Community-Clinical Linkages With Community Health Workers in the United States: A Scoping Review

Telehealth Care Through Internet Hospitals in China: Qualitative Interview Study of Physicians' Views on Access, Expectations, and Communication

BACKGROUND

Internet hospitals in China are an emerging medical service model similar to other telehealth models used worldwide. Internet hospitals are currently in a stage of rapid development, giving rise to a series of new opportunities and challenges for patient care. Little research has examined the views of chronic disease physicians regarding internet hospitals in China.

OBJECTIVE

We aimed to explore the experience and views of chronic disease physicians at 3 tertiary hospitals in Changsha, China, regarding opportunities and challenges in internet hospital care.

METHODS

We conducted semistructured qualitative interviews with physicians (n=26) who had experience working in internet hospitals affiliated with chronic disease departments in 3 tertiary hospitals in Changsha, Hunan province, south central China. Interviews were transcribed verbatim and analyzed by content analysis using NVivo software (version 11; Lumivero).

RESULTS

Physicians emphasized that internet hospitals expand opportunities to conduct follow-up care and health education for patients with chronic illnesses. However, physicians described disparities in access for particular groups of patients, such as patients who are older, patients with lower education levels, patients with limited internet or technology access, and rural patients. Physicians also perceived a gap between patients' expectations and the reality of limitations regarding both physicians' availability and the scope of services offered by internet hospitals, which raised challenges for doctor-patient boundaries and trust. Physicians noted challenges in doctor-patient communication related to comprehension and informed consent in internet hospital care.

CONCLUSIONS

This study explored the experience and views of physicians in 3 tertiary hospitals in Changsha, China, regarding access to care, patients' expectations versus the reality of services, and doctor-patient communication in internet hospital care. Findings from this study highlight the need for physician training in telehealth communication skills, legislation regulating informed consent in telehealth care, public education clarifying the scope of internet hospital services, and design of internet hospitals that is informed by the needs of patient groups with barriers to access, such as older adults.

Community Health Worker Intervention for Newborns Not Passing Initial Universal Hearing Screening

BACKGROUND

Universal newborn hearing screening (UNHS) is effective in identifying newborns with possible hearing loss (HL). Outpatient follow-up for newborns referred after hospital-based screening remains a potential area of improvement. In this study, we evaluate the efficacy of a community health worker (CHW) intervention in promoting adherence to outpatient rescreening for newborns referred after initial UNHS.

METHODS

A mixed prospective-retrospective cohort study was performed to evaluate a CHW intervention at an academic medical center. Caregivers of referred newborns were contacted by CHWs prior to discharge and educated about HL and the importance of follow-up screening. The CHW outreach intervention was performed for 297 referred newborns between May 2020 and June 2021 and compared to a cohort of 238 newborns without the CHW intervention between March 2019 and June 2021. Statistical analyses were conducted using 2 × 2 Chi-square tests, two-tailed unpaired t-tests, multinomial logistic regression, and multiple linear regression.

RESULTS

In the intervention group, 236 of 297 newborns (79.5%) completed their outpatient follow-up rescreening; in the comparison group, 170 of 238 newborns (71.4%) completed their follow-up rescreening (P = .031, OR = 1.55 with regression P = .04). In the intervention group, the average time to follow-up was 13.4 days versus 12.5 days for the comparison group (P = .449, multiple R2 = .02 with P = .78).

CONCLUSIONS

CHW outreach intervention may increase adherence to outpatient follow-up rescreening for newborns referred after initial, hospital-based UNHS. Expansion of nursery teams to include CHWs may thus improve completion of recommended follow-up hearing screens.

Factors influencing community-facility linkage for case management of possible serious bacterial infections among young infants in Kenya

Despite evidence showing the feasibility and acceptability of implementing the World Health Organization's guidelines on managing possible serious bacterial infection (PSBI) in Kenya, the initial implementation revealed sub-optimal community-facility referrals and follow-up of PSBI cases. This study explores facilitators and barriers of community-facility linkages in implementing PSBI guidelines in Busia and Migori counties, Kenya. We used an exploratory qualitative study design drawing on endline evaluation data from the 'COVID-19: Mitigating Neonatal Mortality' project collected between June and July 2022. Data include case narratives with caregivers of sick young infants (0-59 days old) (18), focus group discussions with community health volunteers (CHVs) (6), and in-depth interviews with facility-based providers (18). Data were analysed using an inductive thematic analysis framework. Between August 2021 and July 2022, CHVs assessed 10 187 newborns, with 1176 (12%) identified with PSBI danger signs and referred to the nearest facility, of which 820 (70%) accepted referral. Analysis revealed several factors facilitating community-facility linkage for PSBI treatment, including CHVs' relationship with community members and facilities, availability of a CHV desk and tools, use of mobile app, training and supportive supervision. However, challenges such as health system-related factors (inadequate providers, stockout of essential commodities and supplies, and lack of transport/ambulance) and individual-related factors (caregivers' refusal to take referrals) hindered community-facility linkage. Addressing common barriers and fostering positive relationships between community health workers and facilities can enhance acceptance and access to PSBI services at the community level. Combining community health workers' efforts with a mobile digital strategy can improve the efficiency of the identification, referral and tracking of PSBI cases in the community and facilitate linkage with primary healthcare facilities.

"Too Many Jobs and Not Enough Hands": Immigrant and Refugee Community Health Workers at the Frontlines of the COVID-19 Pandemic

Refugees and immigrants have experienced heightened health inequities related to COVID-19. As community-embedded frontline health personnel, refugee and immigrant community health workers (riCHWs) played essential roles in the provision of informational, instrumental, and emotional support during the unprecedented first year of the pandemic. Despite the importance of this workforce, riCHWs are at high risk for burnout due to low recognition and demanding workloads. This was exacerbated as riCHWs navigated a new and uncertain health delivery landscape. We sought to glean insight into riCHWs' stressors, coping strategies and resources, and self-efficacy to identify ways to support their work and wellbeing. Using a narrative inquiry approach, we conducted semi-structured, in-depth interviews with 11 riCHWs working in a midsized city in the midwestern United States. We generated three distinct yet interrelated themes: (1) Rapid and trustworthy information is key, (2) Creativity and perseverance are good … structural support is better, and (3) Integrating riCHW expertise into health promotion programming and decision-making. Although riCHWs were deeply committed to enhancing community wellbeing, quickly shifting responsibilities in tandem with structural-level health inequities diminished their self-efficacy and mental health. riCHWs relied on work-based friends/colleagues for informational and emotional support to enhance their capacity to deliver services. Findings suggest increasing opportunities for peer support and idea-exchange, professional development, and integration of riCHW expertise in health promotion decision-making are effective strategies to enhance riCHWs' professional self-efficacy and personal wellbeing.

Implementation studio: implementation support program to build the capacity of rural community health educators serving immigrant communities to implement evidence-based cancer prevention and control interventions

PURPOSE

Rural community-based organizations (CBOs) serving immigrant communities are critical settings for implementing evidence-based interventions (EBIs). The Implementation Studio is a training and consultation program focused on facilitating the selection, adaptation, and implementation of cancer prevention and control EBIs. This paper describes implementation and evaluation of the Implementation Studio on CBO's capacity to implement EBIs and their clients' knowledge of colorectal cancer (CRC) screening and intention to screen.

METHODS

Thirteen community health educators (CHEs) from two CBOs participated in the Implementation Studio. Both CBOs selected CRC EBIs during the Studio. The evaluation included two steps. The first step assessed the CHEs' capacity to select, adapt, and implement an EBI. The second step assessed the effect of the CHEs-delivered EBIs on clients' knowledge of CRC and intention to screen (n = 44).

RESULTS

All CHEs were Hispanic and women. Pre/post-evaluation of the Studio showed an increase on CHEs knowledge about EBIs (pre: 23% to post: 75%; p < 0.001). CHEs' ability to select, adapt, and implement EBIs also increased, respectively: select EBI (pre: 21% to post: 92%; p < 0.001), adapt EBI (pre: 21% to post: 92%; p < 0.001), and implement EBI (pre: 29% to post: 75%; p = 0.003). Pre/post-evaluation of the CHE-delivered EBI showed an increase on CRC screening knowledge (p < 0.5) and intention to screen for CRC by their clients.

