Investing in Community Health Workers Is Vital to Population Health

ROBERT JOHNSON:
his is Public Health Review. I'm Robert Johnson. On this episode, the case for keeping community health workers on the job.

SHERRI OHLY:
CHWs are a proven workforce with lots of research that backs up their effectiveness.

JONEIGH KHALDUN:
It's really important to note that there's a business case for community health workers. This is not just a nice thing to have.

JOHNSON:
Welcome to Public Health Review. A podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, why investment in community health workers is critical to population health and the impact of this workforce on people in need. Two guests are here to talk about it. Sherry Ohly is co director of the Envision Equity CHW Training and Technical Assistance Center. She's on later. But first, we hear from ASTHO alum Dr. Joneigh Khaldun. Today, she's the Vice President and Chief Health Equity officer for CVS Health. From early 2019 until late 2021, she was the Chief Medical Executive for the state of Michigan.

KHALDUN:
: Community health workers are an incredibly important piece of our health care workforce in this country.

Community health workers are really people who have lived experience, come from the communities in which they are serving. They have a variety of backgrounds, but really a community health worker at its core is someone who helps an individual navigate their health and navigate the health care system so they can connect with individuals so that they are better able to understand their own health challenges.

They connect with individuals to help them access health care services. Access things from a public health perspective related to vaccinations. For example, they can help someone navigate their clinic appointments. They're incredibly important. I'm excited that more and more in recent years we've seen an appreciation for community health workers in the United States.

JOHNSON:
Their super power really does seem to be that connection. The fact that they're really just like the people they're trying to help.

KHALDUN:
Absolutely, and that's so important. I've always said that the greatest resource in any community are really its people, and that's exactly what a community health worker is. It is someone who has similar experiences and background, whether that's demographic background, whether that's socioeconomic background, they've grown up in the same neighborhood, whatever it may be, they have similar lived experiences to the people that they are connecting with. And that's critically important.

It's important because we know how sometimes confusing and frustrating the healthcare system may be. It's important because we know that people often just need help when it comes to navigating their health care journey. And I'd also say it's really important when it comes to addressing health disparities.

Community health workers are incredibly important, and there's evidence that they really help improve health outcomes, particularly for those communities that have historically been more marginalized in our country.

JOHNSON:
How would you describe the impact they had during the pandemic?

KHALDUN:
Oh, community health workers, incredibly important during the pandemic. If you go back to even early 2020, everyone was scared. We did not have a lot of information. We did not have, you know, appropriate access to sufficient testing. And even later on, when vaccines became available, there were still disparities with people being unable to access a vaccine. And of course, there were challenges around trust and trusting that the vaccines were safe and effective.

So community health workers certainly played an important role and more broadly, just, you know, the bread and butter of public health is really engaging with communities and working closely with trusted members of communities. to advance important public health goals. So community health workers are certainly incredibly important when it comes to that.

JOHNSON:
Your focus now in this new job is on health equity. How do people in the community health worker ranks help advance those priorities, the kinds of things that you're doing at CVS?

KHALDUN:
So how are we thinking about CVS Health Equity Strategy? We really think of it in a few ways. And the first part is really looking internally, foundationally at ourselves, and how we are looking at how our companies are supporting our members, our patients, and our customers.

And so, first, we're really thinking about our colleagues, right? We have over 300, 000 colleagues who work at CVS Health, actually. And so, how are we providing trainings? How are we providing help so that they can look at their own internal policies and procedures and embed that health equity lens? So that's really our first pillar is a lot around training, a lot around improving and standardizing our assessments and how we embed that health equity lens.

Our second pillar is really around data. So we have a lot happening around the company related to increase in the collection and utilization of demographic data, looking at social determinants of health data, and then leveraging those insights to improve our services and programs. The third part of our strategy, which is really where we leverage our community health worker, workforce is taking bold action.

So we've actually aligned our company around specific health topics So cardiovascular health and mental health and we've leveraged our analytic tool. So again going back to improving how we understand the disparities among our own patients and members, how we understand the social determinant of health needs for our patients members and customers, and so we've actually developed very specific interventions based on those disparities that we've identified.

