The U.S. healthcare system faces many challenges in meeting the medical needs of underserved and the minority populations, and reducing the cost of health care. Ensuring access to care especially for underserved and minority populations may require the use of CHWs with cultural, language, and socioeconomic characteristics of the community to bridge the heath care gap.
As demonstrated in this paper, CHWs can render basic health services under the supervision of a professional healthcare worker in a cost-effective manner. However, their deployment in medical care is dependent on competency training and better healthcare system integration. CHWs can be valuable partners in chronic disease management in minority and underserved populations who are disproportionately affected regarding screening, treatment, and mortality.
Despite the latest push by ACA to involve CHWs in population health, funding and the legal framework of operations in some states remain a major obstacle. There are no laws and regulations in nearly 50% of U.S. states in support of CHW program. In addition, programs are heavily dependent on grants and operating budgets of health care facilities which can potentially lead to premature termination of programs when the grant is terminated. This funding model is counter-productive to chronic disease management. Therefore, securing long-term funding and sustainability of CHWs in chronic disease management programs through Medicaid and
partnering with a faith-based organization may be the best strategy. Finally, despite the effort to streamline the workforce development of CHWs, severe variations exist among states in
37 This can affect the competency requirement for a CHW who has moved to a different state and wants to help his/her community as CHW.
The U.S. population has become very diverse, and the development of chronic diseases is on the rise especially among the elderly population. To this end, it is recommended that:
• States should properly regulate CHW program to ensure the continuity of chronic disease management in the community,
• Better supervision of CHWs and their defined roles within the health care system is needed for better integration, and
• CHWs should be salaried workers within the healthcare system to entice highly
competent people in the community such as retired healthcare workers, teachers, opinion leaders, etc. to participate in the program.
38 REFERENCES
Aboagye, J. K., Kaiser, H. E., & Hayanga, A. J. (2014). Rural-Urban Differences in Access to Specialist Providers of Colorectal Cancer Care in the United States: A Physician
Workforce Issue. JAMA Surg, 149(6), 537-543. doi:10.1001/jamasurg.2013.5062. Affordable Care Act (ACA, 2010). Retrieved from
https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf
Allen, C. G., Escoffery, C., Satsangi, A., & Brownstein, J. N. (2015). Strategies to Improve the Integration of Community Health Workers Into Health Care Teams: "A Little Fish in a Big Pond". Prev Chronic Dis, 12, E154. doi:10.5888/pcd12.150199
Allen, C. G., Brownstein, J. N., Satsangi, A., & Escoffery, C. (2016). Community Health Workers as Allies in Hypertension Self-Management and Medication Adherence in the United States, 2014. Prev Chronic Dis, 13, E179. doi:10.5888/pcd13.160236.
Allen, L., Williams, J., Townsend, N., Mikkelsen, B., Roberts, N., Foster, C., &
Wickramasinghe, K. (2017). Socioeconomic status and non-communicable disease behavioural risk factors in low-income and lower-middle-income countries: a systematic review. Lancet Glob Health, 5(3), e277-e289. doi:10.1016/S2214-109X(17)30058-X. Alvisurez, J., Clopper, B., Felix, C., Gibson, C. & Harpe, J. (2013). Funding community health
workers: best practices and the way forward. Retrieved from
http://www.healthreform.ct.gov/ohri/lib/ohri/sim/care_delivery_work_group/funding_chw_ best_practices.pdf
Amanda, D. C. (2011). Community health workers: the critical link to sustainable, healthy societies in low-resource settings – a model for the Baylor shoulder to shoulder foundation.
39 Retrieved from http://digitalcommons.library.tmc.edu/dissertations/AAI1507183/
(Accession number AA11507183).
American Public Health Association (APHA, 2016). Health Reform: ACA Overview. Retrieved from http://apha.org/topics-and-issues/health-reform
Association of State and Territorial Health Officials (ASTHO, 2016). Community health worker certification and financing. Retrieved from http://www.astho.org/Community-Health- Workers/CHW-Certification-Financing/
Barnidge, E. K., Brownson, C. A., Baker, E. A., & Shetty, G. (2010). Tools for building clinic- community partnerships to support chronic disease control and prevention. Diabetes Educ, 36(2), 190-201. doi:10.1177/0145721709359089
Bauer, U. E., Briss, P. A., Goodman, R. A., & Bowman, B. A. (2014). Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA. Lancet, 384(9937), 45-52. doi:10.1016/S0140-
6736(14)60648-6.
