Integrating Community Health Workers (CHWs) Into a Health Plan Setting

Health care has largely realized that it is nearly impossible to fully address health issues without addressing a person's social needs (Opthof, 2020). Evidence suggests that if health policies were to focus on addressing social and behavioral determinants of health, we would have better population health, less inequity and lower costs (Adler et al, 2016). According to Kedar Mate, MD and Chief Innovation and Education Officer at Institute for Healthcare Improvement, we need "an expanded workforce that can actually address the social care needs of our patients and population." (Opthof, 2020). The National Academies of Science, Engineering & Math (NASEM) has concluded that in order to effectively integrate social care into the delivery of health care, it requires an interdisciplinary team approach (2019). An interdisciplinary team can include physicians, social workers, nurses and community health workers.Community health workers (CHWs) is an evolving profession that is projected to grow 11% in the next decade (Callaghan et al, 2019). CHWs are frontline public health workers known by a variety of names including promotora/promotores, outreach worker, community health representative (CHR), peer specialists, care guides, community connectors, transition specialists, case managers, peer leader, advocates and family service connectors among others (Centers for Disease Control [CDC], 2015 & The Leavitt Partners, 2018). No matter what CHWs are called, they are front-line community members that serve as bridge figures between resources in the community and the clients or patients they work with, sharing a goal of addressing inequalities related to social determinants of health (Callaghan et al, 2019). The CHWs are often members of the community they are working with, they speak the same language, have a similar culture and truly understand the needs of the community in which they work, which often have complex and diverse needs (Leavitt, 2018).In Utah, CHWs assist the state in reaching the health care goals previously established by using the Triple Aim (improved health, improved care and reduced costs) by focusing individually on each member of the community (Leavitt, 2018). Community health workers are members of a team that can be integrated into the community, allowing each team member to have clear roles and to work and operate at the top of their licenses where applicable (Lloyd & Thomas-Henkel, 2017). Health insurance plans are given ratings each year based on consumer satisfaction, prevention and treatment (National Committee for Quality Assurance [NCQA], 2019). Healthcare Effectiveness Data and Information Set (HEDIS) is a comprehensive set of standards used for consumers and insurance purchasers to compare health plan quality performance (Centers for Medicare & Medicaid Services [CMS], 2019). In addition to clinical quality measures from HEDIS, health plans are also rated on measures of consumer satisfaction using Consumer Assessment of Healthcare Providers and Systems (CAHPS) and accreditation results from National Committee for Quality Assurance (NCQA) health quality processes (NCQA, 2019). Health plans are rated in three categories: private plans, plans serving Medicare beneficiaries and plans serving Medicaid beneficiaries (NCQA, 2019). The purpose of this paper is to determine the cost/benefit of implementing the use of CHWs in a Medicaid health plan setting. The goal is to determine the best way to utilize CHWs as part of the health plans team by determining oversight, workflows and basic qualities of what CHWs would need to have in order to help improve ratings of the health plan. In this project, the CHW will be implemented as part of the care management team to assist with diabetic adults in the identified target community