Strengthening the Effectiveness of State-Level Community Health Worker Initiatives Through Ambulatory Care Partnerships

Empowering Underserved Communities in Southern Puerto Rico: A Formal Training Program in Community Health Promotion

Community health promotion offers a potential solution to persistent healthcare challenges, with community health workers playing a pivotal role. The Community Training Institute for Health Disparities (CTIHD) implemented a problem-solving curriculum in Community Health Promotion, integrating a competency-based learning model through two courses: Introduction to Community Health Promotion and Design of an Action Plan for the Promotion of Community Health. Each course comprised ten three-hour sessions, featuring pre/post-tests, evaluations, and a cognitive debriefing. Knowledge change was assessed using pre/post-test scores among 27 community leaders from southern Puerto Rico. Cohort 1 and Cohort 2 demonstrated an overall retention rate of 62.6% and 96.7%, respectively. Although differences in knowledge gained between cohorts and courses weren't statistically significant, a trend toward increased knowledge was noted. Cohort 1 experienced a 22% knowledge increase in Course 1 and a 24% increase in Course 2. Cohort 2 demonstrated a 41% knowledge increase in Course 1 and a 25% increase in Course 2. The CTIHD's Community Health Promotion Program has made significant strides in elevating awareness and knowledge, marking a positive step toward reducing health disparities and fostering healthier, empowered communities in southern Puerto Rico.

A Review of Community Health Worker Integration in Health Departments

Community health workers (CHWs) are frontline public health workers who bridge the gap between historically marginalized communities, healthcare, and social services. Increasingly, states are developing the CHW workforce by implementing training and certification policies. Health departments (HDs) are primarily responsible for community health through policy implementation and provision of public health services. The two objectives of this study are to explore: (1) state progress in establishing CHW training and certification policies, and (2) integration of CHWs in HD workforces. In this scoping review, we searched PubMed, CINAHL, and Google Scholar for articles published between 2012 and 2022. We looked for articles that discussed state-level certification and training for CHWs and those covering CHWs working with and for city, county, state, and federal HDs. We excluded studies set outside of the US or published in a language other than English. Twenty-nine studies were included for review, documenting CHWs working at all levels of HDs. Within the included studies, HDs often partner with organizations that employ CHWs. With HD-sponsored programs, CHWs increased preventative care, decreased healthcare costs, and decreased disease risk in their communities. Almost all states have begun developing CHW training and certification policies and are at various points in the implementation. HD-sponsored CHW programs improved the health of marginalized communities, whether CHWs were employed directly by HDs or by a partner organization. The success of HD-sponsored CHW programs and state efforts around CHW training and certification should encourage increased investment in CHW workforce development within public health.

The Role of Community Health Workers in Developing Multidimensional Organizational Relationships

Effective care coordination relies on organizations working collaboratively to meet medically and socially complex participants' needs. This study examines community health workers' (CHWs') roles in developing the organizational relationships on which care coordination efforts depend. Semistructured interviews (n = 13) were conducted with CHWs, CHWs' supervisors, and executive staff at organizations participating in a Washington State care coordination program. Interviewees described how CHWs developed and furthered multidimensional relationships in service of participants between and within participating organizations, as well as external organizations. Relationship-building challenges included COVID-19, geographic context, and staffing. The study concludes with considerations for care coordination efforts to support CHWs.

Barriers, facilitators, and opportunities to optimize care engagement in a diverse sample of older low-income women: A qualitative study

The growing population of aging women in the United States is disproportionately at-risk for adverse physical, behavioral, mental, and psychosocial health conditions. Engagement with preventive care is critical to address these risk factors. A qualitative descriptive approach was used to explore patterns of healthcare use, facilitators, barriers, and opportunities to optimize primary/preventive care engagement among low-income midlife and older women. Themes were deductively derived from the Behavioral Model for Vulnerable Populations. Categories were inductively determined: barriers to care engagement; facilitators of care engagement; opportunities to optimize primary/preventive care engagement. Themes emerging from this study suggest that experiences related to discrimination, psychological health, trauma, and prioritizing care of others negatively influence care engagement; while respect, continuity, and clinician gender and racial/ethnic concordance enhance care participation. Efforts aiming to engage low-income aging women in care should focus on addressing barriers, building on facilitators, and leveraging contemporary telehealth-outreach solutions.