Blendon, R. J., Buhr, T., Cassidy, E. F., Perez, D. J., Sussman, T., Benson, J. M., & Herrmann, M. J. (2008). Disparities in physician care: experiences and perceptions of a multi-ethnic America. Health Affairs (Millwood), 27(2), 507-517. doi:10.1377/hlthaff.27.2.507. Borghi, J., Thapa, B., Osrin, D., Jan, S., Morrison, J., Tamang, S., . . . Costello, A. M. (2005).
Economic assessment of a women's group intervention to improve birth outcomes in rural Nepal. Lancet, 366(9500), 1882-1884. doi:10.1016/S0140-6736(05)67758-6.
Braveman, P. A., Kumanyika, S., Fielding, J., Laveist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: the issue is justice. Am J Public Health, 101 Suppl 1, S149-155. doi:10.2105/AJPH.2010.300062.
40 Brown, H. S., 3rd, Wilson, K. J., Pagan, J. A., Arcari, C. M., Martinez, M., Smith, K., &
Reininger, B. (2012). Cost-effectiveness analysis of a community health worker intervention for low-income Hispanic adults with diabetes. Prev Chronic Dis, 9, E140. doi:10.5888/pcd9.120074.
Callahan, R. (2012). MassHealth pediatric asthma bundled payment pilot. Retrieved from http://www.mass.gov/hdc/docs/2012/march/masshealth-pedi-asthma.ppt.
California Health Workforce Alliance (CHWA, 2013). Taking Innovation to Scale: Community Health Workers, Promotores, and the Triple Aim. Retrieved from
http://www.phi.org/uploads/application/files/dwjet18q0tvqvzg9iwizi6ts5shmektcxn9tntu7rr p5tugfk5.pdf
Canada Pediatric Society (n. d.). How culture influences health. Retrieved from https://www.kidsnewtocanada.ca/culture/influence
Casey, M. M., Thiede Call, K., & Klingner, J. M. (2001). Are rural residents less likely to obtain recommended preventive healthcare services? Am J Prev Med, 21(3), 182-188.
Centers for Disease Control and Prevention (CDC, 1999). Achievements in public health, 1900- 1999. Mortality and Morbidity Weekly Report. 48:29. Retrieved from
https://www.cdc.gov/mmwr/PDF/wk/mm4829.pdf
Centers for Disease Control and Prevention (CDC, 2015). Addressing chronic disease through community health workers: a policy and system level approach. Retrieved from
https://www.cdc.gov/dhdsp/docs/chw_brief.pdf
Centers for Disease Control and Prevention (CDC, 2016). States law factsheet: a summary of state community health worker laws. Retrieved from
41 Centers for Disease Control and Prevention (2017). National Diabetes Statistics Report.
Retrieved from https://www.cdc.gov/diabetes/data/statistics/statistics-report.html Centers for Disease Control and Prevention (CDC, n. d (a). Social determinates of health.
Retrieved from https://www.cdc.gov/nchhstp/socialdeterminants/definitions.html
Centers for Disease Control and Prevention (CDC, n. d (b). Chronic disease overview. Retrieved from https://www.cdc.gov/chronicdisease/overview/index.htm#ref1
Centers for Disease Control and Prevention (CDC, n. d (c). Hearts disease facts. Retrieved from https://www.cdc.gov/heartdisease/facts.htm
Centers for Disease Control and Prevention (CDC, n. d (d). Racial and ethnic approaches to community health. Retrieved from https://www.cdc.gov/nccdphp/dnpao/state-local- programs/reach/
Chin, M. H., Walters, A. E., Cook, S. C., & Huang, E. S. (2007). Interventions to reduce racial and ethnic disparities in health care. Med Care Res Rev, 64(5 Suppl), 7S-28S.
doi:10.1177/1077558707305413.
Chin, M. H., Zhang, J. X., & Merrell, K. (1998). Diabetes in the African-American Medicare population. Morbidity, quality of care, and resource utilization. Diabetes Care, 21(7), 1090-1095.
Chola, L., Nkonki, L., Kankasa, C., Nankunda, J., Tumwine, J., Tylleskar, T., . . . Study Group, P.-E. (2011). Cost of individual peer counselling for the promotion of exclusive
breastfeeding in Uganda. Cost Eff Resour Alloc, 9(1), 11. doi:10.1186/1478-7547-9-11. Clarke, M., Dick, J., & Bogg, L. (2006). Cost-effectiveness analysis of an alternative
42 health service contraction. Scand J Public Health, 34(1), 83-91.
doi:10.1080/14034940510032220.
