Community Workers Lend Human Connection To COVID-19 Response
2020; Project HOPE; Volume: 39; Issue: 7 Linguagem: Inglês
10.1377/hlthaff.2020.00836
ISSN2694-233X
Autores Tópico(s)Mental Health Treatment and Access
ResumoLeading To HealthDeterminants Of Health Health AffairsVol. 39, No. 7: Food, Income, Work & More Community Workers Lend Human Connection To COVID-19 ResponseRob Waters Affiliations This article is part of a series on transforming health systems published with support from The Robert Wood Johnson Foundation. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/. Rob Waters ([email protected]) is an independent writer in Oakland, California, who writes about health and science and has contributed to Kaiser Health News, STAT, Mother Jones, and Psychotherapy Networker, among other publications.PUBLISHED:July 2020Open Accesshttps://doi.org/10.1377/hlthaff.2020.00836AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InReddit ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits AbstractSystems are investing in workers who come from the communities they serve to meet patient needs that extend well beyond clinic walls.TOPICSCommunity health workersHealth professionalsMental healthCOVID-19CoronavirusPandemicsPublic healthOrganization of careLow incomeSocial determinants of healthSystems of careClinicsBefore COVID-19: Philadelphia's IMPaCT community health workers, such as Orson Brown (right), visited patients, including Walter Briggs (left), in their homes. Most visits take place virtually now, but workers continue to help patients navigate the same challenges.Photo courtesy of the Penn Center for Community Health WorkersClaude Clements has spent most of his life living, working, and serving in and around the Southwest Philadelphia, Pennsylvania, neighborhood he calls home. He started at age fourteen, volunteering with a local children's mental health program mostly because he wanted to hang out with friends who went there after school. But he soon found that he enjoyed being a surrogate big brother. "I fell in love with this work," he says.He left to go to college in Tennessee for a couple of years but then came back to Philadelphia and finished his undergraduate degree at Temple University. Since then, he has devoted much of his career to working in violence prevention and youth programs. Two years ago a friend told him about a position that seemed tailor-made for him. He applied for and got the job, which has a title that pretty much summarizes his life and work: community health worker. Today, at age fifty, he is one of thirty people deployed by the University of Pennsylvania's Penn Center for Community Health Workers as part of the Individualized Management for Patient-Centered Targets program, also known as IMPaCT.According to the Bureau of Labor Statistics, almost 124,000 community health workers and health educators (a related category) are employed across the country.1 Some work for health systems and clinics, some for community-based organizations, and some for public health entities. Although there are differences in their areas of focus, all share the common goal of helping people address the many nonmedical issues in their lives that directly affect their health, including the ability to get nutritious food and housing, to find emotional and social support, to transport themselves to medical appointments, and to care for their children or elderly parents."Community health workers are almost like doctors of social services that intersect to improve health," says Asaf Bitton, a primary care physician and director of Ariadne Labs, a health system innovation center at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts. "They serve as the intersection point and advocate for our patients between the formal health care system and legal, food, housing, and behavioral health services. We've found them to be immensely valuable."Clements sees his role as helping patients meet basic needs, gain access to services, and solve problems, using his own experiences and insights to gain patients' trust. "We open the door, using health care to get in, but once we do, we try to assist the patient holistically with any issues they may be having," he says. "You name it, we do it."Now, as people across the United States and the world grapple to survive and eventually emerge from the novel coronavirus disease (COVID-19) pandemic, a growing number of health planners and advocates propose hiring tens of thousands of additional community health workers to help. An expanded community health workforce could respond to the enormous need for social, material and psychological support, helping people who have lost their incomes get food, strategize ways to pay their rent or mortgage, fill prescriptions, and figure out how to live more safely in crowded apartments. These needs are especially dire in low-income African American and Latino communities, which have been disproportionately afflicted by the virus.Two professors from Yale Law School have called for a Community Health Corps that "would put millions of Americans to work caring for one another."2 Organizations from the National Association of Community Health Workers to HealthBegins have issued similar calls, including in posts published on Health Affairs Blog.3,4 Sen. Kirsten Gillibrand (D-NY) and Sen. Michael Bennet (D-CO) have proposed creating a national Health Force to recruit, train, and employ "hundreds of thousands" of community health workers to perform contact tracing and testing and provide a range of services.5"I think community health workers in the COVID-19 era have the potential for being like the Civilian Conservation Corps [CCC] of the Great Depression," Bitton says. "We could pay huge numbers of people who will be out of work to serve their community; get trained in a set of skills, both inside and outside of health care; produce better health; and offer a massive economic, social, and medical