Gabriel Perna | March 10, 2021
In a multi-part series, Health Evolution is examining the future of the health care workforce. As we reach the one-year mark of when the pandemic begun disrupting lives across America, how has the virus changed the mindset of CEOs and organizational leaders in terms of how they view their employees and the skills they need to cultivate? For part two, we’re exploring the rising need for community health workers and the importance of empathy in reducing disparities.
The disparities of health care facing vulnerable communities and patients, especially during the COVID-19 pandemic, is a problem that seemingly every CEO is trying to solve.
A recent survey of health care executives and clinical leaders from NEJM Catalyst explored the different initiatives that organizations are likely to try out to address care disparities: organizational commitment (59 percent), interpreter services (59 percent) and community outreach (46 percent) were listed at the top.
A less used strategy, halfway down NEJM’s list, was the idea of including social care providers—aka community health workers—as an integral part of the care team. But experts say to address these disparities, more leaders should consider cultivating and building a community health workforce in the post-pandemic future and emphasizing their importance in addressing these problems.
“I think there’s a bias in health care where we hire based on pure technical content and biomedical expertise. There’s a disconnect because those aren’t the factors that drive the bulk of health. It certainly drives the bulk of health care, but if you look at the social determinants pie and all the factors that make people healthy or unhealthy, a lot of it is social and relational,” says Shreya Kangovi, MD, the founding executive director of the Penn Center for Community Health Workers.
Kangovi’s organization helped design IMPaCT, a standardized, scalable community health worker program that’s been used successfully by health systems across the country. In one case, IMPaCT reduced hospitalizations by 65 percent, according to a study in 2018 JAMA Internal Medicine. It also doubled patient satisfaction, while increasing primary care access by 12 percent and quality by 13 percent. Another recent survey in Health Affairs found that every dollar invested in the IMPaCt intervention would return $2.47 to an average Medicaid payer within the fiscal year.
AIRnyc is also seeing success with community health workers. The South Bronx, New York-based organization leverages analytics and aims to meet people where they live, connect families to social care and build equity at the individual and community levels.
It works with providers and payers, sending out community health workers to improve outcomes for patients with various social and economic challenges, says founder and CEO Shoshanah Brown. So far, health plans and payers leveraging the program have seen a return on investment, she says. In one recent case, the program helped reduce ED visits for patients with asthma by admissions by 51 percent and hospital length of stay by 46 percent.
“What we’re seeing across the country is that we have real gaps in care to address. Community health workers have been historically undervalued in the United States, whereas in developing countries, where there aren’t sufficient doctors or health care, they have long been relied upon to address these gaps in social and health care,” says Brown. “The evidence and need to invest in community health workers are clear. Community health workers can really be an extension of a person’s care team, taking on functions and tasks that create a lot of value for everyone involved, most importantly, the patient who might need additional support around medication adherence or social service navigation.”
The power of empathy
The best community health workers, Kangovi says, may not exactly be the person you find on Indeed or through a traditional hiring platform. Instead, they may need to seek people out in the local YMCA or through grassroots organizations, she says. It’s important that the person is someone who can build trust and can understand the challenges patients are facing.
One word that seems to come up quite often when describing a productive community health worker is empathy. Jennifer Radin, chief innovation officer for Deloitte’s Health Care practice, is a firm believer that health care organizations will need to cultivate a workforce with employees who possess empathy to reduce disparities of care as they move beyond the pandemic.
“It’s not to say health care leaders and workers were not empathetic before COVID. They always were. This notion of empathy is not just an individual attribute, but an organizational one. It can be defined, measured, and increased. That will be a cultural shift coming out of this,” says Radin.
In fact, she says Deloitte is launching a study with an academic institution to test a hypothesis about empathy being a learned skill. “If you can have a role in the organization that is solely focused on creating empathic relationships and truly listening to patients and families, you can move the needle on outcomes,” Radin notes.
Brown says empathy is a critical skill in developing a community health worker because these are people who are engaging patients with multiple medical and social needs, who have most likely been underserved and marginalized. “The work starts when the patient leaves the doctor’s office,” she says. “Community health workers learn to support patients through extremely difficult challenges at critical moments such as transitions of care, and it requires a real commitment to show up for people this way.