CONCLUSION

Implementation Studio can address unique needs of low resource rural CBOs. An implementation support program with training and consultation has potential to build the capacity of rural CBOs serving immigrant communities to implementation of cancer prevention and control EBIs.

CLINICAL TRIALS REGISTRATION NUMBER

NCT04208724 registered.

Enhancing Diabetes Care in LMICs: Insights from a Multinational Consensus

The International Cardio-Metabolic Forum held a plenary session to establish a multinational consensus on the challenges faced in diabetes management within lower-middle-income countries (LMICs) and their potential solutions. Stakeholders, including patients, family/caretakers, healthcare professionals, and healthcare policymakers & organizations, participated in discussions. The audience of 280 doctors from 15 different countries (Pakistan, Qatar, Sri Lanka, Kenya, Myanmar, Georgia, Nigeria, Philippines, Uzbekistan, Iraq, Tanzania, Cambodia, Kazakhstan, South Sudan and Libya) was divided into 4 groups led by Group Leaders to represent each stakeholder group. Questionnaires addressing key challenges and solutions specific to each group were used to facilitate consensus development. Participants voted on relevant options based on their clinical experience. SLIDO software was used for polling, generating separate results for each group. The insights shared by healthcare professionals highlighted the importance of improving medication accessibility and cost-effectiveness for patients, emphasizing the need for adherence to treatment plans and lifestyle modifications. The significance of balanced nutrition with low glycemic index food for enhancing quality of life was recognized. Caregivers of diabetic patients with comorbidities face increasing demands for care, particularly in relation to age-related milestones. Healthcare professionals emphasized the challenges posed by cultural beliefs and health awareness, underscoring the importance of teamwork and early referral for managing comorbidities. Healthcare policymakers need to focus on disease education, awareness programs, screening guidelines, and advocacy for community and clinical screening. By addressing these challenges, a more comprehensive and effective approach to diabetes management can be achieved in LMICs, ultimately improving outcomes for individuals with diabetes.

Community-based nursing: a concept analysis with Walker and Avant's approach

BACKGROUND

Community-based nursing in recent years has received much attention from nursing schools in different countries as a suitable solution in response to existing and future problems and challenges, but there is yet no comprehensive and correct understanding of this concept and considering its importance, the present study was conducted to the aim of analyzing the concept of community-based nursing.

METHODS

Concept analysis was done using Walker and Avant's 8-step approach. Nursing dictionary, Persian dictionary, research articles, journals and conferences articles, dissertations, thesis, books, and other sources related to the concept of research were investigated through search engines and available databases using the keywords of nursing, community-based, concept analysis and Walker and Avant from 1990 to 2023. Finally, 54 articles related to the concept were reviewed and analyzed.

RESULTS

The results showed that community-based nursing has attributes such as individual-oriented/ family-oriented/ community-oriented, social partnership with the communities and stakeholders, social justice, and group and interprofessional cooperation, the community as the main activity setting, providing services based on cultural diversity, providing services according to the context, conditions and community needs, caring for individuals and families with health problems throughout life, responding to the community needs, community-based experiences and facing real-life issues in the context of community, using a problem-based and service-based approach, providing context-based care and considering factors affecting health. In this regard, borderline and related cases (community health nursing, community-oriented nursing, population-based nursing, and public health nursing) were also presented to clarify the concept. Antecedents of community-based nursing included: determining the position of community-based nursing, making infrastructure and structure, the partnership between university, hospital and community, identifying all settings, the presence of educators proficient in education, survey of community needs, having knowledge, communication and community-based skills, expanding the role of the nurse, stakeholders' attitude towards community-oriented nursing and management and financial support. Consequences of community-based nursing included: competence development in nurses, solving community-based nursing challenges, meeting the health needs of individuals, families and communities, social justice, and increasing access to health care services.

CONCLUSION

The results of this study can provide an objective and understandable image of the use of community-based nurses and their education in practice. Conducting more quantitative and qualitative studies about community-based nursing is also recommended.

Addressing knowledge gaps: the key role of community health workers and healthcare providers in human papillomavirus prevention and vaccine uptake in a border community

The Human Papillomavirus (HPV) is the most common sexually transmitted infection and nearly every person who is sexually active will get HPV at some point in their lifetime without having the HPV vaccine. Healthcare Providers (HCPs) and Community Health Workers (CHWs) play an essential role in promoting the HPV vaccine and providing education about HPV in communities. Three focus groups with CHWs (n = 17) and HCPs (n = 7) were conducted and led by trained facilitators. In addition to participating in the focus group, CHWs and HCPs completed a brief questionnaire. Focus groups were voice recorded and transcribed for qualitative analysis. Independent coders conducted content analysis to identify the salient themes of the focus groups. Several important findings emerged from this study highlighting the barriers to HPV knowledge, gaps in the self-perceived role of HPV cancer prevention, and opportunities to action. Financial, knowledge, patriarchy, behaviors, attitudes, and fears were identified as the perceived patient-related barriers to promoting HPV cancer prevention. Both CHWs and HCPs explained that their female patients are often discouraged by their husbands from seeking out sexual health-related healthcare. Finding suggest the need for community tailored education on HPV and "best practice" trainings for HPV prevention that is applicable to both CHWs and HCPs.

Evaluation of an online research best practices training for community health workers and promotoras

Introduction

Community health workers and promotoras (CHW/Ps) have a fundamental role in facilitating research with communities. However, no national standard training exists as part of the CHW/P job role. We developed and evaluated a culturally- and linguistically tailored online research best practices course for CHW/Ps to meet this gap.

Methods

After the research best practices course was developed, we advertised the opportunity to CHW/Ps nationwide to complete the training online in English or Spanish. Following course completion, CHW/Ps received an online survey to rate their skills in community-engaged research and their perceptions of the course using Likert scales of agreement. A qualitative content analysis was conducted on open-ended response data.

Results

104 CHW/Ps completed the English or Spanish course (n = 52 for each language; mean age 42 years SD ± 12); 88% of individuals identified as female and 56% identified as Hispanic, Latino, or Spaniard. 96%-100% of respondents reported improvement in various skills. Nearly all CHW/Ps (97%) agreed the course was relevant to their work, and 96% felt the training was useful. Qualitative themes related to working more effectively as a result of training included enhanced skills, increased resources, and building bridges between communities and researchers.

Discussion

The CHW/P research best practices course was rated as useful and relevant by CHW/Ps, particularly for communicating about research with community members. This course can be a professional development resource for CHW/Ps and could serve as the foundation for a national standardized training on their role related to research best practices.

An interactive national digital surveillance system to fight against COVID-19 in Bangladesh

Background

COVID-19 has affected many people globally, including in Bangladesh. Due to a lack of preparedness and resources, Bangladesh has experienced a catastrophic health crisis, and the devastation caused by this deadly virus has not yet been halted. Hence, precise and rapid diagnostics and infection tracing are essential for managing the condition and limiting its spread. The conventional screening procedure, such as reverse transcription polymerase chain reaction (RT-PCR), is not available in most rural areas and is time-consuming. Therefore, a data-driven intelligent surveillance system can be advantageous for rapid COVID-19 screening and risk estimation.

Objectives

This study describes the design, development, implementation, and characteristics of a nationwide web-based surveillance system for educating, screening, and tracking COVID-19 at the community level in Bangladesh.

Methods

The system consists of a mobile phone application and a cloud server. The data is collected by community health professionals via home visits or telephone calls and analyzed using rule-based artificial intelligence (AI). Depending on the results of the screening procedure, a further decision is made regarding the patient. This digital surveillance system in Bangladesh provides a platform to support government and non-government organizations, including health workers and healthcare facilities, in identifying patients at risk of COVID-19. It refers people to the nearest government healthcare facility, collecting and testing samples, tracking and tracing positive cases, following up with patients, and documenting patient outcomes.