benefit. Yes, it will cost a lot of money, but so did the CCC. We are still getting the dividends of their work many years later."Such efforts will face substantial resistance. Existing federal rules governing the Medicaid program do not generally reimburse health care providers for using community health workers. And although community health workers are comparatively inexpensive, expanding their numbers would still cost money at a time when state and local budgets are being decimated and the federal deficit is ballooning.Stepped-up contact tracing efforts aimed at identifying and counseling those who may have been exposed to COVID-19 may provide a way to hire community health workers.Stepped-up contact tracing efforts aimed at identifying and counseling those who may have been exposed to COVID-19 may provide a way to hire community health workers. In Massachusetts, for example, Partners in Health, an international health charity, has contracted with the state and hired 246 case investigators, 1,004 contact tracers, and 137 care resource coordinators, according to Eric Hansen, director of external relations. Each team of seven or eight contact tracers includes a resource coordinator to help people meet needs such as food, mental health services, and visiting nurses. The effort is slated to run until next January.Overcoming TraumaIn West Philadelphia, Clements has about twenty-five people on his caseload. Among them is a West Philly resident named Lazette Rosser. Clements has been working with Rosser, age forty-eight, since January, and visited her home twice in February. They focus on overcoming substance use and trauma, along with the struggles she has faced raising six children amid the violence and poverty that plague their city.In mid-March, as the pandemic was ramping up, Rosser's oldest son, David, was shot and killed on the street four miles from her home. His death at age thirty-three sparked fresh waves of grief in Rosser. She texted Clements with the news the same week that IMPaCT paused all home visits because of COVID-19. Clements and Rosser have connected since through telephone and video calls.In mid-April they allowed me to observe their Zoom chat. Clements starts gently: "We need to update on some things, but from the beginning I just want to say, how are you feeling? I know it's only been a month. How's everything going?"Rosser says she has had to stop watching television and remove herself from the Internet and social media. "It's too depressing for me right now," she says. "I start crying and thinking about my son."Her mood brightens as she tells him she's been listening to gospel music: "What gets me through is Yolanda Adams," she says. In two weeks, she adds, she'll have been alcohol-free for six months. He applauds and asks whether she would like to speak to a grief counselor. He also wants her to start making a plan for how she'll resist the temptations she's likely to face when she starts leaving her home."I'm going to give you a number just in case you can't reach me, and you need somebody to talk to," he says. "I know you're resilient, but you're dealing with something. We want to be real, to be honest and up-front."March was a tough month, Rosser says. Not only was her son killed, but "this virus hit, and I couldn't properly bury him like I wanted to."She says she'd like to talk to a therapist and "get started on the grieving." Then Clements provides an update on his own efforts to stay in good health: "I'm up to ten push-ups now, and I ain't had a soda in two weeks," he says. "You hold me accountable and I'll keep you accountable."Rosser returns the praise and then tells me about her relationship with Clements. "You know how you can meet somebody and see that they keep it real?" she says. "Real recognize real. I'm one of the realest persons you ever met."Clements's clients aren't the only ones dealing with stress and loss. He has lost three elderly aunts to COVID-19 in nursing homes in Virginia and North Carolina, along with a thirty-five-year-old cousin in Detroit. "I get phone calls every day," he says. "This person passed, that person passed, this person is on a ventilator. Some days I don't even want to pick up the phone."But he does, and people like Rosser are grateful. Since the pandemic, however, he and his colleagues are under strict orders aimed at preventing burnout: "At five o'clock we shut it down," he tells me. "Put up your cell phone and no work. Try to get some kind of normalcy and relax our brains."The rapport and trust between Clements and Rosser, evident when watching them interact, is key to the success that community health workers have demonstrated in many studies, both in the US and around the world. It also will be vital to the success of efforts to trace contacts and identify those who may be infected, as well as those needing services and support. That core idea, despite the novel circumstances, is not new. For all his epidemiological skills, nineteenth-century physician John Snow might not have identified the contaminated water pump behind London's cholera epidemic of the 1850s had it not been for the assistance of Henry Whitehead, the affable clergyman who knew the streets and people of West London intimately.6Paying For HealthThe program that employs Clements is not the oldest in the country, but it may be the most rigorously evaluated and one of the most carefully designed. It was started ten years ago by Shreya Kangovi, who was then a fellow, and is now an associate professor of medicine, at the Perelman School of Medicine at the University of Pennsylvania, in Philadelphia. The Affordable Care Act had just passed, which she saw as "the beginning of a shift towards paying for health rather than paying to treat sickness." She envisioned health systems investing in low-income communities because "all of a sudden, they could actually make money by improving outcomes and getting value-based payments."Kangovi and Tamala Carter, a