And so a key part of that, again, are community health workers. So for example, we now have community health workers embedded in our care management programs for our Aetna Medicare members. We now have in Medicaid, similarly, we have community health workers on the ground in states who are helping us identify members with health related social needs, and we're helping them to navigate to services.

Another thing I'm really excited about is last year in 2023, we launched the Community Equity Alliance. And so through that alliance, our initial three partners are actually training community health workers. So building out that community health worker workforce, and we're embedding them into care teams.

Into clinical care teams and FQHCs and other clinical areas to really help members with their health. So, community health workers, again, are really important to our broader health equity strategy at CVS Health.

JOHNSON:
So, these are people who are working for CVS or are they assigned some other way? Can you give us a little more detail here?

KHALDUN:
So, it depends, and that's a really good point. There are different models for how an organization can really leverage community health workers. So within our Medicaid and Medicare teams, we actually employ them through CVS Health. Through our Community Equity Alliance, we have partnered with Meharry Medical College an Historically Black College and University in Tennessee.

We've partnered with Sinai Chicago and also Wayne State University in Detroit. And so those partner organizations are the ones who employ the community health workers in that particular situation.

JOHNSON:
It's interesting that a private sector entity, a business like CVS, would be able and willing to support that kind of public health. Is this something that you brought to the table after you took the job, or has it been going on for a while? Is it new?

KHALDUN:
So I would say that, you know, certainly health equity at CVS Health did not start with me. But what my team and others across the organization have really been invested in doing is being very strategic in scaling our community health worker workforce and initiatives.

I'd also say that it's really been exciting. CVS Health is not the only organization who's leveraging community health workers, and it's been really exciting to see more and more health care organizations, including health plans. recognize their importance. I also think it's important that we recognize and acknowledge the regulatory environment, which I think has been very positive when it comes to promoting the community health worker workforce. We've seen a lot of investment at the federal level in this workforce, and we're seeing requirements from whether it's a state Medicaid. plan, whether it's CMS talking about Medicare, but we're seeing requirements for organizations, hospitals to actually screen for and address social determinants of health.

So that's really, really important and the final thing I'll say is that there's a business case. This is not just about, yeah, yeah, it's a nice thing to have. There's one study that actually showed that for every dollar invested in a community health worker, you can actually gain more than 2 back in kind of health care costs for those members.

And so, it's really important to note that there's a business case for community health workers. This is not just a nice thing to have.

JOHNSON:
Is that because when a community health worker says have your blood pressure checked, the person actually goes and does that? Whereas maybe if they hear it from a doctor, they might do it or maybe they won't?

KHALDUN:
I think it's really back to that trust. I'm a practicing emergency medicine physician. You know, I see my residents, my peers, and sometimes, you know, I'll be honest, we aren't the best at really earning the trust of our patients, oftentimes, even in primary care settings, sometimes there's not time to, you know, spend 30 minutes just talking about making sure a patient understands what they need to be able to even take their medications.

This concept of understanding. You know, if people are just trying to live paycheck to paycheck, or quite frankly if they don't have a paycheck, if they're just trying to survive and put food on the table, make sure their lights stay on, they don't have a car, so transportation to a health care facility or just to get their medications can be challenging.

A community health worker really can help to bridge that gap and really, you know, deeply understand what members, what patients need to be healthy. And I think that's really what it is. What you also will see is that community health workers can really support shifting where patients are getting care.

So away from as much as I support and value my practice of emergency medicine, I recognize that people often don't need to be there, right? We want them to be getting primary care or maybe an urgent care center. And so community health workers can help to shift where patients get care so that it's the right care at the right place at the right time.

JOHNSON:
Do you have any favorite stories about community health workers that come to mind? Anything you'd like to share?

KHALDUN:
One anecdote that I recall goes back to my time when I was the Detroit Health Commissioner, we actually had community health workers as part of our broader maternal health program, where we were really working on improving maternal health outcomes in the city and decreasing infant mortality.

