© The University of Texas at El Paso Beyond Traditional Medicine: Community Health Workers –...

© The University of Texas at El Paso

Beyond Traditional Medicine: Community Health Workers – Promotores(as) de Salud

Eva M. Moya – Department of Social Work Maria Covernali – Familias Triunfadoras, Inc.

4th Annual Cultural Competence ConferenceMarch 27th, 2015

The University of Texas at El Paso

College of Health Sciences

Photographs courtesy of Nuestra Casa Initiative and Damien Schumann


Background

http://www.wfisd.net/page/609


United States

• Leads the world on medical research and technology• Vast health disparities persists• Rank 37th on the WHO scale in health performance• Highest health care costs globally (WHO, 2000).• Severe racial and economic disparities (from birth outcomes

to HIV/AIDS)• Patient Protection and Affordable Care Act of 2010 goals of

health care reform


Health Disparities in America

• Social and environmental factors including housing, education, job security, neighborhood safety, and social connectivity (social capital) have profound effects on health

• Essential to well-being of a population• Vulnerable populations are the most affected • Elderly, disabled, pregnant women and children,

the homeless (home-free) that live in poverty.• Higher rates of injury, detrimental effects on a

child’s mental health • Lack of housing, food and economic insecurity

higher rates of hospitalization


Root Causes of Disease

• Burden of diseases of obesity and diabetes

• Presence of “food deserts” • Poor health found in prison system,

agricultural and farmworkers, homeless populations and communities of color

• Strong correlations between health outcomes and education, housing, food access, and incarceration rates


In the U.S.-Mexico Border……..


Socioeconomic Status

• Low income

• Low education level

• High unemployment rate

• Three of the ten poorest counties in the U.S. are

located in the border

• Twenty-one of the counties on the border have

been designated as economically distressed areasDe Navas, Proctor, & Smith, 2011


Unique Health and Medical Characteristics of the Border

Complementary Alternative Methods

Cross-Border Service Utilization

Protective Factors

Promotores(as) de Salud or Community Health Workers


Challenges and Opportunities for Health and Human Service Professionals

a) Shortages of direct care providers

b) Primary health care providers

c) Culturally and linguistic competency

d) Multidisciplinary approach to chronic illnesses

e) Innovative training and service approaches


CHWs are a vital workforce and methodology to improve community self-sufficiency, foster meaningful use of health and human service systems, and improve health and well-being in communities with complex needs.

So….

Community Health Workers (CHWs)


History and Status of Community Health Workers and

Promotores(as)

http://justcoachit.com/blog/2012/07/06/optimize-humanize-monetiz/


History and Status

• Long history throughout time and the world.

• More than 300 years of how communities assumed the role of helping other member

• In the U.S. more than 60 years (Perez & Martinez, 2008; Moya Sanchez-Bane, 1998)

• Frontline public health professionals and advocates who are trusted members of and have an unusually close understanding of the communities they serve through ethnicity, culture, language, and life experiences.

• Bridge social/cultural barriers


Community Health Workers

• Build individuals and community capacity through a range of activities such as outreach, health education, home visiting, community organizing, informal counseling, social support, translation/interpretation and advocacy (Definition of CHW by APHA, 2010)

• Extensive research on their ability to improve quality and access to health and human systems, reduce costs and address health equity issues (Lewin et al, 2005; Swider, 2002; Ross & Patrick, 2006)

• Recent trends suggest severe shortage of medical and health professionals to meet growing demand and disease burden (Sataline & Wang, 2010)


Bridges or Puentes between communities and providers

CHW possess an asset and strengths-based orientation. “One of my first clients was a teenage mother who

had a new baby.. She was sleeping on a friend’s couch. She had nothing for the baby and she was sleeping in a cardboard box. Still, she was keeping him safe and close to her, and she seemed to desperately want to do better for herself and him. I helped the mother get diapers, clothes, and bassinet. She told me that I had given her something bigger than the stuff-I had given her hope.”

Nadia, CHW, American Red Cross


Asset Based Orientation of CHW

• Conventional wisdom and funding streams support a need-based, problem specific, reactive approach.

• CHW look for what they can work with and foster within an individual or community, by identifying what is right versus what is wrong.

“Empowerment starts with you… I have to be positive.. I have to thrive, so that I can help

others” Malik, CHW


Para mi es algo natural….

“I was a CHW before I ever knew what a CHW was and got a job that actually paid me to so this work… this is what I have been doing in my neighborhood all my life.”

Y. Ozorio, CHW Buffalo CHC


CHW are known as…

• Promotor(a) de Salud• Health navigators• Community health representatives (CHR)• Peer educators• Outreach workers• Neighborhood Aids• DHHS estimates there were 86,000 CHW in

the U.S in 2010 (HRSA, 2012); 2/3 were paid, rest were unpaid (HRSA, 2007)

• Workforce has expanded greatly


Roles and contributions

• Educate and assist persons with prescribed treatment protocols

• Possess ‘hard’ and ‘soft’ skills• Enroll individuals in coverage• Participate in health promotion and research

endeavors• Help them navigate a complex system(s) • Help place increased focus on health in a ‘holistic’

sense• May collect data to identify community needs• Complement to the usual focus on health services• Potential to contribute to the “triple aim” (improve

experience of care, improve health of population, and reduce per capital costs of health care (Berwick et al., 2008, Bisognano and Kenney, 2012)


Their Background Varies

• Personal• Health • Education training• Employment • Compensation • Time-limited, low paying (mostly) or

volunteer based


Work settings

• Homes• Clinics• Medical offices• Hospitals• Schools, universities• Rural and urban settings• Domestically and internationally organizations• Community based organizations• Faith-based settings• Interact with professionals, para professionals and

community members


CHW Create Bridges or Puentes

Figure 1. How CHWs create bridges between clients and community resources (The Urban Institute, 2013)


Education and Training of CHWs

• Soft and hard skills • On-the-job training• Formal training combines with

experience within a well-managed team

Figure 2: Roles and definitions (The Urban Institute, 2013)


Skills and Training of CHWs

Competencies include “hard skills”.• Communication• Advocacy• Referrals• Outreach • Teaching• Foundations of health“Soft skills” • Interpersonal, compassion, & empathy.


