The integration of community health workers (CHW) into existing home visiting practice has not been widely tested but holds promise for greater efficiency and impact on the health and well-being of families. Every Child Succeeds (ECS) research about an integrated team service model that maximize the skills and strengths of CHW and professional home visitors is an important next step. CHW are becoming part of the medical and community health systems across the country. With Medicaid agencies in states such as Ohio, Massachusetts, Minnesota, New Mexico, and Wisconsin investing in CHW, home visiting leaders must learn more about how to optimize CHW roles within a community-based team (Johnson et al, 2012; Rosenthal et al, 2010). New community teams, with well- defined roles and responsibilities, could lead to improved program efficiency, earlier engagement and longer program retention, and improved outcomes..
ECS pilot of a team approach for professional home visitors and community health workers
Combining state Medicaid and private philanthropic funding, ECS is developing and conducting a pilot project in 2017-2018 that will combine evidence-based home visiting with CHW. As part of Ohio’s effort to reduce infant mortality, funding has been provided through five Medicaid managed care entities to support additional CHW in select high-risk communities. In Hamilton County, Cradle Cincinnati received this two-year Ohio Medicaid funding to support the deployment of 12 CHW to help reduce infant mortality in 16 high-risk zip codes. Three CHW positions were allocated to ECS using these resources. With additional funding from the Bethesda Foundation, ECS researchers will evaluate how to maximize the respective roles of home visiting programs and CHW in supporting families at higher risk.
ECS is developing and studying an integrated, team approach that combines home visiting (accredited by Healthy Families America) with services delivered by CHW. In this pilot project, ECS will leverage and integrate the complementary expertise of home visitors and CHW. Home visitors will deliver intensive, evidence- based home visiting focused on healthy pregnancies, parenting, child development, and family self-sufficiency. CHW will engage in community-level outreach, recruitment, baseline risk assessment, and connecting families to resources that address social determinants of health.
The project design anticipates that clear delineation of roles and leveraging of differential expertise will optimize outcomes for children and families. The pilot project seeks to deliver measurable results in areas including:
- More effective recruitment of pregnant women or women with infants to home visiting;
- Earlier prenatal engagement in home visiting;
- Longer home visiting program retention;
- Greater adherence to home visit schedules;
- More successful and completed referrals and follow up; and
- Improved parenting, health status, and nurturing home environments.What do we know about community health workers?ECS has reviewed the literature on the role of CHW in the community, in improving maternal and child health, and in working as part of community-based teams.
To download our list of resources and references on CHW, click here: REFERENCES.
In brief, a series of studies indicates that CHW can be strongly connected to communities and have the ability to engage at-risk families. CHW provide: linkages to health care, care coordination, culturally appropriate health education, coaching, and community capacity building (Hohl et al, 2016; Islam et al, 2015a; Cosgrove et al, 2014; Brownstein et al, 2011; Witmer et al, 1995). Care coordination linked to medical homes has been a strength (Matiz et al, 2014; Mooney et al, 2014).
When engaged as health educators and agents for outreach, enrollment, and information agents, CHW appear to increase healthy behaviors in patients, especially for minority women (Willock et al, 2015; Kangovi et al, 2014; Andrews 2004; Becker, 2004). Health effects appear strongest for interventions to prevent worsening of chronic disease and promote preventive health behaviors among adults (CG-CVD;Costa 2015;AHRQ- Viswanathan 2009). Interventions that engage CHW as part of team-based health care have shown promise, particularly working with nurses and other health professionals (Landers & Levinson, 2016; Siemon et al, 2015; Zandee et al, 2013; Ingram et al, 2012; Brownstein et al, 2011). In team interventions, CHW can reduce disparities and enhance health equity (Hohl et al, 2016; Islam 2015; Katigbak et al, 2015; CG-CVD; Zandee et al, 2013; Cochrane- Lewin 2010).
Perhaps most important for home visiting programs, studies suggest that program success can result from CHW working in teams with nurses and other health professionals (Raffo el al, 2017; Meghea et al, 2013; Roman et al, 2012; Roman et al, 2009; Roman et al, 2007; de la Rosa et al, 2005; Barnes-Boyd et al, 2001). Working alone, CHW and other paraprofessional home visitors have not been as effective (Olds et al, 2004; Korfmacher et al, 1999). For pregnant women and infants, CHW implementing the Pathways Model (which incorporates care plans and protocols toward specific measurable outcomes) may enhance access to prenatal services and reduce the incidence of low-birthweight births among at-risk clients, including both white and black women. This is particularly true in some federal Healthy Start infant mortality reduction sites using CHW in teams (AHRQ HCIE-Redding; AHRQ HCIE-Roberts). Some studies of CHW also show increased breastfeeding among low income women and African American women (Furman & Dickinson, 2012; Cochrane-Lewin 2010).
What challenges can be addressed by using teams of professional home visitors and CHW?
Incomplete referrals and poorly coordinated service systems are a substantial problem among higher risk families with young children. Services are often fragmented and/or difficult to access. Referrals for nutrition, housing, mental health, developmental, or other services are often not effectively completed. Working as part of a team, CHW can provide an ongoing source of support in navigating service systems, resulting in reduced likelihood of families “falling between the cracks” between referrals and receipt of needed services.
For home visitors finding the time for intensive care coordination can be a challenge. For home visitors, referrals that require extensive follow up take away from time in directly educating and coaching parents. Using CHW as part of team-based primary care has shown promise, particularly working with nurses and other professionals. Using a team approach for home visiting, primary care, and CHW could increase family support and practice effectiveness.
For home visiting models that begin in the prenatal period, impact on outcomes depends on recruiting and retaining families, beginning early in pregnancy. Results of ECS research indicate that too few participating pregnant women receive the duration and intensity of home visiting needed to improve birth outcomes. This research points to the potential value of leveraging the cultural knowledge and outreach skills of CHW. Teaming with home visitors, CHW could help recruit women earlier in pregnancy and support continued participation, increasing the opportunity to improve birth outcomes. The CHW can support the family, as well as the roles of professional home visitors and health clinicians.
This is the third issue brief in a periodic series by Every Child Succeeds. The first brief described a pilot QI program linking home visiting and primary care. The second brief focused on the topic of “what works best for whom”. Please visit our website to download briefs and learn more about our work.