long-time community member whom Kangovi calls a "natural ethnographer," began interviewing low-income Philadelphia residents, focusing on those who had chronic health conditions but were not superusers of health services."We interviewed about fifteen hundred patients on porches and bedsides and shelters, and asked what made it hard to stay healthy," Kangovi recalls. "They spoke about how traditional personnel in health care did not understand what life was really like. They wished for support from someone to whom they could relate, who would be nonjudgmental and who actually had lived expertise in addressing these issues."Kangovi was born in India, and she knew about the use of community health workers there dating to the 1960s, modeled after the "barefoot doctors" who addressed the health needs of rural peasants in China. She says she locked herself up for six months and read "every single paper ever written about community health workers over the last two hundred years." She was impressed by the concept of deploying trained, trusted community people to help patients with their health and social needs, but she also noted where things went awry and the errors made by programs. Some hired the wrong people or had high turnover or inadequate training or supervision. Others were narrowly focused on specific diseases or were overly clinical."Our patients were telling us loud and clear they were dying of food insecurity, of loneliness, of racism," Kangovi says. "If you're just doing a diabetes or asthma educator program, you're missing the big picture."Kangovi and a group of colleagues began working to design a program that would correct these weaknesses, apply input from patients, and follow a protocol that would allow it to scale and be replicated. In 2011 they launched IMPaCT, the program that now employs Clements. The first step was hiring the right people."You would think we want someone who's going to stand up in front of their church and be a leader," Kangovi says. "But when you talk to patients, nobody actually wants that—why would you tell your business to that person? They'll judge you. Turns out you want someone who's more of a listener than a talker, someone who's nonjudgmental and nondirective."IMPaCT's health workers must have a high school diploma and empathic personalities, and they receive a month of training in skills such as motivational interviewing. When the program began, Kangovi produced a manual describing how the work should be done. She hired two part-time workers and "followed them around for weeks with the manuals in one hand and a red pen in another," she wrote last year in the Harvard Business Review.7 When the workers diverged from the manual's recommendations and it worked, the protocols were revised. Even now, ten years on, the program continues to make adjustments, she says. "There's a real kind of lab here."The health workers are supervised not by medical personnel, but by social workers or people with public health training. One supervisor works with each team of six workers, who, before COVID-19, spent most of their time in the field, visiting patients in their homes or going to community meetings. Every six months the thirty community health workers and thirty other staff members meet for a "design jam" to review and revise their manual and procedures.The program has two groups. One serves patients from Penn Medicine outpatient clinics and the local Veterans Affairs Medical Center who need extra support. The other helps patients coming out of the hospital after treatment. In both cases, patients must be low income. Most live in certain West Philadelphia ZIP codes and have two or more chronic health conditions. They stay in the program for up to six months while they develop skills and find resources that boost their independence. The program is funded by the Department of Veterans Affairs and Penn Medicine, which finds it financially worthwhile because it reduces hospitalization of uninsured or Medicaid-insured patients, keeping beds open for those covered by higher-paying commercial insurers, Kangovi says.At the beginning of their relationships, the health workers introduce themselves to patients and get to know them, asking open-ended questions about what they think would improve their health. The health workers help each patient develop and implement an individualized action plan, communicating regularly with the clinical team to report on progress and discuss clinical issues.The workers talk with their patients once a week and lead a weekly support group aimed at building connections among patients. They assist with meal planning, organize outings to farmers markets, and convene nutrition sessions with dietitians. Clements has helped patients get cheaper medications by switching to generics and once walked to the apartment of a pregnant woman who had no working phone to bring her back to the clinic so her obstetrician could share some critical test results.Multiple studies have found that community health workers programs are beneficial. An assessment by the Centers for Disease Control and Prevention found that there was "a strong evidence base" that community health workers were effective in helping people with chronic disease and that deploying them as part of multidisciplinary teams "improved health-related outcomes."8Kangovi and her colleagues have evaluated the IMPaCT program three times in controlled trials that included more than 1,300 patients. In one trial, conducted from 2013 to 2014, 302 patients were asked to set goals for their own health.9 For six months, half of the patients were assigned to receive standard care only from a primary care practitioner; the other half also received support from a community health worker.At the end of six months, the patients who had worked with the community health workers smoked less; had lost more weight; and had lower glucose levels, better blood pressure, and better self-reported