What Makes a Good CHW? (CDC 2010, Moya et al., 2013)

• Flexibility• A desire to give/share• Patience• Persistence & tenacity • Empathy• Responsibility• Honesty• Self-sufficiency• The spirit of service• Humility• Good listening

• Compassion• Sincerity • Humor• Trust• Tact• Hope• Passion• An open mind• Sensitivity • Mucho Corazon• Somos es puente


Formal Certification and State-Recognized Trainings (1990-present)

• Legislative efforts (1990’s)• Training centers/conferences

(ongoing)• In 1999, Texas passed the 1st state-

recognized certification program (8 competencies, 160-hrs or 1000 cumulative of experience within 6 years (TDSHS, 2012)

• No national standardized curricula exisits

• As of 2010, 14 states had certification programs in place


Key Elements of CHW Models

Typically work as part of multifaceted intervention

Figure 3: Key elements of CHWs interventions (The Urban Institute, 2013)

Research InterventionsDirect servicesMarket Place


Key Findings

• Language and framing social determinants of health and CHW is a challenge (population and community health)

• Workforce AND a set of principles and values

• Connectors between AND within neighborhoods and institutions


Evidence

• Increased visibility• Lead journals• Bureau of Labor Statistics recognized CHWs as a

separate occupation (BLS, 2010)

• CDC and HRSA have been supportive (CDC 2011;

HRSA 2007, 2011)

• Numerous briefs at state/national level • DHHS launched a Promotores de Salud Initiative

(OMH, 2013)

• ACA creates new opportunities for transformation


Evidence (Cont)

• Benefits (mixed) given diversity of roles and settings

• Improved immunization rates, breast feeding (Lewin et al., 2005)

• Improvements in client knowledge, management of child asthma, hypertension, DM (Bronstein et al., 2007)

• Potential to improve access, quality or cost in at least a half a dozen roles (Rosenthal et al., 1998; IOM, 2003)


Evidence (Cont)

• Highest quality reviews are the RCTs (promising evidence) (infectious control, maternal and infant) (Lewin, 2010)

• Cost and cost-effectiveness studies are rare

• More qualitative data to be collected as part of RCTs to understand what influences variation of similar interventions across locations (mixed-methods)


Despite Evidence to Support CHWs

• Workforce remains fractured and poorly organized.

• Some states have formalized a CHW workforce through training, credentialing, and reimbursement/health financing.

• Challenges in raising their profile and financial viability while maintaining the preeminence of the qualities that are impossible to regulate or even teach: cultural competence, empathy, respect, compassion, and an ability to be trusted.


To Support Employment of CHWs

• Make a business case: benefits to the funder and accrual within reasonable time

• Traditional funding sources• Grants and contracts• Medicaid payment• Governments • Private employers• Systemic financing issues


Recommendations

• Develop and build capacity for an independent CHW organization or network

• Formalize a process to train and credential CHW – increase visibility, legitimacy and earning power

• Implement neighborhood based projects that use CHWs as organizers that build capacity and inform institutional knowledge of communities they serve

• Utilize asset and strengths based versus deficit and need-based approaches


Recommendations

• Measure key indicators of success based on individual, family, and neighborhood self-sufficiency, stability and satiety and meaningful use (looks at multidimensional outcomes).

• Community based participatory research should be adopted as the primary research and evaluation mechanism.

• Messaging matters


Case management for maternal and child health: HEAL http://www.pciglobal.org/united-states/

Family Health Navigators: building bridges between families and health care systems

PCI Global experiences with Community Health Workers

http://www.pciglobal.org/united-states/

http://www.pciglobal.org/united-states/


Community Health Worker Graduates 2014https://vimeo.com/10675495

https://vimeo.com/10675495





The Border Youth Alcohol Project Brief Intervention (BI) in the Emergency Department (ED) (UMC and TTUHSC, 2013)

BI in the ED setting has generally been found to be efficacious in reducing patients’ alcohol consumption, little is known about cultural differences, especially language of the intervention, on outcomes.

Promotoras as Researchers


• The border provides a rich learning and practice environment

• CHWs have made substantial gains, culminating with the recognition in the ACA

• The factors discussed have implications for CHW teaching and social justice practice

• Build on available evidence (improvement in the social determinants of health, personal health behaviors, belter connections between high-need and health insurance care, chronic care.

• Build institutional support for CHWs & expand scope of practice

• Unique and innovative approaches are needed

Conclusion


Thank you


Photo courtesy of Nuestra Casa project

Questions, comments –

Eva M. [email protected]

(915) 747-8493

mailto:[email protected]

© The University of Texas at El Paso Beyond Traditional Medicine: Community Health Workers –...

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