Results

This study began in April 2020, and the results are provided in this paper till December 2022. The system has successfully completed 1,980,323 screenings. Our rule-based AI model categorized them into five separate risk groups based on the acquired patient information. According to the data, around 51% of the overall screened populations are safe, 35% are low risk, 9% are high risk, 4% are mid risk, and the remaining 1% is very high risk. The dashboard integrates all collected data from around the nation onto a single platform.

Conclusion

This screening can help the symptomatic patient take immediate action, such as isolation or hospitalization, depending on the severity. This surveillance system can also be utilized for risk mapping, planning, and allocating health resources to more vulnerable areas to reduce the virus's severity.

A Scoping Review of the Community Health Worker Model Used for Food Systems Interventions Within the United States

OBJECTIVE

To document and analyze the food systems interventions delivered by community health workers (CHW) serving as educators within the United States (U.S.).

DATA SOURCE

Ten databases (ie, Agricola, CAB Abstracts, CINAHL, ERIC, Proquest Social Science and Education, Proquest Theses and Dissertations, PubMed, Scopus, SocIndex, Web of Science) and gray-literature repositories were searched for publications between 2005-2020.

STUDY INCLUSION AND EXCLUSION CRITERIA

English-language and U.S. studies included with CHW as educators or facilitators for food systems interventions. Food systems defined as processes of production, processing, distribution, marketing, access, preparation, consumption, and disposal of food products. Studies excluded for clinical settings; non-adult CHWs; CHWs with medical or public health credentials; and programming guides, reviews, and commentaries.

DATA EXTRACTION

Variables included CHW and intervention description, priority population, food system processes, and targeted and unexpected outcomes.

DATA SYNTHESIS

Data were analyzed by the lead investigator and described narratively.

RESULTS

Of 43 records, CHWs educated for consumption (n = 38), preparation (n = 33), and food access (n = 22) to improve health of priority populations. Community health workers educated for the highest number of food system processes in garden-based interventions. Programs reached many underserved racial and socioeconomic populations.

CONCLUSIONS

The CHW model has been used to educate in interventions for all food systems processes and reached many diverse underserved audiences. Future work must explore garden-based food systems education and CHWs as community change agents.

Healthy Here: A Promising Referral System Model for Community–Clinical Linkages to Prevent Chronic Disease

Linking clinical services to community-based resources is a promising strategy for assisting patients with chronic disease prevention and management. However, there remains a gap in understanding how to effectively develop and implement community–clinical linkages (CCLs), especially in communities of color. The Healthy Here initiative used Stage Theory of organizational change to implement a centralized wellness referral system, linking primary care clinics to community organizations in majority Hispanic/Latinx and Native American communities. Data were collected using a standardized referral form. Facilitators and challenges were identified through semi-structured discussions with partner organizations. Between 2016 and 2021, 43 clinics and 497 health care providers made 7,465 referrals, the majority of which were from the focus populations. The average proportion of patients referred by clinic champions decreased significantly over time, reflecting diffusion of the intervention within clinics. Facilitators to system success included building on existing networked partnerships, utilizing a centralized referral center, leveraging funding, sharing data, addressing challenges collectively, incorporating multilevel leadership, and co-developing and testing a standardized referral form and process with a single clinic and provider before scaling up. Challenges included funding restrictions, decreasing referrals within clinics over time, changing availability of resources and programs, and the COVID-19 pandemic. This innovative initiative demonstrates that CCLs can be developed and implemented to successfully reach Hispanic/Latinx and Native American communities and provides strategies for overcoming challenges.

Models for establishing linkages between healthcare and community: A scoping review

Community-based programmes can support healthcare systems by delivering preventive services and health promotion. This study aimed to determine the nature, range, and extent of theoretical models that guide the development of linkages between healthcare settings and community programmes. A scoping review guided by the Joanna Briggs Institute methodology and the PRISMA-ScR was conducted. Four databases (MEDLINE, EMBASE, CINAHL and PsycINFO) were searched on August 8, 2020. Two reviewers independently screened articles by title and abstract and divided the remaining articles for full-text screening. Articles that described the development of a theoretical model to guide the establishment of linkages between healthcare settings and community programmes, were peer-reviewed, and in English, were included. Articles that solely applied linkage models were excluded. One reviewer extracted data on study and model characteristics (e.g. model purpose, model components and relationships between components from the included articles). Categorical data were summarised using frequencies and percentages. Conventional content analysis was used for variables that had lengthier descriptions and variable terminology. The search identified 8926 records. Six articles describing six unique models were included in the review. Of the four models that described intended users, three (75%) identified primary care. Healthcare settings were identified in all models, with three (50%) focusing on primary care. Models used two or more linkage strategies: (1) agreeing on sharing resources, staff, and information, (2) coordinating services and referral processes, (3) planning and evaluation, (4) leadership, policies, and funding, (5) boundary spanning and (6) brokering. All models used the linkage strategy of agreeing on sharing resources, staff, and information. Findings provide important considerations for healthcare and community programme providers planning linkages. Future research should investigate the role and characteristics of community programmes in linkages, and linkages with other types of healthcare settings.

Linkages between health systems and communities for chronic care: a scoping review protocol

INTRODUCTION

Linkages between health systems and communities may leverage community assets to address unmet needs and provide services for improved continuity and coordination of care. However, there are limited examples of specific strategies for such linkages for chronic disease management. Guided by a local need from stakeholders, this scoping review aims to clarify and map methods and strategies for linkages between communities and health systems across chronic diseases, to inform future implementation efforts.

METHODS AND ANALYSIS

The scoping review will be conducted following Arksey and O'Malley's methodological framework and latest Joanna Briggs Institute (JBI) guidelines, with continuous stakeholder engagement throughout. A structured literature search of records from January 2001 to April 2022 will be completed in MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, in addition to grey literature. Two reviewers will independently complete study selection following inclusion criteria reflecting population (chronic disease), concept (integrated care) and context (health systems and communities) and will chart the data. Data will be analysed using descriptive qualitative and quantitative methods, to map and operationalise the linkages between health systems and communities.

ETHICS AND DISSEMINATION

The scoping review does not require ethics approval as it will examine and collect data from publicly available materials, and all stakeholder engagement will follow guidelines for patient and public involvement. Findings will be reported through a summarising list of considerations for different linkage strategies between health systems and community resources and implications for future research, practice and policy will be discussed and presented. The results will also be used to inform an integrated knowledge translation project to implement community-health system linkages to support chronic pain management.

REGISTRATION NUMBER

10.17605/OSF.IO/UTSN9.

Bridge to Health/Puente a la Salud: a pilot randomized trial to address diabetes self-management and social needs among high-risk patients

Social needs contribute to persistent diabetes disparities; thus, it is imperative to address social needs to optimize diabetes management. The purpose of this study was to determine determine the feasibility and acceptability of health system-based social care versus social care + behavioral intervention to address social needs and improve diabetes self-management among patients with type 2 diabetes. Black/African American, Hispanic/Latino, and low-income White patients with recent hemoglobin A1C (A1C) ≥ 8%, and ≥1 social need were recruited from an integrated health system. Patients were randomized to one-of-two 6-month interventions: (a) navigation to resources (NAV) facilitated by a Patient Navigator; or (b) NAV + evidence-based nine-session diabetes self-management support (DSMS) program facilitated by a community health worker (CHW). A1C was extracted from the electronic health record. We successfully recruited 110 eligible patients (54 NAV; 56 NAV + DSMS). During the trial, 78% NAV and 80% NAV + DSMS participants successfully connected to a navigator; 84% NAV + DSMS connected to a CHW. At 6-month follow-up, 33% of NAV and 34% of NAV + DSMS participants had an A1C < 8%. Mean reduction in A1C was clinically significant in NAV (-0.65%) and NAV + DSMS (-0.72%). By follow-up, 89% of NAV and 87% of NAV + DSMS were successfully connected to resources to address at least one need. Findings suggest that it is feasible to implement a health system-based social care intervention, separately or in combination, with a behavioral intervention to improve diabetes management among a high-risk, socially complex patient population. A larger, pragmatic trial is needed to test the comparative effectiveness of each approach on diabetes-related outcomes.

