Straight to the people: Community health worker advances in training, practice, and policy

CHWs have shown a unique capacity to promote positive change in underserved communities through relationships based on trust and mutual respect.  Individual projects have shown very promising results in terms of, e.g., reducing low birthweight deliveries, improving self-management of chronic diseases and increasing participation in screening services. Yet the evidence base for CHW practice remains weak due to fragmented research efforts and methodological challenges, which in turn has impeded development of coherent federal and state policy on engagement of CHWs in public health.  The lack of a common definition of the CHW occupation, and project grant funding which favors innovation, have also led to a proliferation of seemingly unrelated job titles.  Yet a consensus is emerging on a common set of generic core competencies that define CHWs as a distinct occupation, and there is a growing appreciation of the holistic, capacity-building approach CHWs apply to individual and community-level work.  We organized a national invitational conference in January 2007 to launch a national research agenda on CHWs.  I have also had the opportunity to work with HRSA to produce a national workforce study on CHWs (released in May 2007) and develop and deliver educational programs for CHWs, including community college curricula. My work has stimulated interest in the potential of CHWs among state and federal agencies, including CMS. We have been able to focus attention on the need for standards as a step toward sustainable funding for CHW services, recognizing that the CHWs themselves experience value conflicts in becoming more accountable to healthcare institutions as distinct from the community itself. Other organizations may benefit from our experience in developing standards, raising the visibility and distinct identity of the CHW workforce and learning how to manage and supervise CHWs successfully. We have developed some business models for CHW employment which may be adapted in other settings. We have also been able to interest national organizations in recognition and standards for the CHW workforce, including the American Dental Association, the National Council on Aging and the National Association of Community Health Centers. We have learned the importance of understanding and working with the actors in the system based on their incentive structure. For example, while CHWs can produce cost savings in healthcare, those savings appeal to payers and not necessarily to providers. We have learned that people with good intentions have vastly different impressions of who CHWs are and what they do. While it is also vital to involve practitioners (CHWs) in advancing this field, their employment status and attitudes of employers and other professionals make it difficult for CHWs to participate in professional development through associations and networks. With patience and persistence, we have convinced organizations such as Medicaid HMOs that CHWs may be the only answer to serious challenges confronting them. They were initially unwilling to invest their own resources to try CHW interventions, but have come to realize that clinical interventions are often ineffective for reasons that have more to do with relationship, communication and culture.