Community Health Workers Fill Gaps in Rural Healthcare

November 12, 2019 - Transportation is one of the biggest challenges to rural healthcare. Often, the most remote areas of the country do not have robust public transportation networks; and for those with access to transportation, they might have to travel for hours before reaching high-quality healthcare facilities.

Patients managing a variety of health conditions are more likely to have poorer health outcomes and lead to unhealthy lifestyles if they do not have access to high-quality healthcare.   

One strategy many health systems and government organizations are implementing to overcome this barrier is community health workers. Community health workers are members of the community trained to provide essential healthcare services, educate patients on how to live a healthy lifestyle, and coordinate care. Community health workers tend to have shared language and life experiences with the patients they are helping, making them more apt to provide care in a way that is understandable and culturally appropriate to the patient.

The use of community health workers is not limited to one patient population or one specific disease. Depending on the training community health workers receive, they can help with a multitude of populations and conditions. To articulate the diversity of gaps community health workers can fill, HealthPayerIntelligence.com spoke with three programs that are leveraging community health workers to tackle multiple conditions in patient populations ranging from newborns to the elderly.

Each program provides a unique perspective on the challenge of implementing a community health worker program but promotes similar best practices.

Help Patients Understand Where to Start

READ MORE: Strategies for Managing Chronic Conditions in Rural Areas

The Kentucky Homeplace, located in rural Kentucky, helps residents manage a slew of chronic conditions and barriers to accessing quality care. William (Mace) Baker, RN, director of the Kentucky Homeplace program, outlines the role community health workers can play managing complex chronic conditions.

“We do health coaching and teach people the basics about their chronic disease. Our services aren’t limited,” Baker explained. “People come in with different needs. We look at the whole person and their surroundings.”

Through an anecdote, Baker described how community health workers partnered with a Medicaid managed care organization to unload gravel on a rural road, which then allowed a patient to drive to a healthcare appointment. 

“That’s just one example of the many things we do,” Baker noted.

He explained that many individuals do not know the full extent of the ways community health workers can help. The Kentucky Homeplace offers clients a variety of services, from educational information to routine exams and referrals to aid in enrolling in government-funded programs.

READ MORE: Medicaid Spending Drops When Members Transition to Community Care

One of the key role community health workers at Kentucky Homeplace play is helping individuals navigate the benefits available to them. 

“A lot of folks just don’t know how to start to navigate these different programs,” Baker said. “Different programs get people in the door, and then we enroll them to screen for other barriers and needs they might have that they may not even be aware of."

Partner with Healthcare Providers

Community health workers might be met with resistance if they are seen as taking a traditional healthcare provider’s job. Providers might be resistant to giving information on patients or feel that the community health workers are stepping on their toes.

Becky Mitchell, RN, works as the program coordinator for Perinatal Health Partners in rural South Georgia, an in-home nursing care management program that helps high-risk pregnant women maximize their health outcomes and the health outcomes of their babies.

Mitchell said that to avoid being seen as a competitor to the provider community, they emphasized their work was an extension of traditional health services, not a competitor.

READ MORE: ACA Medicaid Expansion Boosted Care Access, Patient Outcomes

“Patients have to be referred to us by their primary care provider or their perinatal care provider, Mitchell said. “All of our patients still see their private providers and get their routine care. We are an extra set of eyes and ears in the home in between their doctor’s visits who then communicate back to their doctor about what we see and find.”

Each time a community health worker visits a patient, they provide information on the patient back to the referring physicians.

“The physician is a partner with us, and he gets feedback every time we see the patient to know exactly what we did while we were there, what the vital signs were, and what we discussed,” Michell continued. “We do a lot of education on what her reason for referral was, how that affects her pregnancy, and what we need to change to have the best pregnancy outcome possible.”

Working in a traditional referral system is how the Perinatal Health Partners can give their patients quick response times.

"Whenever we get a referral, we have 24 hours to attempt to contact the patient, and once we get in contact with her, we have five working days to get out and see her for the first time,” stated Mitchell.

The partnership with providers not only demonstrates that the community health workers are partners in care but emphasizes that they are an extra set of eyes on the patient to ensure the patient and her baby have the best possible health outcomes.

Leverage Funding Sources for Sustainability

Funding community health worker programs can be one of the biggest challenges to this work. One-time grants eventually expire, and programs are left wondering how to sustain the positive work they have done. In order to ensure program sustainability, many program developers begin thinking about sustainability from day one.

The Health Coaches for Hypertension Control built program sustainability into existing federal funding streams. The lead investigator of the program, Cheryl Dye, PhD, director of the Clemson University Institute for Engaged Aging, described the program as a peer-to-peer educational program that offers individuals with hypertension effective strategies to make lifestyle changes.

"We were originally grant-funded to develop the program," Dye explained. "Now it's being sustained because these organizations apply for the Older Americans Act funding. The Act has been in effect for a long time, and I don't see that stopping anytime soon."