Relationships at Work: Integrating the Perspectives of Disability Partners to Enhance a Peer Navigation Intervention

Objective

The Our Peers-Empowerment and Navigational Support (OP-ENS) community-based participatory research study developed, implemented, and evaluated a peer navigator intervention aimed at improving health and healthcare access among Medicaid beneficiaries with disabilities. Peer navigators are community partners with physical disabilities trained to deliver structured peer support interventions that can address barriers to care. The purpose of this paper is two-fold. First, it explicates the relational work the peer navigators do with peers in delivering the intervention. Second, it illustrates how our community-based participatory approach empowered peer navigators to share their knowledge to refine the intervention.

Methods

Clinical coordinator team meeting notes, critical incident documentation reports, peer navigator reflections (n = 20) were analyzed thematically to understand the peer navigators' relational work and intervention refinements. Following Labov's 6-stage approach to personal narratives and a collaborative writing process academic, clinical, and disability partners co-wrote descriptive exemplars to showcase these processes.

Findings

Through the manualized OP-ENS intervention process, peer navigators helped peers achieve incremental successes. Peer navigators used their training and personal experiences to engage with peers and forge deep connections and relationships of trust. As a result, peers identified a wide-range of social health concerns, including poverty, social isolation, and racial and disability related discrimination that might otherwise go unaddressed. True to the principles of community-based participatory research, by fostering an equity-focused collaboration and listening to peer navigators, the project team implemented subtle but salient refinements to the intervention. Refinements included an explicit focus on social determinants of health affecting peers' health and wellbeing and supplemental trainings to help peer navigators support peers with significant mental health needs.

Conclusion

The peer navigators were intentional and skilled at relationship building, thus complex elements which impact peers' health were addressed. Peer navigators were empowered to communicate their perspectives with the study team, who worked together to strengthen the intervention processes and infrastructure. This atmosphere of trust and collaboration amongst diverse stakeholders was instrumental to OP-ENS' successful implementation. Healthcare systems should consider implementing peer support interventions that are responsive to consumer input to address social determinants of health for persons with disabilities.

Adaptation of a Community Clinical Linkages Intervention to the COVID-19 Pandemic: A Community Case Study

In this community case study, we describe the process within an academic-community partnership of adapting UNIDOS, a community health worker (CHW)-led community-clinical linkages (CCL) intervention targeting Latinx adults in Arizona, to the evolving landscape of the COVID-19 pandemic. Consistent with community-based participatory research principles, academic and community-based partners made decisions regarding changes to the intervention study protocol, specifically the intervention objectives, participant recruitment methods, CHW trainings, data collection measures and management, and mode of intervention delivery. Insights from this case study demonstrate the importance of community-based participatory research in successfully modifying the intervention to the conditions of the pandemic and also the cultural background of Latinx participants. This case study also illustrates how a CHW-led CCL intervention can address social determinants of health, in which the pandemic further exposed longstanding inequities along racial and ethnic lines in the United States.

Development and Feasibility Testing of the Clinical-Community Linkage Self-Assessment Survey for Community Organizations

Introduction

Clinical-community linkages (CCLs) can improve health, but few instruments exist to evaluate these partnerships. To address this gap, we develop and test the Clinical-Community Linkage Self-Assessment Survey (CCL Self-Assessment).

Materials and Methods

We built on an existing framework and conducted a literature review to guide the design of our survey, and obtained feedback from academic, clinical, and community-based experts. To pretest the instrument, we conducted 10 think-aloud interviews with community-based health-promotion organizations. We performed feasibility testing with 38 staff from 20 community organizations, followed by criterion-validity testing.

Results

The 15-item final instrument includes five domains: Nature of the Relationship, Communication, Referral Process, Feedback Loop, and Timeliness. Expert feedback included keeping the CCL Self-Assessment brief and actionable. Think-aloud interviews produced a range of revisions related to item wording, instructions, brevity, and formatting. Feasibility testing showed high response rate and ease of administration. Sites scoring high on the CCL Self-Assessment also scored high on the criterion measure.

Discussion

We demonstrate feasibility, as well as face, content, construct, and criterion validity. Initial results suggest the CCL Self-Assessment survey may be used by community organizations to identify strengths and weaknesses of their linkages. Next steps include additional statistical validation and testing to determine how the CCL Self-Assessment survey works in the field as well as providing specific tools to improve linkages.

Community Health Worker-Led Community Clinical on the U.S. / Mexico Border: Lessons Learned

BACKGROUND

Community-clinical linkages (CCLs) connect public health organizations and health care providers to better support patients. Community health workers (CHWs), representatives from priority populations with special connections to their community, can lead CCLs.

OBJECTIVES

Our objective was to learn about how to conduct a CHW-led CCL from the perspectives of those implementing the intervention.

METHODS

We conducted focus groups with CHWs and their supervisors and regularly consulted community partners while coding and analyzing data.

RESULTS

We learned that CHWs thrive when supported by peers, supervisors, institutions, and researchers. Supervisors- who are new to the CHW role-should consider seeking training in CHW professional development and performance evaluation. Focus group participants agreed that by balancing the strengths and weaknesses of their organization, CHW-led CCLs benefit patients because the collaboration helps them to better manage their health.

CONCLUSIONS

Future CHW-led CCL practitioners should consider how to best institutionally support CHWs to maximize benefits for patients.

Community health workers and promotoras' perspectives of a research best practice course: A focus group study

Introduction

Community Health Workers and Promotoras (CHW/Ps) are valued for their role in helping to engage community members in research. CHW/Ps have traditionally received variable training in research fundamentals, including importance and promotion of research rigor to establish consistency in the methods used over time. Research best practices training exists for research professionals, but no standard training is provided as part of the CHW/P job role. To develop this CHW/P research best practices training, our team engaged English- and Spanish-speaking CHW/Ps to watch an early version of an online module and to examine perceptions of the relevance of such a training and optimal delivery methods.

Methods

Six virtual focus group discussions were conducted (three in English and three in Spanish) across different US geographic regions with currently employed CHW/Ps.

Results

Forty CHW/Ps participated (95% female, mean age 44 years, 58% identifying as Hispanic/Latino). Four themes emerged: relevance of training, benefits of providing a certificate of completion, flexible training delivery modalities, and peer-led training.

Discussion

With participation from representatives of the intended learner group of CHW/Ps, our team found that CHW/Ps valued learning about research best practices. They perceived culturally- and linguistically appropriate health research training to be highly relevant to their role, particularly for communicating key information to community members about their participation in health research. Additionally, participants provided input on effective dissemination of the training including the benefit of having proof of course completion, involvement of peer trainers, and value of providing the option to participate in online training.

Shifting to virtual breastfeeding counseling for low-income women in the US during COVID-19: A partner-engaged multimethod evaluation of program adaptations

Background

The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact.

Methods

Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources.

Results

Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions.

Discussion

BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed.

Community health worker roles and their evolving interprofessional relationships in the United States

In the United States, growing attention to the cost of care, the social determinants of health, prevention, and population health, signals a refocusing of efforts on value-based care. Just as Accountable Care Organizations and alternative payment models exemplify this shift in attention, so does the increasing integration of Community Health Workers (CHWs) into the US health care system. CHWs are often referred to as "bridge figures," helping clients to navigate what are oftentimes complicated pathways to access a variety of needed services. The integration of CHWs into interprofessional care teams is a process that takes time, and can lead to conflict as traditional care models are disrupted. Through focus groups with CHWs in rural and urban areas of four states, this work identifies and describes three early stages in the evolving interprofessional relationships between CHWs and other care providers. These stages are characterized by: (1) a lack of knowledge and understanding of CHW roles, (2) conflict and competition, and (3) engagement and integration of CHWs into patient care teams. A better understanding of the evolving process of CHW integration is critical to facilitate education and training that will more quickly encourage the development and efficacy of modern models of interprofessional care that include CHWs.

Integrating community health workers into a community hearing health collaborative to understand the social determinants of health in children with hearing loss

BACKGROUND

Children with hearing loss (HL) require coordination of care to navigate medical and social services. Strong evidence supports the role of community health workers (CHWs) to identify and address social barriers.