mental health than the patients who had received only standard care. After one year, they had 28 percent fewer hospitalizations than those receiving standard care.In a follow-up article published in February in Health Affairs, Kangovi's team used the outcome data from the same trial to project the savings that one team of six community health workers serving 330 patients could realize.10 They obtained data on the cost of each patient's hospitalizations and outpatient visits and calculated the cost of salaries for the health workers and their supervisors, along with expenses. They found that for a cost of $568,000, or approximately $1,720 for each of the 330 patients served, the six workers saved the Medicaid program more than $1.4 million a year, for a return of $2.47 for every dollar invested.So what might a scaled-up program cost and achieve? Kangovi offered me an estimate based on her analysis in the February article.10 It assumes that programs follow the IMPaCT model, use the same ratio of health workers and supervisors to patients, and achieve the same return on investment. In 2017 Medicaid spent about $606 billion to provide care for seventy-three million people.11 To provide support to 15 percent of those patients would require 198,000 community health workers, cost $18.6 billion, and result in savings of $46 billion a year.'A Listening Ear'In mid-March, with the COVID-19 pandemic growing, the IMPaCT program made a pivot. Home visiting was cancelled, and the program opened up, sending text messages offering short-term assistance to a larger number of patients who visited the Penn Medicine outpatient clinics than the program normally serves."Hello. This is the Community Health Worker team," the message began. "We're checking up on our patients during these stressful times with COVID. We help patients with issues like food delivery, paying bills, child care, benefits, making appointments, or just being a listening ear. Would you like us to give you a call to see how we can help?"The team thought that for the most part, it would be dealing with food deliveries or toilet paper supplies. "But when we got on the phone with our patients, they still had the same needs," Kangovi says. "People are still getting shot. People are still lonely. They're still in intimate partner abuse situations, and they're still struggling with health behavior change and smoking."Now the health workers perform intake tasks and introduce themselves to patients by phone. The distance hasn't posed a problem for Clements. Some patients still want him to accompany them to appointments, even virtually—such as one who asked him to be on the phone during a psychotherapy session."I sat there and didn't say anything, just so the patient could feel comfortable," Clements says. Another patient, a ninety-year-old woman who had been hospitalized twice with COVID-19, worried about how she would get groceries. "I got on the phone with her nephews and grandkids, and we set up a schedule for them to bring food," he says.Knowledge Of Community NeedsIn the chaotic, bewildering moment that is today, the deep personal knowledge of community needs and resources held by people like Clements is particularly valuable.In normal times, community health workers have proved effective in helping meet the diverse needs of low-income people dealing with chronic health conditions. In the chaotic, bewildering moment that is today, the deep personal knowledge of community needs and resources held by people like Clements is particularly valuable: It enables the kind of flexibility this moment demands, almost uniquely positioning these workers to address the now-magnified social needs that, unmet, turn into expensive medical crises.But if the Claude Clementses of the world are to make a dent in meeting the unique challenges created by COVID-19, their footprint within the health and social services systems will need to expand rapidly. Even before the pandemic, Kangovi was doing her best to facilitate that. She and her team have brought the IMPaCT model to programs in twenty states, providing training and technical assistance and helping them plan, hire, and deploy workers.In the past two years, University Hospital in Newark, New Jersey, has used grant funds to pay for seven community health workers and chaplains, as well as supervisors, to receive two weeks of IMPaCT training. Alyssa Lord, the hospital's executive director of community and population health services, says that the IMPaCT program is highly replicable. "If there is organizational buy-in," a health system could operationalize the program in three to four months, including recruiting, hiring, and training, she says.The Newark health workers staff a violence intervention program, visiting the bedsides of people injured by violence to help them get services as they return to the community. The chaplains serve patients who are heavy users of emergency department care, using their skills to reduce stigma and connect with patients in a community with "strong tenets of faith," Lord says.In response to the pandemic, the hospital shifted its deployment of chaplains, asking them to canvass previously hospitalized patients to see who needed help. In early May, chaplain Victor Algariv, age fifty-three, told me he had four patients with COVID-19 in his caseload of fifteen patients, one of whom was seriously ill and in an intensive care unit. He now connects with his patients by telephone or video chat.Algariv's aim is to "help patients use their spiritual resources" to deal with the health issue they are facing, as well as the previous traumas that often add to their anxiety. "One trauma connects you to the other traumas you have lived," he says. "Even though they're talking about fears and anxieties coming up now, their past experiences complicate the issue." He helps patients address their current, often pandemic-related, fears and then move on to deal with past experiences.The