The Older Americans Act has money set aside to support evidence-based programs, so the Health Coaches for Hypertension used their initial grant funding to help build their evidence base.

“Our program was designated as an evidence-based practice in 2018. To get this designation, you had to go through a lengthy process that required a lot of good statistics to show effectiveness,” Dye noted.

Once the program received official designation as evidence-based, community organizations could use funding from the Older Americans Act rather than relying on one-time grant funding.

The thoughtful planning in understanding where to leverage long-term sustainable funding allowed the Health Coaches program to continue promoting its work rather than disappearing when grant funding ran out.

Partner with Community Organizations

Another way to overcome the challenges of sustainable funding is to partner with community-based organizations. As Mace Baker at Kentucky Homeplace noted, if organizations’ missions align, it’s a win-win for all.

“The Department of Public Health and the University of Kentucky Center for Excellence in Rural Health, where the program is housed, have helped us sustain the program,” he said. “Our current director got the program off the ground. She’s been a champion of this program and has been able to keep it going at the government level.”

This sustainable funding source leverages the needs of both parties. Tapping into these comprehensive resources allows Kentucky Homeplace to provide better care for their members as well, connecting members to community resources.

“We’ve built a big network of partners. For our community health workers to be effective, they have to be connected to the community partners and resources,” Baker said. “A lot of our community health workers work closely with the housing authority to help get people roofs, ramps, and fix different problems around the house.”

Partnering with community organizations is essential to the success of community health workers as it allows them to recommend resources local to the patient that are likely more accessible.

Build Credibility Through Evidence

One of the most significant ways to gain credibility around the effectiveness of a community health worker program is to help build the evidence.

"Evidence-based is important because you don't want anybody doing something that's not evidence-based. Everything in medicine is evidence-based, and that's what everybody expects it to be," Mitchell said.

Mitchell noted that having strong evidence for the Perinatal Health Partner’s effectiveness helped them gain buy-in from providers.

 “You’ve got the evidence that what you’re doing is going to work instead of just trying this for two or three years,” she continued.

Promoting evidence-based practices also gives credibility to the program to the patient population the programs are serving.  

“You want everything that you tell a patient to be evidence-based so that you have the credibility that you need in the community,” reiterated Mitchell.

Measure Success in a Variety of Ways

Qualitative success stories are useful, but quantitative measures of success help demonstrate success to stakeholders and further provide evidence for support of the program.

Dye said the Health Coaches for Hypertension Control measured success in multiple ways.

“We tracked process, impact, and outcome variables,” she said.

Process measures included how health coaches were recruited, the training curriculum, and the measurement of the health coaches’ ability to gain the skills they need to be effective leaders. All of these measures aimed to understand if the program was running effectively and helped ensure resources were in place for the program to run efficiently.

Impact measures included demonstrated the effect of the program on individuals.

"The impact measures were things like changes in knowledge, changes in readiness to make a health behavior change, changes in behaviors themselves," Dye continued. "We used a health risk appraisal that was pretty extensive and created personalized reports for each participant so they could see where their strengths were and where there were areas for improvement.”

The final measures that Dye and her team examined were traditional clinical outcome measures, including changes in blood pressure, BMI, triglyceride, and glucose levels. These conventional measures of success demonstrated not just a change in attitude, but also a change in physical well-being.

Using all three ways to measure a program's success helped Health Coaches for Hypertension Control demonstrate their effectiveness no matter how their data was sliced.

“There’s just not enough resources and time to implement programs that haven’t been tested. It’s a matter of efficiency to choose programs that are evidence-based practices,” Dye explained.

Promote Individual Patient Connections

One of the primary reasons community health worker interventions have been proven effective across populations and disease type is because of the personal connection with patients the programs promote. Baker, Mitchell, and Dye all emphasized the importance of individual patient connections their community health workers provide.

“Being in a patient’s home and seeing them as frequently as we do, we can spend as much time as that patient needs us to with them,” Mitchell emphasized. “They start to trust us a whole lot and open up, telling us things they may not even consider telling their physician.”

Beyond the individual, community health workers understand their patient's context. Being integrated into the community, health workers understand the uniqueness of each community and the resources in it.

“The peer coaches know the people in the community. They know the norms and values, but they also understand that you keep it confidential,” Dye emphasized. “If you have a peer leader that can assure confidentiality of anything they discuss, you can get over some of these barriers. If you don’t understand the rural culture, it’s really hard to make connections.”

While this can be difficult to capture in an outcome measurement, patients and the community health workers know the benefit.

“We have a patient satisfaction survey that we put out. We know the service value,” Baker said.

Particularly in rural areas, community health workers' connection with patients can help promote positive health outcomes and trust in the medical community.

“In a rural culture, you tend to have a feeling that you need to take care of yourself. You don’t share your problems. You don’t complain. You feel like you have to be independent,” Dye concluded. "These are good traits in many ways, but at the same time, it can keep you from reaching out and getting the help you need. That's why it helps to have peer leaders in classes. They're from the community that they serve. They understand the values and norms of the community."