OBJECTIVE

The goal of this study was to evaluate the impact of integrating CHWs into the medical teams of children with HL and identify the social needs associated with their caregivers at a large urban hospital center.

METHODS

A retrospective chart review was conducted for 30 children with HL whose caregivers enrolled in a CHW program between August 1, 2017 and December 31, 2019. Baseline demographic data were collected, including social circumstances such as food and housing insecurity, status of social security supplemental income (SSI), and need for referral to early intervention (EI) or preschool/school services. Caregivers were assessed for confidence in self-management; baseline distress level was measured via a distress thermometer.

RESULTS

Of the 30 charts reviewed, 93% demonstrated social needs including food insecurity (24%) and educational service needs (45%). Eighty-seven percent of caregivers reported a sense of control over the child's condition, yet 73% reported a stress level of four or greater on the distress thermometer scale. At 3 months follow-up, 70% of patients completed referrals; a significant number of patients had obtained hearing aids and cochlear implants compared to baseline (p = 0.017).

CONCLUSIONS

Caregivers of children with HL face multiple social obstacles, including difficulties connecting to educational and financial resources. CHWs are instrumental in identifying social needs and connecting caregivers to services.

A Community Health Worker-Led Community-Clinical Linkage Model to Address Emotional Well-Being Outcomes Among Latino/a People on the US-Mexico Border

INTRODUCTION

Compared with their non-Hispanic White counterparts, Latino/a people have limited access to health resources that might improve their emotional well-being. Interventions that prioritize the Latino/a population, address social determinants of health, and decrease health disparities are needed. The objective of this study was to describe a community-clinical linkage intervention led by community health workers (CHWs) in 3 Latino/a populations along the US-Mexico border.

METHODS

Researchers at the Arizona Prevention Research Center conducted the Linking Individual Needs to Community and Clinical Services (LINKS) study during 2017-2018. Clinic-based CHWs referred participants to community-based CHWs who met with participants monthly for 6 months to assess participant needs, provide support for emotional well-being, and link them to resources. Two community-based CHWs collaborated to maximize participant care; they also administered an emotional well-being questionnaire at baseline and at 3-month and 6-month follow-up. We estimated changes in emotional well-being outcomes.

RESULTS

Scores for social support, perceived hopefulness, and quality-of-life measures among 189 LINKS participants increased significantly during the study period, especially among men and participants with low baseline scores. For each of the 3 outcomes, the standardized change was approximately 0.28 per 3 months of intervention, a decrease of more than half an SD (0.56) during 6 months of follow-up.

CONCLUSION

A CHW-led community-clinical linkage intervention can result in positive emotional well-being outcomes. We encourage policy makers, funders, and public health practitioners to further investigate such interventions as a solution to reduce disparities in emotional well-being.

Facilitators to referrals to CDC's National Diabetes Prevention Program in primary care practices and pharmacies: DocStyles 2016-2017

Despite evidence of the effectiveness of behavioral change interventions for type 2 diabetes prevention, health care provider referrals to organizations offering the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) remain suboptimal. This study examined facilitators of LCP referrals among primary care providers and pharmacists (providers). We analyzed data on 1956 providers from 2016 to 2017 DocStyles web-based surveys. Pearson chi-square or Fisher's exact tests were used for bivariate associations between facilitators, provider characteristics, and their self-reported referral and bi-directional referral (where they received patient status updates back from the LCPs) to an LCP. Multiple logistic regressions were used to estimate the effects of facilitators to referral practices, controlling for providers' characteristics. Geocoding was done at the street level for in-person, public LCP class locations and at the zip code level for survey respondents to create a density measure for LCP availability within 10 miles. Overall, 21% of providers referred their patients with prediabetes to LCPs, and 6.4% engaged in bi-directional referral. Provider practices that established clinical-community linkages (CCLs) with LCPs (AOR = 4.88), used electronic health records (EHRs) to manage patients (AOR = 2.94), or practiced within 10 miles of an in-person, public LCP class location (AOR = 1.49) were more likely to refer. Establishing CCLs with LCPs (AOR = 8.59) and using EHRs (AOR = 1.86) were also facilitators of bi-directional referral. This study highlights the importance of establishing CCLs between provider settings and organizations offering the National DPP LCP, increasing use of EHRs to manage patients, and increasing availability of in-person LCP class locations near provider practices.

Effect of Community Health Workers on 30-Day Hospital Readmissions in an Accountable Care Organization Population: A Randomized Clinical Trial

IMPORTANCE

Value-based care within accountable care organizations (ACOs) has magnified the importance of reducing preventable hospital readmissions. Community health worker (CHW) interventions may address patients' unmet psychosocial and clinical care needs but have been underused in inpatient and postdischarge care.

OBJECTIVE

To determine if pairing hospitalized patients with ACO insurance with CHWs would reduce 30-day readmission rates.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted in 6 general medicine hospital units within 1 academic medical center in Boston, Massachusetts. Participants included adults hospitalized from April 1, 2017, through March 31, 2019, who had ACO insurance and were at risk for 30-day readmission based on a hospital readmission algorithm. The main inclusion criterion was frequency of prior nonelective hospitalizations (≥2 in the past 3 months or ≥3 in the 12 months prior to enrollment). Data were analyzed from February 1, 2018, through March 3, 2021.

INTERVENTION

CHWs met with intervention participants prior to discharge and maintained contact for 30 days postdischarge to assist participants with clinical access and social resources via telephone calls, text messages, and field visits. CHWs additionally provided psychosocial support and health coaching, using motivational interviewing, goal-setting, and other behavioral strategies. The control group received usual care, which included routine care from primary care clinics and any outpatient referrals made by hospital case management or social work at the time of discharge.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day hospital readmissions. Secondary outcomes included 30-day missed primary care physician or specialty appointments.

RESULTS

A total of 573 participants were enrolled, and 550 participants (mean [SD] age, 70.1 [15.7] years; 266 [48.4%] women) were included in analysis, with 277 participants randomized to the intervention group and 273 participants randomized to the control group. At baseline, participants had a mean (SD) of 3 (0.8) hospitalizations in the prior 12 months. There were 432 participants (78.5%) discharged home and 127 participants (23.1%) discharged to a short rehabilitation stay prior to returning home. Compared with participants in the control group, participants in the intervention group were less likely to be readmitted within 30 days (odds ratio [OR], 0.44; 95% CI, 0.28-0.90) and to miss clinic appointments within 30 days (OR, 0.56; 95% CI, 0.38-0.81). A post hoc subgroup analysis showed that compared with control participants, intervention participants discharged to rehabilitation had a reduction in readmissions (OR, 0.09; 95% CI, 0.03-0.31), but there was no significant reduction for those discharged home (OR, 0.68; 95% CI, 0.41-1.12).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that pairing ACO-insured inpatient adults with CHWs reduced readmissions and missed outpatient visits 30 days postdischarge. The effect was significant for those discharged to short-term rehabilitation but not for those discharged home.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03085264.

Connecting Provider to home: A home-based social intervention program for older adults

OBJECTIVE

Patients with multiple medical conditions and complex social issues are at risk for high utilization and poor outcomes. The Connecting Provider to Home program deployed teams of a social worker and a community health worker (CHW) to support patients with social issues and access to primary care. Our objectives were to examine the impact of the program on utilization and satisfaction with care among older adults with complex social and medical issues.

DESIGN

Retrospective quasi-experimental observational study with matched comparator group.

SETTING

Community-based program in Southern California.

PARTICIPANTS

Four hundred twenty community dwelling adults.

INTERVENTION

Community-based healthcare program delivered by a social worker and CHW team for older adults with complex medical and social needs.

MEASUREMENTS

Acute hospitalization and emergency department (ED) visits in the 12 months preceding and following enrollment in the pilot program. A "difference-in-difference" analysis using a matched comparator group was conducted. Comparator group data of patients receiving usual care were obtained. Surveys were conducted to assess patient satisfaction and experiences with the program.

