbyterian Hospital created a new CHW position to work with triage nurses in the emergency departments. The CHW arranged to re-route patients to primary care appointments, educated patients about the value of primary care, and followed up with patients to determine their satisfaction.

Through the efforts of the community liaisons, the hospital found that the broken appointment rate at its primary care clinics dropped from 50% to 11% over a three-year period. Nonurgent emergency department visits by adults decreased by 42%. The percent of patients who kept their first primary care appointment rose to 89%, and 61% of adults and 51% of pediatric patients had no further ER visits. Patients went from being high users of the ER and low users of the clinics, to high clinic users and low ER users.

As a result of this success, Presbyterian Hospital added permanent CHW liaison positions to its staff, and was able to close one of its ER Rapid Evaluation units.

Cooke J and Finneran K. A Clearing in the Crowd: Innovations in Emergency Services, United Hospital Fund of NY, 1994., p .11 and 12.

IV. Prevention/Perinatal

Increasing Access to Preventive Services in an HMO Serving Medicaid Enrollees

Since 1971 Kaiser Hawaii has employed CHWs to increase Plan X5 Medicaid enrollees' access to preventive services. Kaiser wanted a single point of contact--a CHW Health Coordinator--from whom members could obtain information, advice in understanding how to utilize Kaiser Permanente facilities, and linkages to other services not provided by Kaiser Permanente, such as housing, food stamps, legal services and so forth. Approximately 75% of CHW Health Coordinators' time is devoted to recruitment, enrollment and orientation of eligible AFDC recipients--i.e. marketing. The current program emphasis is on managing high risk members who are primarily pregnant, asthmatic or diabetic. Roughly 10% of Medicaid enrollees have complex social, psychological and medical problems which consume a great deal of the outreach team's time.

An Outreach team consisted of eight CHW Health Coordinators, 2.4 FTE Visiting Nurses, and 4.25 FTE administrative and clerical staff.

Results of program evaluations:

• Initially skeptical physician and nurse leaders expressed the wish that all members could have outreach workers.
  
• Financing: During most of the two decades reviewed, the capitated amount charged by Kaiser Permanente was 15-20% below fee-for-service Medicaid charges. In recent years, the savings to the government has narrowed and is currently less than five percent (p 5).
  
• Utilization: Plan X5 members use more preventive services such as immunization than commercial group members. They make more visits to nurse practitioners than other members, and less visits to specialists. The average utilization of ambulatory care is almost identical to the utilization pattern of commercial members.

Knobel Richard F., "Medicaid and Managed Care with Kaiser Permanente in Hawaii, "Remarks at a Conference on Medi-cal and Managed Care sponsored by the California Association of HMOs, Sacramento CA Nov 17, 1992," and "Case Management in Kaiser Permanente's Medicaid Program in Hawaii, "Remarks at the New Visions, New Ventures Conference, Oakland CA December 5, 1992."

V. Other

Pediatric Upper Respiratory Infections-Los Angeles

Researchers in the Pediatric Emergency Room of Los Angeles County-University of Southern California Medical Center hypothesized that parents instructed by CHWs would be as likely to comply with doctors' orders on the handling of an Upper Respiratory Infection as parents instructed by physicians or public health nurses. Parents were randomly assigned to receive instructions from CHWs, public health nurses, or pediatricians after the doctor diagnosed an Upper Respiratory Infection. Among parents assigned to receive their instructions from these groups, there was no difference in the level of compliance.

The CHWs had a high school education, and were either of African-American or Latino backgrounds, representing the population attending the Pediatric Emergency Room.

This project demonstrated that CHWs can assume important responsibilities in health education while working in a well-functioning health care team.

Cauffman JG, et. al, AJPH, 60(10): 1904-1909, October 1970., abstracted in Community Health Advisors: Models, Research and Practice, Vol. I, Sept. 1994, p. 51, CDC.
Vicki Legion

CHW Training Program
1600 Holloway Avenue
San Francisco, CA 94132
415 338-3034
415 338-7948 (fax)
vlegion@sfsu.edu

(Please obtain permission before quoting.)

fn: researchroundup/pr

There is exciting potential for the San Francisco Bay Area to take a national leadership role in pushing research and policy questions ahead. There is a remarkable constellation of resources concentrated here:

1. A city Department of Health (San Francisco) with a strong commitment to the potential role of health workers;
   
2. A state California Conference of Local Health Officers whose leadership is committed to CHWs;
   
3. Dynamic community organizations with long histories in the CHW field, and strong CHW leaders;
   
4. A strong partnership of a state university and community college with a deep commitment to CHWs, as well as a proven applied research and training record, and the ability to prepare a wide range of health professionals: San Francisco State University and City College of San Francisco.
   
5. A leading health national professional education and policy institute with a commitment to CHWs, the Pew Health Professions Commission at UCSF

Because of the promise shown in these studies, the CHW Training Program advocates for a significant social investment in expanding and systematizing this body of research. This investment by government and private funders should be of a parallel scope and scale to that made in proving the effectiveness of mid-level practitioners in primary health care. To establish the nurse practitioner and physician's assistant fields, a significant investment was made in research, national training centers, and policy work.

Related to the health delivery research questions, there is a need for exploration of the health policy questions regarding CHWs and community health teams. What have been the policy and reimbursement issues that have kept the Community Health Worker role from developing further here in the US? Does the current flux in the health system open new potential for the field to advance?

© SFSU/CCSF Community Health Works of San Franciso, 1997.
For more information contact: CHTDC, Department of Health Education, 1600 Holloway Ave., San Francisco, CA 94132.
Phone: 415/338-3034 Fax: 415/338-7948 Email: chw@sfsu.edu

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