Racial disparities in treatment and outcomes of children with type 1 diabetes

OBJECTIVE

The aim of this study was to assess racial disparities in treatments and outcomes between Non-Hispanic black (NHB), Hispanic and Non-Hispanic white (NHW) children with type 1 diabetes (T1D).

METHODS

We reviewed electronic health records of children (<18 years) attending a large, pediatric tertiary care diabetes center in the United States between October 1, 2018, and December 31, 2019. Health care utilization (appointment attendance, ED visits, hospitalizations), technology use (insulin pumps, continuous glucose monitors [CGM]) and hemoglobin A1c (HbA1c) were examined for each race/ethnicity and stratified by insurance type (private/government) as a proxy for socioeconomic status (SES).

RESULTS

Of 1331 children (47% female) with a median (IQR) age of 14.2 (11.5, 16.3) years and T1D duration of 5.8 (3.8, 9) years; 1026 (77%) were NHW, 198 (15%) NHB, and 107 (8%) Hispanic. Government insurance was used by 358 (27%) children, representing 60% of NHB and 53% of Hispanic, but only 18% of NHW children. NHB children had higher HbA1c, more ED visits and hospitalizations, and were less likely to be treated with insulin pumps or CGM than NHW children (P < .001 for all). There were no racial disparities with regard to the number of appointments attended.

CONCLUSIONS

Racial disparities in technology use and diabetes outcomes persist in children with T1D, regardless of insurance status. To ensure equitable care, pediatric healthcare providers should remain cognizant of racial disparities in diabetes treatment. The impact of provider and patient factors should be explored when studying the etiology of these health disparities.

Insulin Pump Use in Children with Type 1 Diabetes: Over a Decade of Disparities

PURPOSE

Racial disparities have been shown in outcomes and treatment of children with type 1 diabetes (T1D). The purpose of this study was to examine temporal trends in insulin pump use among non-Hispanic white (NHW), non-Hispanic black (NHB) and Hispanic children attending a large urban diabetes center. . This study was a retrospective chart review of insulin pump usage by race (NHW/ NHB) in 2005, and race/ethnicity (NHW/NHB/Hispanic) in 2011-2019. Demographic data (age, sex, diabetes duration, SES) and most recent hemoglobin A1c were also abstracted in 2011-2019.

RESULTS

In 2005, NHW children were twice as likely to use an insulin pump as NHB children. From 2011 to 2019, the odds ratio increased to 2.5 for NHW compared to NHB children. The odds of Hispanic children using insulin pumps were also higher than NHB. Insurance status (government versus private), a surrogate for SES, had very little influence on these trends, with NHW children consistently more likely than NHB children to be treated with insulin pumps in 2011, 2013, 2017, 2019 (p < 0.001).

CONCLUSIONS

We have demonstrated that racial disparities in insulin pump use have persisted over the past 15 years, and are not determined by SES. This inequity in diabetes treatment may be playing a role in the poorer glycemic control and higher rates of diabetes complications in NHB children.

PRACTICE IMPLICATIONS

Healthcare providers should be cognizant of racial and ethnic disparities in the treatment of children with T1D. Standardized treatment protocols may reduce unconscious bias in prescribing.

Diabetes Management in Community Health Centers: a Review of Policies and Programs

PURPOSE OF REVIEW

Community health centers (CHCs) provide care to millions of vulnerable patients in the USA, including a disproportionate number with diabetes. Policies affecting diabetes management in CHCs therefore have broad implications for clinical practice and patient outcomes nationwide. We describe prior policies that have influenced diabetes management in CHCs, discuss current policies and programs, as well as present emerging innovations and future directions for diabetes care in this setting.