RESULTS

The mean age of patients was 74 years, and the program demonstrated statistically significant reductions in acute hospitalizations and ED use compared with 700 comparator patients. Pre/post-acute hospitalizations and ED visits were reduced in the intervention group. The average per patient per year reduction in acute hospitalizations was -0.66, whereas the average per patient reduction in ED use was -0.57. Patients enrolled in the program reported high levels of satisfaction and rated the program favorably.

CONCLUSIONS

A care model with a social worker and CHW can be linked to primary care to address patient social needs and potentially reduce utilization of healthcare services and enhance patient experiences with care.

Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes

OBJECTIVES

Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased health-care utilization. In this study, we describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals, and assess the correlation between SDOH, glycemic control and health-care utilization.

METHODS

Caregivers of children aged 4 to 18 years with a diagnosis of T1D of >1 year, poor glycemic control (glycated hemoglobin [A1C] ≥9.5%) or high health-care utilization (≥2 diabetes-related hospitalizations, emergency department attendances or missed outpatient appointments in the previous year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (Maternal Self-Efficacy in Diabetes [MSED] scale) and SDOH were assessed. Goals were identified after assessment by a community health worker.

RESULTS

Fifty-three families were included, most (n=48, 91%) of whom had government insurance. Children had a median age of 13.4 (interquartile range [IQR], 12 to 15.3) years and a median A1C of 11.1% (IQR, 10% to 13%). Almost half of the families (n=24, 45%) reported at least 1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [IQR, 38.5 to 70.7] vs 77.8 [IQR, 60.8 to 92.4], p=0.004), but not associated with A1C (p=0.3), emergency department visits (p=0.9) or MSED (p=0.5).

CONCLUSIONS

Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high health-care utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population.

Lay health worker as interventionist training: reflective writing in US family health promotion practice

Lay health worker-led health promotion interventions are well received within racial and ethnic minority communities. Increasing numbers of trained lay health workers will be needed to meet global health goals. The purpose of this process evaluation was to gain insights about how lay health worker as interventionists used theory-based approaches within a nutrition and physical activity health behavior change intervention in a clinical trial enrolling immigrant and refugee families. Data were comprised of ongoing reflective writing statements from four health workers about their implementation of the intervention. Using content analysis three themes emerged: (i) encouraging setting of small, family focused and relevant goals, (ii) being flexible in content delivery and (iii) being personally transformed (i.e. gained a sense of meaning from their experience). Lay health worker interventionist reflections on practice revealed they delivered the intervention within the primacy of the family partnering relationship by attending to unique family needs, and adjusting educational content and goal setting accordingly. Our results provide guidance for training and process evaluation of lay health worker intervention delivery in ethnically and racially diverse populations. Incorporating real-time reflection upon what was learned about skills of facilitating family motivation and family confidence enhanced affective learning and may be useful in future research studies and health promotion practice. The processes identified including setting small goals, flexibility and personal transformation could be considered in future lay health worker-delivered health promotion interventions.

Physical activity assessment, prescription and referral in US healthcare: How do we make this a standard of clinical practice?

Numerous guidelines and recommendations reinforce the important role of healthcare providers promoting physical activity (PA) through assessment, prescription, and referral. This paper summarizes what is required to accomplish these actions as a standard of care. The sections describe the importance of measurement development and standardization, the integration of PA into the care continuum, suggested roles and responsibilities for the healthcare team, the role of technology and telehealth in promoting PA, connecting patients to different PA modalities and settings, a summary of the overall regulatory and policy plan to accomplish integration of PA into delivery of care, and areas for future research. Integrating PA assessment, prescription, and referral into delivery of care requires a multi-stakeholder, coordinated effort with government agencies, payers, non-governmental organizations, professional societies, the United States Congress, state legislatures, healthcare systems, and the healthcare industry.

Examining Associations between Community Health Worker-Rated Health and Mental Health among Latino Adults with Chronic Disease

Latinos with chronic disease often experience comorbid depression, but confront barriers to mental health treatment. Community health workers (CHWs) develop trusting relationships with the communities they serve, and may be uniquely positioned to identify Latinos with mental health care needs. Research has not examined whether their rating of clients’ health is indicative of their mental health. This mixed-methods study examines CHWs’ appraisals of Latino adults’ health and their relation to mental health outcomes, and explores factors informing CHWs’ rating of health status. The current study utilized baseline data from the Linking Individual Needs to Community and Clinical Services (LINKS) study. We assessed associations between CHW-rated health (CHWRH), or rating of health status as poor–excellent, and mental health outcomes with multilevel linear regression modelling. We qualitatively analyzed CHWs’ written perceptions of participants’ health status to understand what influenced their health rating. The quantitative results showed that CWHRH was significantly related to depressive symptoms and emotional problems severity. The qualitative results showed that CHWs took a holistic and ecological approach in rating health. The findings suggest that CHWRH could be indicative of mental health among Latino adults. Further studies investigating CHWRH as an independent indicator of mental health are warranted.

Healthcare Utilization Patterns Among Children With a History of Child Protective Services Investigations

PURPOSE

Examine whether children with a prior child protective services (CPS) investigation had different healthcare utilization compared to children without a history of CPS investigations.

METHODS

The Children's Health Assessment and Planning Survey assessed 6,492 primary caregivers of children ages 0-17 years residing in North Texas in 2015. Caregivers reported prior CPS investigations and child healthcare utilization (emergency department [ED] use, unmet medication needs, and unmet medical care needs).

PRINCIPLE FINDINGS

A total of 408 (5%) caregivers reported their child had a CPS investigation. Children with CPS investigations had greater odds of visiting the ED (OR = 1.9; 95% CI: 1.4, 2.5) and not receiving necessary medical care (OR = 1.9; 95% CI: 1.4, 2.8) compared to children without a CPS investigation.

CONCLUSIONS

Prior CPS investigation was associated with disparities in receipt of necessary medical care and ED utilization for children.

Community health workers: improving population health through integration into healthcare systems

PURPOSE OF REVIEW

The purpose of this review is to describe the role, responsibilities, hiring, training, and retention of community health workers (CHWs) on clinical care teams in the United States.

RECENT FINDINGS

CHWs are unique members of clinical care teams because of their ability to foster a deep trust and understanding with patients by sharing similar life experiences, participating in home visits, and providing constant support and advocacy. By partnering with CHWs, other clinical care members also gain a better understanding of their patients allowing them to deliver more culturally competent, patient/family-centered care. CHWs when incorporated into interdisciplinary teams have shown to lower healthcare costs, reduce hospital stays and admissions, and improve health outcomes and quality of life for children and families. However, the lack of standardization among CHW programs makes it difficult to quantify the overall effect and impact of integrating CHWs into clinical care teams.

SUMMARY

CHWs are able to improve health outcomes and address social determinants of health when properly integrated into clinical care teams. However, without adequate support, integration, funding, and training, CHWs are not able to reach their full potential. The standardization of CHWs' responsibilities and training, like other clinical care team members, is lacking within the United States, making it a challenge to evaluate programs and maintain sustainable funding for these vital members of the clinical care team.

Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce

BACKGROUND

Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort.

CASE PRESENTATION

In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally.

CONCLUSIONS

Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Network-Based Delivery and Sustainment of Evidence-Based Prevention in Community-Clinical Partnerships Addressing Health Equity: A Qualitative Exploration

Background: Increased delivery of evidence-based preventive services can improve population health and increase health equity. Community-clinical partnerships offer particular promise, but delivery and sustainment of preventive services through these systems face several challenges related to service integration and collaboration. We used a social network analysis perspective to explore (a) the range of contributions made by community-clinical partnership network members to support the delivery of evidence-based preventive services and (b) important influences on the ability of these partnerships to sustain service delivery. Methods: Data come from an implementation evaluation of the Prevention and Wellness Trust Fund initiative, which supported nine Massachusetts communities to coordinate delivery of evidence-based prevention and address inequities in hypertension, pediatric asthma, falls among older adults, or tobacco use. In 2016, we conducted semi-structured interviews with (a) leadership teams representing nine community-level partnerships and (b) practitioners from four high-implementation partnerships (n = 23). We managed data using NVivo11 and utilized a framework analysis approach. Results: Key network contributions for delivery of evidence-based preventive services included creating referrals, delivering services, providing links to community members, and administration and leadership. Less emphasized contributions included wraparound services, technical assistance, and venue provision. Implementers from high-implementation partnerships also highlighted contributions such as program adaptation, creating buy-in, and sharing information to improve service delivery. Expected drivers of program sustainability included the ability to develop a business case, ongoing network facilitation, technology support, continued integrated action, and sufficient staffing to maintain programming. Conclusion: The study highlights the need to take a long-term, infrastructure-focused approach when designing community-clinical partnerships. Strategic partnership composition, including identifying sources of necessary network contributions, in conjunction with efforts from the outset to link systems, align effort, and build a long-term funding structure can support the required coordinated action around preventive services needed to improve health equity.