hospital plans to double the number of health workers and chaplains from seven to fourteen, Lord says.Promotoras De SaludIn California, Be There San Diego, a nonprofit group, has been working for a decade to reduce heart attacks and strokes in the community, especially among low-income residents. One strategy is to train community health workers in prevention techniques and to push primary care practices and clinics to hire them. In another approach, started last year, the group created a novel way to get health plans to pay for community health workers. Executive director Kitty Bailey calls it a "social IPA" (independent practice association), modeled after the groups that doctors form to contract with health systems or health plans to provide care."We figured, just like you have an IPA of physicians, wouldn't it be great to have an IPA comprised of community-based organizations that hired community health workers?" Bailey told me. So far, she has four contracts with health plans, bringing in money that goes to groups such as the Chula Vista Community Collaborative to hire promotoras de salud, or community health workers, to work with patients enrolled in health plans in Medi-Cal, California's version of Medicaid. The partnership has led to the hiring of eight workers, a number Bailey hopes to double this year. That could happen quickly if her group wins a county contract to use community health workers to perform COVID-19 contact tracing.Bailey's funding scheme may help protect one group of community health workers, but many more of the 5,700 community health worker positions currently filled in California may be lost, especially if their funding comes from the state. Like most states, California is facing massive budget cuts to cope with plummeting tax revenues. Eliminating these positions would undermine a valuable resource just when it's needed most.'The Best Community Health Worker Programs In The World'In recent decades community health workers have played a huge role in providing health care in parts of the world that desperately lack health professionals, especially in the face of infectious disease outbreaks. Raj Panjabi, an instructor in medicine at Harvard Medical School, believes that US policy makers would be wise to learn from those examples."The US can learn lessons from Brazil, Ethiopia, Liberia, Bangladesh, and Alaska—the best community health worker programs in the world," Panjabi says. "All of them started in response to some infectious disease epidemic."Panjabi was a medical student at the University of North Carolina at Chapel Hill when, in 2005, he returned to Liberia, the country of his birth. He had lived there until he was nine, when his family fled civil war and came to the US as refugees. When he went back to Liberia, he says, the country of 4.5 million people had just fifty-one physicians, which is as if San Francisco had only eight doctors.As he worked in rural Liberia, he saw large numbers of people "dying from conditions they really shouldn't be: complications of childbirth, untreated pneumonia, malaria, HIV." He has since joined the faculty at Harvard and founded a nonprofit, Last Mile Health, dedicated to building health care infrastructure in developing countries.In the aftermath of the 2014 Ebola outbreak, Last Mile Health worked with the Liberian government to hire and train more than 4,000 community health workers and 400 clinical supervisors. Deployed to remote parts of the country, the workers greatly boosted the number of children treated for everyday conditions such as diarrhea, pneumonia, and fever, according to a 2018 study.12Community health workers also can be rapidly trained to deliver the basic mental health treatments that will be needed to address the anxiety, depression, and suicide rates that are already rising because of COVID-19, says Vikram Patel, a professor of global health and social medicine at Harvard Medical School. Even before the pandemic, more than one billion people around the world were living with a mental health or substance use disorder, he says."The two most important consequences of COVID-19, apart from the mortality we're witnessing, are the massive amounts of young people rendered unemployed and the massive need for care," Patel says. "This model provides an answer to both problems."In recent years he and others have trained hundreds of community mental health workers and measured their impact in controlled studies. In Uganda; Pakistan; and Goa, India, lay counselors were trained to deliver psychosocial interventions for depression or anxiety. In all three trials, more than 70 percent of those cared for by trained community members recovered. In comparison villages, fewer than half recovered.13–15"The question, Is it effective for a community health worker to deliver a psychological treatment?, is a done deal," Patel says. "Now the question is, How do you scale this up?"He created a not-for-profit initiative called Empower, whose mission is to create digital training materials that can enable "anyone, anywhere, to master the delivery of evidence-based psychological treatments." The digital trainings are nearly as effective as face-to-face trainings and offer the only way to rapidly deliver care at the scale needed, he says."We don't have a choice," he adds. "We've been doing business as usual for a hundred years, and look where we are."'When This Settles Down'The COVID-19 pandemic is decimating the ability of state and local governments to fund the very expansion that is needed.After years of demonstrated effectiveness, but only incremental growth in numbers, the future of community health workers seems to hang in the balance. At the very time that advocates are calling for expanding their numbers to meet the massive needs of the moment, the COVID-19 pandemic is decimating the ability of state and local governments to fund the very expansion th
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