Cligler, L., Gergen, J. & Perry, H. (2013). Supervision of community health workers. Retrieved from https://www.mchip.net/sites/default/files/mchipfiles/09_CHW_Supervision.pdf Collinsworth, A., Vulimiri, M., Snead, C., & Walton, J. (2014). Community health workers in
primary care practice: redesigning health care delivery systems to extend and improve diabetes care in underserved populations. Health Promot Pract, 15(2 Suppl), 51S-61S. doi:10.1177/1524839914539961
Cooper, R., Cutler, J., Desvigne-Nickens, P., Fortmann, S. P., Friedman, L., Havlik, R., . . . Thom, T. (2000). Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the united states: Findings of the national conference on cardiovascular disease prevention. Circulation, 102(25), 3137-3147.
Cowie, C. C., & Harris, M. I. (1997). Ambulatory medical care for non-Hispanic whites, African-Americans, and Mexican-Americans with NIDDM in the U.S. Diabetes Care, 20(2), 142-147.
Cutts, T., Gunderson, G., Carter, D., Childers, M., Long, P., Marisiddaiah, L., . . . Baker, B. (2017). From the Memphis Model to the North Carolina Way: Lessons Learned from Emerging Health System and Faith Community Partnerships. N C Med J, 78(4), 267-272. doi:10.18043/ncm.78.4.267.
Davis, k., Schoen, C., Guterman, S., Shih, T., Schoenbaum, S. C. and Weinbaum, I. (2007) Slowing the Growth of U.S. Health Care Expenditures: What Are the Options? The Commonwealth Fund. Retrieved from
43 http://www.commonwealthfund.org/publications/fund-reports/2007/jan/slowing-the-
growth-of-u-s--health-care-expenditures--what-are-the-options
Denman, C. A., Rosales, C., Cornejo, E., Bell, M. L., Munguia, D., Zepeda, T., . . . Guernsey de Zapien, J. (2014). Evaluation of the community-based chronic disease prevention program Meta Salud in Northern Mexico, 2011-2012. Prev Chronic Dis, 11, E154.
doi:10.5888/pcd11.140218.
Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017). Inequality and the health-care system in the USA. Lancet, 389(10077), 1431-1441. doi:10.1016/S0140-6736(17)30398-7. Dye, C. J., Williams, J. E., & Evatt, J. H. (2015). Improving hypertension self-management with
community health coaches. Health Promot Pract, 16(2), 271-281. doi:10.1177/1524839914533797.
Families USA (2016). Health equity and health system transformation: How states can fund community health workers through Medicaid to improve people’s health, decrease costs, and reduce disparities. Retrieved from
http://familiesusa.org/sites/default/files/product_documents/HE_HST_Community_Health _Workers_Brief_v4.pdf
Fedder, D. O., Chang, R. J., Curry, S., & Nichols, G. (2003). The effectiveness of a community health worker outreach program on healthcare utilization of west Baltimore City Medicaid patients with diabetes, with or without hypertension. Ethn Dis, 13(1), 22-27.
Ferguson, W. J., Lemay, C. A., Hargraves, J. L., Gorodetsky, T., & Calista, J. (2012).
Developing community health worker diabetes training. Health Educ Res, 27(4), 755-765. doi:10.1093/her/cyr080.
44 Findley, S. E., Matos, S., Hicks, A. L., Campbell, A., Moore, A., & Diaz, D. (2012). Building a
consensus on community health workers' scope of practice: lessons from New York. Am J Public Health, 102(10), 1981-1987. doi:10.2105/AJPH.2011.300566.
Frieden, T. R., Centers for Disease, C., & Prevention. (2011). Forward: CDC Health Disparities and Inequalities Report - United States, 2011. MMWR Suppl, 60(1), 1-2.
Gaziano, T., Abrahams-Gessel, S., Surka, S., Sy, S., Pandya, A., Denman, C. A., . . . Levitt, N. S. (2015). Cardiovascular Disease Screening By Community Health Workers Can Be Cost- Effective In Low-Resource Countries. Health Aff (Millwood), 34(9), 1538-1545.
doi:10.1377/hlthaff.2015.0349.