Strengthening community-clinical linkages to reduce cardiovascular disease risk in rural NC: feasibility phase of the CHANGE study

BACKGROUND

Community Health Workers (CHW) are recommended for delivery of interventions to prevent cardiovascular disease, but there is insufficient evidence to guide implementation of CHW interventions in rural, medically underserved areas.

METHODS

Using a hybrid implementation-effectiveness design, we evaluated the implementation and effectiveness of an adapted, evidence-based cardiovascular disease risk reduction intervention among rural high-risk adults. CHWs at a community health center and local health department recruited, enrolled and counseled participants during 4 monthly home visits and 3 brief phone contacts. Participant data collection included pre- and post-intervention measurements of blood pressure, weight, and dietary and physical activity behaviors. We evaluated implementation with measures of intervention reach and delivery fidelity. Statistical analyses included descriptive statistics and paired t-tests.

RESULTS

Study participants (n = 105) had a mean age of 62 years and included 88% Non-Hispanic Blacks and 82% females. Recruitment strategies resulted in the enrollment of 38% of interested and eligible participants who received 80% of the planned intervention visits and phone contacts. Mean differences in pre-/post-intervention measures showed significant mean reductions in blood pressure (- 5.4 mmHg systolic, p = .006; - 2.3 mmHg diastolic, p = .04) and body weight (- 3.8 lb., p = .02). Self-reported dietary and physical activity behaviors also improved significantly.

CONCLUSION

This feasibility study demonstrated preliminary implementation and program effectiveness of a CHW-delivered intervention to reduce cardiovascular disease risk factors. Additionally, it identified areas for future refinements to strategies that strengthen community-clinical linkages with an integrated role of CHWs in rural health care delivery. If results from this feasibility study can be enhanced in a larger sample, there would be significant potential to positively impact the excess burden of chronic diseases that adversely impact rural, low-income, and medically underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03582696.

Community health worker perspectives of an academic community medication therapy management collaboration

OBJECTIVE

To qualitatively assess community health workers' (CHWs') perceptions of the challenges and benefits associated with participating in a collaborative, interprofessional medication therapy management (MTM) program for rural, underserved, predominantly Latinx, patients with diabetes and hypertension.

METHODS

Nine CHWs participated in a 1-hour, semistructured focus group that explored their experiences while assisting in the delivery of MTM services through an academic community partnership between an MTM provider and participating rural clinics. Audio recordings of the focus group were transcribed and thematically analyzed by 2 independent reviewers.

RESULTS

All program-involved CHWs participated in the focus group. Qualitative analysis identified 2 overarching themes: (1) opportunities and (2) challenges. Opportunities were further subcategorized as benefits to (1) CHWs, (2) patients, or (3) academic community MTM research. The CHWs perceived that they served as a liaison among the medical provider (prescriber), patient, and MTM pharmacist. Benefits to the patients focused on the integration of CHWs as essential to patient recruitment, especially for those who were reluctant to participate or receive a phone call from a stranger. The major challenges identified were (1) interruptions in workflow and (2) communication between CHWs and the health care practitioners (physicians, nurse practitioners, pharmacists). Specifically, the CHWs universally agreed that they needed more time after receiving patient report, scheduling a visit with the patient, and communicating with the patient's health care provider to better understand the individual's circumstances and needs.

CONCLUSION

This study identified perceived opportunities and challenges faced by CHWs and chronically ill, rural Latinx patients in the acceptance of MTM program. These findings may be useful for all interprofessional health care team members to better understand and appreciate the role of CHWs, while simultaneously enhancing and improving respective medication adherence efforts, and to improve collaborative, academic community programs in the future.

Cost-Effective Care Coordination for People With Dementia at Home

Background and Objectives

People with dementia (PWD) represent some of the highest-need and highest-cost individuals living in the community. Maximizing Independence (MIND) at Home is a potentially cost-effective and scalable home-based dementia care coordination program that uses trained, nonclinical community workers as the primary contact between the PWD and their care partner, supported by a multidisciplinary clinical team with expertise in dementia care.

Research Design and Methods

Cost of care management services based on actual time spent by care management personnel over first 12 months of MIND at Home intervention was calculated for 342 MIND at Home recipients from Baltimore, Maryland and surrounding areas participating in a Centers for Medicare and Medicaid Services (CMS) funded Health Care Innovation Award demonstration project. Difference-in-differences analysis of claims-based Medicaid spending of 120 dually-eligible MIND at Home participants with their propensity score matched comparison group (n = 360).

Results

The average cost per enrollee per month was $110, or $1,320 per annum. Medicaid expenditures of dually-eligible participants grew 1.12 percentage points per quarter more slowly than that of the matched comparison group. Most savings came from slower growth in inpatient and long-term nursing home use. Net of the cost of the 5-year MIND at Home intervention, 5-year Medicaid savings are estimated at $7,052 per beneficiary, a 1.12-fold return on investment.

Discussion and Implications

Managed care plans with the flexibility to engage community health workers could benefit from a low-cost, high-touch intervention to meet the needs of enrollees with dementia. Limitations for using and reimbursing community health workers exist in Medicare fee-for-service, which CMS should address to maximize benefit for PWD.

Variation in Electronic Health Record Documentation of Social Determinants of Health Across a National Network of Community Health Centers

INTRODUCTION

This paper describes the adoption of an electronic health record-based social determinants of health screening tool in a national network of more than 100 community health centers.

METHODS

In 2016, a screening tool with questions on 7 social determinants of health domains was developed and deployed in the electronic health record, with technical instructions on how to use the tool and suggested clinical workflows. To understand adoption patterns, the study team extracted electronic health record data for any patient with a community health center visit between June 2016 and May 2018. Patients were considered "screened" if a response to at least 1 social determinants of health domain was documented in the electronic health record tool.

RESULTS

A total of 31,549 patients (2% of those with a visit in the study period) had a documented social determinants of health screening. The number of screenings increased over time, time; 71 community health centers (67%) conducted at least one screening, but almost 50% took place in only 4 community health centers. Over half (55%) of screenings only included responses for only 1 domain. Screening was most likely to occur during an office visit with an established patient and documented in the electronic health record by a medical assistant.

CONCLUSIONS

Screening documentation patterns varied widely across the network of community health centers. Despite the growing national emphasis on the importance of screening for social determinants of health, these findings suggest that simply activating electronic health record tools for social determinants of health screening does not lead to widespread adoption. Potential barriers to screening adoption and implementation should be explored further.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Reducing cardiovascular disease in a rural community

In this case report, we describe the one-year formative phase of a five-year study to develop, implement, and test a community health worker (CHW)-delivered cardiovascular disease (CVD) prevention intervention. The purpose of the formative phase was to engage community partners in the adaptation of an existing evidence-based CVD prevention intervention to fit the needs and preferences of a rural, predominantly African-American community. The formative work was guided by a framework for adapting evidence-based interventions and involved engaging stakeholders in assessing the intervention's fit with the local context and then applying assessment findings to iteratively adapt the intervention's contents, materials, and delivery methods. Findings from the formative work were then applied to develop CHW position descriptions, workflow diagrams, and a training plan. Findings also were applied to adapt intervention materials and protocols to fit the needs of the community. This case report illustrates how community-engaged formative work can be applied to adapt an evidence-based intervention to fit community needs and resources.