AIRnyc has developed a curriculum for training and developing community health workers and has been hired by other agencies looking to build and professionalize this workforce. Brown says while states and organizations differ in their goals and policies around community health worker care and reimbursement models, there is a core set of competencies and functions that are consistent around the country given the state of healthcare, public health and the enormity of unmet social need. Futuro Health CEO Van Ton-Quinlivan adds that her organization has created a program that produces community health workers with behavioral health emphasis to address mental health consequences derived from the pandemic.
Shreya Kangovi, MD, The founding executive director of the Penn Center for Community Health Workers.
“I think we all want to make sure there is equity in health care and that’s why Futuro Health is investing in community health workers with behavioral health skillsets,” says Ton-Quinlivan. “The consternation with community health workers is it doesn’t have common standards. But with President Biden putting emphasis on that, perhaps at the national level it can be mimicked across the country. The faster we can train, the less variability there will be.”
Success and challenges
Of course, empathy isn’t the only skill that helps community health workers thrive. Brown says they should understand the social service landscape in a given geography and be able to navigate that to ensure patients’ needs are being met. Kangovi says effective community health workers are non-judgmental and good listeners. She also says they need to be “truly authentic” and share a common background with people they serve.
Organizational structure is essential too. Administrative and clinical leaders should understand what community health workers do in day-to-day work and not try to “over-medicalize” the role. “Our secret sauce is getting to know people as people and asking each person what they need to improve their lives and health. And then doing those things,” she notes.
Kangovi also says there should be an enabling infrastructure with supportive supervision, safety protocols and manageable caseloads. At AIRnyc, organizational support and infrastructure also comes in the form of data and analytics. Brown says that over the years the organization has built its own electronic health record and data management system.
“It’s allowed our community health workers to have tablets in the field. It’s allowed us to manage our performance and understand how we deploy resources. And importantly, it’s allowed us to report back to our clinical and payer partners,” Brown says. “The investment in data and technology, and enabling this workforce to use the technology, has allowed us to pivot from a charity that relies exclusively on philanthropy to a social enterprise that earns revenue by partnering with payers and providers to connect with and support patients and people who are vulnerable.”
What’s challenging, she says, is a fragmented landscape in health care where stakeholders are siloed, especially when it comes to technology. She says when community health workers refer patients to social services, such as a food pantry or a legal aid attorney, or even facilitate a connection to a person’s PCP, it’s not always clear that those needs are being met. These disconnects were a problem before COVID-19 and what should be clear now is that both the urgency and the opportunity to do better for vulnerable people has never been greater; the time is now for investing in tech-enabled Community Health Workers.
Another challenge incumbering organizations deploying a community health workforce is buy in and investment, Kangovi says. “Doing it the right way instead of skimping, cutting corners, or checking the boxes is important. You can’t just turn it into a case management program. That’s our instinct in health care but it’s not as effective,” she says. “It’s also a culture change. It requires changes of human resources processes.”
As Ton-Quinlivan noted, President Biden has emphasized building the community health workforce when he was campaigning last year. Kangovi, along with Rebekah Gee, MD, CEO of Healthcare Services for Louisiana State University, and Rear Admiral Susan Blumenthal, MD, senior medical advisor at amfAR, recently wrote an op-ed for CNN encouraging the federal government to direct COVID-19 dollars towards fulfilling this promise. The trio said community health workers could guide the U.S. through “public health, economic and moral recovery.”
Going beyond that, Kangovi says she would like to see Medicaid ensure that the full range of evidence-based supports that community health workers provide are considered allowable expenses. Because it is currently very narrowly defined. She also says that on top of directing COVID-19 dollars towards building a community health workforce, they need to ensure the programs are structured well and adequately financed.
“This past year, I’ve been struck by the fact, even though there has been some increasing traction from a policy and organizational standpoint, on the importance of community health workers, it hasn’t been enough. It’s easy for community health workers to be overlooked because of the same biases that plague our health system. Many community health workers are Black or Brown or Rural White. They may or may not have letters behind their name. And those same biases that plague our health system make people tend to overlook community health workers,” Kangovi says.
She notes that these people have expertise and deserve to be treated as such. Too many people aren’t willing to bring them into the fold. Giving credit to her own organization, she adds that Penn Medicine is taking the step of creating a community health worker/health care executive mentorship program.
“Even when people in health care see community health workers, they tend to co-opt them,” Kangovi says. “They see them not as leaders, but as a service workforce. They need to be at the table making programmatic and policy decisions alongside health care executives.”