Gerteis, J., Izrael, D., Deitz, D., LeRoy, L., Ricciardi, R., Miller, T., & Basu. J. (2014). Agency for Healthcare Research and Quality: multiple chronic conditions chart book. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic- care/decision/mcc/mccchartbook.pdf
Goldfield, N. (2017). Dramatic Changes in Health Care Professions in the Past 40 Years. J Ambul Care Manage, 40(3), 169-175. doi:10.1097/JAC.0000000000000201.
Goodwin, K. & Tobler, L. (2008). Community health workers: expanding the scope of the health care delivery system, National Conference of State Legislatures. Retrieved from
http://www.ncsl.org/print/health/chwbrief.pdf
Graham, G. (2015). Disparities in cardiovascular disease risk in the United States. Curr Cardiol Rev, 11(3), 238-245.
Health Resource and Services Administration (HRSA, 2007). Community health worker national taskforce study. Retrieved from
45 https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/communityhealthworkforce. pdf
Hostetter, M. & Klein, S. (2015). In focus: integrating community health workers into care teams. Retrieved from
http://www.commonwealthfund.org/publications/newsletters/transforming- care/2015/december/in-focus
Hoy, W. E., Kondalsamy-Chennakesavan, S., Scheppingen, J., Sharma, S., & Katz, I. (2005). A chronic disease outreach program for Aboriginal communities. Kidney Int Suppl(98), S76- 82. doi:10.1111/j.1523-1755.2005.09814.x
Hoyert, D. L. & Xu, J. Q. (2012). Deaths: preliminary data for 2011. National vital statistics reports; volume 61, number 6. Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf
Internal Revenue Service (IRS, n. d). New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act. Retrieved from https://www.irs.gov/charities-non-profits/charitable- organizations/new-requirements-for-501c3-hospitals-under-the-affordable-care-act Institute of Medicine (IOM, 2003). In Smedley, B. D., Stith, A. Y. & Nelson, A. R. (Eds.),
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC). National Academy Press. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK220358/pdf/Bookshelf_NBK220358.pdf
Institute of Medicine (IOM, 2013). In Smith M, Saunders R, Stuckhardt L, et al., (Eds). Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington DC: National Academy Press. Retrieved from
46 Institute of Medicine (IOM, 2014). Eden J, Berwick D, Wilensky G, editors. Graduate Medical
Education That Meets the Nation's Health Needs. Washington DC: National Academies
Press Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK248024/
Islam, N., Nadkarni, S. K., Zahn, D., Skillman, M., Kwon, S. C., & Trinh-Shevrin, C. (2015). Integrating community health workers within Patient Protection and Affordable Care Act implementation. J Public Health Manag Pract, 21(1), 42-50.
doi:10.1097/PHH.0000000000000084.
Jackson, C. S., & Gracia, J. N. (2014). Addressing health and health-care disparities: the role of a diverse workforce and the social determinants of health. Public Health Rep, 129 Suppl 2, 57-61. doi:10.1177/00333549141291S211
Jarvis, J. D., Kataria, I., Murgor, M., & Mbau, L. (2016). Community Health Workers: An Underappreciated Asset to Tackle NCD. Glob Heart, 11(4), 455-457.
doi:10.1016/j.gheart.2016.10.004.
Jonas, J. R. and Kovner, A. R. (2015). Health Care Delivery in the United States, 11th edition. Kovner, Knickman Eds. Springer Publishing.
Kurian, A. K., & Cardarelli, K. M. (2007). Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis, 17(1), 143-152.
Lehmann, U., & Sanders, D. (2007). Community health workers: What do we know about them? Geneva, Switzerland. Retrieved from
http://www.who.int/hrh/documents/community_health_workers.pdf
London, K., Carey, M. & Russell, K. (2016). Community health worker certification requirements by state. Connecticut Health Foundation. Retrieved from
47 https://www.cthealth.org/wp-content/uploads/2016/02/CHW-Certificaiton-by-State-Final- Final.pdf
Martin, L. R., Williams, S. L., Haskard, K. B., & Dimatteo, M. R. (2005). The challenge of patient adherence. Ther Clin Risk Manag, 1(3), 189-199.
Martinez, J., Ro, M., Villa, N. W., Powell, W., & Knickman, J. R. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? Am J Public Health, 101(12), e1-5. doi:10.2105/AJPH.2011.300335.
Mensah, G. A., Mokdad, A. H., Ford, E. S., Greenlund, K. J., & Croft, J. B. (2005). State of disparities in cardiovascular health in the United States. Circulation, 111(10), 1233-1241. doi:10.1161/01.CIR.0000158136.76824.04.