Immigrant health access in Texas: policy, rhetoric, and fear in the Trump era

BACKGROUND

Since the 2016 presidential election, reports have suggested that President Trump's rhetoric and his administration's proposed policies could be exacerbating barriers to accessing health care for undocumented as well as lawfully present immigrants and their families in the United States. However, very little empirical work has analyzed this possibility or detailed how these reports and rhetoric have altered the health seeking behavior of mixed immigration status families.

METHODS

Using a series of focus groups throughout Texas in both English and Spanish, this qualitative study analyzes changes to health access for immigrants. We consulted Community Health Workers to better understand the barriers encountered by their otherwise hard-to-reach undocumented clients and their families as they interface with the health system, revealing key insights about the changing nature of barriers to access under the Trump administration.

RESULTS

We identify four key themes about the changing nature of immigrant health access in the United States: growing fear of interacting with health and social services; that social networks are paradoxically limiting health access in the current political climate; that the administration's rhetoric and proposed policies are impeding health seeking behavior; and that children are encountering new barriers to social program participation.

CONCLUSIONS

The Trump administration, its proposed immigration policies, and his rhetoric are posing new and significant barriers to health access for immigrants and their families.

Community Health Workers in Hawai'i: A Scoping Review and Framework Analysis of Existing Evidence

Introduction: Community health workers (CHWs) play a vital role in health across Hawai'i, but the scope of this work is not comprehensively collated. This scoping review describes the existing evidence of the roles and responsibilities of CHWs in Hawai'i. Methods: Between May and October 2018, researchers gathered documents (eg, reports, journal articles) relevant to Hawai'i CHWs from health organizations, government entities, colleges/universities, and CHWs. Documents were reviewed for overall focus and content, then analyzed using the Centers for Disease Control and Prevention's 10 Essential Public Health Services as well as the Community Health Worker Core Consensus Project roles to identify workplace roles and gaps. Results: Of 92 documents received, 68 were included for review. The oldest document dated to 1995. Document types included curricula outlines, unpublished reports, and peer-reviewed articles. Documents discussed trainings, certification programs, CHWs' roles in interventions, and community-, clinical-, and/or patient-level outcomes. Cultural concordance parity between CHWs and patients, cost savings, and barriers to CHW work were noted. Most roles named by the Community Health Worker Core Consensus Project were mentioned in documents, but few were related to the roles of "community/policy advocacy" and "participation in research and evaluation." Workplace roles, as determined using the 10 Essential Public Health Services, focused more on "assuring workforce competency" and "evaluation," and less on "policy development," and "enforcing laws." Discussion: CHWs are an important part of Hawaii's health system and engage in many public health functions. Although CHW roles in Hawai'i mirrored those identified by the CHW Core Consensus Project and 10 Essential Public Health Services frameworks, there is a noticeable gap in Hawai'i CHW professional participation in research, evaluation, and community advocacy.

Community Health Workers in Action: Community-Clinical Linkages for Diabetes Prevention and Hypertension Management at 3 Community Health Centers

In 2014, the Hawai'i State Department of Health (HDOH) received funding from the Centers for Disease Control and Prevention (CDC), via the 1422 Cooperative Agreement, to conduct diabetes prevention and hypertension management. To implement one grant-required strategy-the engagement of community health workers (CHWs) to promote community-clinical linkages-the HDOH partnered with the Hawai'i Primary Care Association and 9 federally qualified health centers (FQHCs). This qualitative evaluation case study sought to understand how 3 of the funded FQHCs engaged CHWs, the types of community-clinical linkages the CHWs promoted, and the facilitators of and barriers to those linkages. Evaluators conducted 2 semi-structured group interviews with 6 administrators/clinicians and 7 CHWs in April 2018. The transcribed interviews were deductively and inductively analyzed to identify major themes. First, CHWs made multiple internal and external linkages using resources provided by the grant as well as other resources. Second, CHWs faced barriers in making community-clinical linkages due to individual patient, geographic, and economic constraints. Third, CHWs have unmet professional needs related to building community-clinical linkages including professional development, networking, and burnout. Reimbursement and payment mechanisms are an all-encompassing challenge to the sustainability of CHW positions, as disease-specific funding and a complete lack of reimbursement structures make CHW positions unstable. Thus, CHWs fulfill a number of grant-specific roles at FQHCs due to this patchwork of funding sources, and this relates to CHWs' experiences of burnout. Policy implications of this study include funding and reimbursement stabilization so FQHCs may consistently engage and support the CHW workforce to meet their patients' complex, diverse needs. More professional development opportunities for CHWs are necessary to build sustainable networks of resources.

Community and stakeholders' engagement in the prevention and management of Type 2 diabetes: a qualitative study in socioeconomically disadvantaged suburbs in region Stockholm

Background: Community-based approaches have been identified as an effective strategy to address the growing burden of noncommunicable diseases (NCDs) worldwide. However, little is known about community as a concept among people living in socioeconomically disadvantaged settings and stakeholders' interactions and engagement in NCDs prevention and management. Objective: The aim of this study was to understand; (1) the meaning of community among people living in socioeconomically disadvantaged suburbs in Region Stockholm and (2) how communities interact and engage with stakeholders at local and regional levels for the prevention and management of type 2 diabetes (T2D). Methods: This qualitative study was conducted in three municipalities in Region Stockholm with a high proportion of migrants. Multiple data collection methods were used, including observations of community activities; interviews with community members, representatives of public authorities and NGOs; and group interviews with healthcare providers. Data were analyzed using content analysis. Results: Community was perceived as living in close proximity with shared beliefs, values and resources. Although they recognized its social and cultural diversity, community members focused more on the commonalities of living in their neighborhood and less on their differences in country of birth and languages spoken. Several mismatches between awareness of community needs and the available skills and resources among stakeholders for T2D prevention were identified. Stakeholders expressed awareness of T2D risk and interest in addressing it in a culturally appropriate manner. Conclusion: Interaction between the communities and stakeholders was limited, as was engagement in T2D prevention and management. This highlights barriers in the collaboration between community, healthcare institutions and other stakeholders which consequently affect the implementation of preventive interventions. Innovative ways to link the community to the healthcare sector and other local government institutions are needed to build the capacity of health systems for T2D prevention in socioeconomically disadvantaged communities.

Protocol for LINKS (linking individual needs to community and clinical services): a prospective matched observational study of a community health worker community clinical linkage intervention on the U.S.-Mexico border

Background

Latinos are currently the largest and fastest growing racial/ethnic group in the United States and have the lowest rates nationally of regular sources of primary care. The changing demographics of Latino populations have significant implications for the future health of the nation, particularly with respect to chronic disease. Community-based agencies and clinics alike have a long history of engaging community health workers (CHWs) to provide a broad range of tangible and emotional support strategies for Latinos with chronic diseases. In this paper, we present the protocol for a community intervention designed to evaluate the impact of CHWs in a Community-Clinical Linkage model to address chronic disease through innovative utilization of electronic health records (EHRs) and application of mixed methodologies. Linking Individual Needs to Community and Clinical Services (LINKS) is a 3-year, prospective matched observational study designed to examine the feasibility and impact of CHW-led Community-Clinical Linkages in reducing chronic disease risk and promoting emotional well-being among Latinos living in three U.S.-Mexico border communities.

Methods

The primary aim of LINKS is to create Community-Clinical Linkages between three community health centers and their respective county health departments in southern Arizona. Our primary analysis is to examine the impact of the intervention 6 to 12-months post program entry. We will assess chronic disease risk factors documented in the EHRs of participants versus matched non-participants. By using a prospective matched observational study design with EHRs, we have access to numerous potential comparators to evaluate the intervention effects. Secondary analyses include modeling within-group changes of extended research-collected measures. This approach enhances the overall evaluation with rich data on physical and emotional well-being and health behaviors of study participants that EHR systems do not collect in routine clinical practice.

Discussion

The LINKS intervention has practical implications for the development of Community-Clinical Linkage models. The collaborative and participatory approach in LINKS illustrates an innovative evaluation framework utilizing EHRs and mixed methods research-generated data collection.

Trial registration

This study protocol was retrospectively registered, approved, and made available on Clinicaltrials.gov by NCT03787485 as of December 20, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6725-1) contains supplementary material, which is available to authorized users.