RECENT FINDINGS

Domains for current diabetes policies and programs in CHCs include coverage requirements, quality reporting and incentives, prescription discounts, healthy behavior incentives, and team-based care. Policies in these areas affect the management of diabetes at multiple levels, from organizations that support CHCs to individual health centers, and the providers and patients based there. Several domains of interrelated policies and programs impact CHC diabetes management at multiple levels. Stakeholders' understanding of these policies and programs may identify opportunities to improve diabetes care.

Successes and Lessons Learned From Implementing Community Health Worker Programs in Community-Based and Clinical Settings: Insights From the Gulf Coast

CONTEXT

Community health workers (CHWs) are an increasingly viable component of the American health system. While organizations may be interested in incorporating CHWs into the health care workforce, there are challenges to doing so.

OBJECTIVE

This study characterizes the successes and lessons learned from implementing new CHW programs in clinical and community-based settings in 4 US Gulf states.

DESIGN

Semistructured interviews were conducted with CHWs and their supervisors.

SETTING

Interviews were conducted with participants in 16 community-based organizations and federally qualified health centers located in coastal counties and parishes of Louisiana, Florida, Alabama, and Mississippi.

PARTICIPANTS

Study participants consisted of 22 CHWs and 17 CHW supervisors.

RESULTS

Although most challenges and strategies were reported by participants working in both clinical and community-based settings, some were workplace-specific. Participants from predominantly clinical settings described the importance of strengthening organizational cohesion and coordination, whereas participants from community-based participants discussed the need for specialized training for CHWs. In both work environments, participants indicated that CHW functioning was constrained by limited organizational resources, difficulty accessing the client population, and limited knowledge regarding the CHW's scope of practice. Strategies to improve CHW functioning in both settings included investing in local partnerships, streamlining resources, prioritizing strong communication and outreach, and establishing explicit operating procedures. The majority of participants noted that challenges lessened over time.

CONCLUSIONS

Evaluating successes and lessons learned in CHW work is critical to maximize CHWs' abilities to address clients' health needs and promote health in underserved communities. This study provides important insights into how to successfully integrate CHWs into the public health workforce.

What Is It Like to Experience Improved Care Coordination Through a Community Outreach Program? A Qualitative, Descriptive Study

Community-based programs deploying community health workers (CHWs) who collaborate with other entities are beginning to emerge as the US health system evolves. Although these programs have used various evaluation criteria to determine program success, little research has been completed to examine the experiences of program participants as they receive these services. The purpose of this qualitative descriptive study was to describe what it was like to experience the benefit of improved care coordination through a community-based program featuring CHWs, in collaboration with community-based interprofessional providers. Knowing the help I needed emerged as the overarching theme.

Roles and Functions of Community Health Workers in Primary Care

Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.

Interventional Audiology to Address Hearing Health Care Disparities: Oyendo Bien Pilot Study

Interventional audiology, specifically community-based outreach, can connect people with the hearing health care system. Community-based participatory research methods were applied in two phases of research to: (1) investigate the needs of families affected by hearing loss in a rural Arizona community on the U.S.-Mexico border; and (2) evaluate an outreach program on hearing health. The needs assessment included interviews with persons with hearing loss and focus groups with family members and the greater community. The needs assessment revealed that despite perceived severity of hearing loss, help-seeking for audiologic care was limited due to barriers, stigma, and low self-efficacy. Results informed development of a community-based pilot study conducted as part of an academic-community partnership between audiology, public health, and community health workers of a federally qualified health center. An outreach program, Oyendo Bien (hearing wellness), a 5-week, Spanish-language health education program for older adults (n = 21) incorporated communication strategies and behavioral change techniques. Postprogram focus groups revealed increased self-efficacy and decreased stigma. After 1 year, 7 of 9 participants with hearing loss contacted for follow-up had sought some form of hearing-related health care. Future research should further investigate interventional audiology approaches to address health disparities.