Miller, P., Bates, T. & Katzen, A. (2014). Community health worker credentialing: states approcehes. Retrieved from https://www.chlpi.org/wp-content/uploads/2014/06/CHW- Credentialing-Paper.pdf
Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., . . . Stroke Statistics, S. (2015). Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation, 131(4), e29-322.
doi:10.1161/CIR.0000000000000152
Murdock, S. H., Hoque, N., McGehee M. (2005). Population change in the United States: implications of an aging and diversifying population for health care in the 21st century. In: T Miles; A Furino, editors. Annual Review of Gerontology and Geriatrics: Aging Health Care Workforce Issues. New York (NY): Springer Publishing Company, Inc. p. 19-63. National Cancer Institute (NCI, n. d (a). Risk factors for cancer. Retrieved from
48 National Cancer Institute (NCI, n. d (b). Cancer health disparity research. Retrieved from
https://www.cancer.gov/research/areas/disparities
National Conference of State Legislatures (NCSL, n. d). Chronic disease prevention and management. Retrieved from http://www.ncsl.org/documents/health/chronicdtk13.pdf National Rural Health Association (NRHA, n. d). Health Care Workforce Distribution and
Shortage Issues in Rural America. Retrieved from
https://www.ruralhealthweb.org/getattachment/Advocate/Policy-
Documents/HealthCareWorkforceDistributionandShortageJanuary2012.pdf.aspx?lang=en- US
Newell, K. W. (1975). Health by the People. World Health Organization, Geneva, Switzerland. Olaku, O. O., & Taylor, E. A. (2017). Cancer in the Medically Underserved Population. Prim
Care, 44(1), 87-97. doi:10.1016/j.pop.2016.09.020.
Perry, H. (2003). A brief history of community health worker program. Retrieved from https://www.mchip.net/sites/default/files/mchipfiles/02_CHW_History.pdf Plumb, J., Weinsten, L. C., Brawer, R. & Sco, K., (2012). Community-Based
Partnerships for Improving Chronic Disease Management. Department of Family & Community Medicine Faculty Papers. Paper 29. Retrieved from
http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1029&context=fmfp
Putnam, R. D. & Campbell, D. E. (2010). How religion divides and unites us. Simon & Schuster New York.
Putsch, R. W. & Joyce M (1990). Dealing with Patients from Other Cultures. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths.
49 Rifkin, S. (2008). Community Health Workers. In: Kirch W, ed. Encyclopedia of Public Health.
Berlin: Springer Reference; p 773–81.
Roberts, N. J., Younis, I., Kidd, L., & Partridge, M. R. (2012). Barriers to the implementation of self management support in long term lung conditions. London J Prim Care (Abingdon), 5(1), 35-47.
Rosenthal, E. L., Brownstein, J. N., Rush, C. H., Hirsch, G. R., Willaert, A. M., Scott, J. R., . . . Fox, D. J. (2010). Community health workers: part of the solution. Health Aff (Millwood), 29(7), 1338-1342. doi:10.1377/hlthaff.2010.0081.
Rosenthal, E. L., Rush, C. H. & Allen, C. G (2016). Understanding scope and competencies: a contemporary look at the United States community health worker field. Progress report of the community health worker (CHW) Core Consensus (C3) project: building national consensus on CHW core roles, skills, and qualities. Retrieved from
https://sph.uth.edu/dotAsset/28044e61-fb10-41a2-bf3b-07efa4fe56ae.pdf
Rural Health Information hub (n. d.). Training materials for community health workers program. Retrieved from https://www.ruralhealthinfo.org/community-health/community-health- workers/3/materials
Rush, C. H. (2012). Return on investment from employment of community health workers. J Ambul Care Manage, 35(2), 133-137. doi:10.1097/JAC.0b013e31822c8c26.
Shavers, V. L., & Brown, M. L. (2002). Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst, 94(5), 334-357.
Selby, J. V., Beal, A. C., & Frank, L. (2012). The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda. JAMA, 307(15), 1583- 1584. doi:10.1001/jama.2012.500.
50 Sidney, S., Quesenberry, C. P., Jr., Jaffe, M. G., Sorel, M., Nguyen-Huynh, M. N., Kushi, L. H., .
. . Rana, J. S. (2016). Recent trends in cardiovascular mortality in the united states and public health goals. JAMA Cardiol, 1(5), 594-599. doi:10.1001/jamacardio.2016.1326. Siegel, R. L., Miller, K. D., & Jemal, A. (2017). Cancer Statistics, 2017. CA Cancer J Clin,