And so I remember one particular time where there was a woman who had given birth, was in a hospital, but had nowhere to go, literally was going to be discharged from a hospital with a newborn baby to a car, and we weren't even sure if they had that car. And so the community health worker, we also had a social worker as part of the team in our health department, but the community health worker, I mean, they were, you know, at the hospital, they were on the phone, they really were a support, almost like a best friend, big sister type of support for this woman, because I'm saying all these things, but it also was just really stressful and hard and just mentally challenging for this woman, and so we were able to provide that really important social support, and also, you know, through the work of a social worker and others on our team, we're able to find that individual some stable housing and even longer term able to connect to job resources.

JOHNSON:
Considering the whole of your experience across the public and private sectors, could you imagine doing your work without the help of community health workers?

KHALDUN:
You know, at my core, I really have in my career and will always be someone who's trying to help improve health outcomes for even those who, again, have been historically most marginalized.

And so if you're doing public health, and quite frankly, if you're doing anything that is seeking to improve health outcomes for everyone, everyone, regardless of income, demographic, et cetera, then you have to be engaged with community health workers. Again, there's plenty of evidence about the importance of community health workers and how they improve health outcomes.

I think it's really, for most organizations, a matter of not if, but how and really taking those next steps of building that infrastructure to make it a sustainable part of your own organization's strategy.

JOHNSON:
Sherri Ohly has spent much of her career supporting community health workers, but it's her lived experience that gives her a special connection to the workforce. For more information visit www.FEMA.gov

OHLY:
I'm a community health worker ally. I've worked in state government for a number of years. Now I'm working at the University of Wisconsin Madison, the Population Health Institute.

And where my story begins is almost 40 years ago now, where I was a teen mom and my son is about to be 40 this year. And I worked my way through that childcare and finishing school. And ultimately when I first joined the workforce, I worked with other teen moms. And so I learned the power of lived experience.

That the fact that I had faced similar things to the teen moms I was now working with and had to learn by experience what how to overcome things like lack of child care, insurance, finding a provider who could support me as a teen mom through my pregnancy and delivery really made all the difference in the support that I was able to give to the teen moms that I then worked with.

I got a degree in social work and went into case management and continued to work with community for lots of years, but never forgot that start to my career. That is the magic that now informs what I now know and put to support community health workers is that, you know, it takes one to know one and that there is so much power in community and wisdom in understanding what the best right next steps are.

And in that close relationship, trust is built and people will get farther faster. So while I'm not a community health worker, my roots are deep in understanding what makes community health workers so magical.

JOHNSON:
So what role do they play in these neighborhoods, in these communities at that micro level?

OHLY:
eah, that's right. Community leaders, the ones that you think of when you have a question, “Oh, my child is experiencing such and such”. What should I do about this? I don't know how to navigate getting into this care system or into this program that will help me with my addictions. What do you know? That person in your community is oftentimes a community health worker.

They're the ones who have the knowledge and can help guide and also the ones that people listen to and respect. The American Public Health Association definition of community health workers is the one that we uplift and it describes community health workers as having a close relationship, similar lived experiences to the people that they are working with and they are trusted messengers who not only support healthcare access and understanding and health in that way, but also address all the health related social needs and the social determinants of health that really determine what's going to make a person healthy and they use that knowledge and wisdom to the benefit of the entire community.

And they may do that through working one on one with folks, or through outreach, through providing education, through civil movement, and shifting policies, and changing the way that we do things. Community health workers are very versatile, and this very versatility also makes it sometimes hard to understand what it is a community health worker does, and they can be pigeonholed into, they do this lane of what I just described, or that lane.

And the National Council on the CHW core consensus standards has really looked to elevate what the skills and roles that community health workers do are, as well as the attributes of how they carry themselves and who they are in the first place. And looking to those two sources are very definitional of who the community health worker workforce is, both the APHA CHW section and the National Council for CHW core consensus standards.

JOHNSON:
How many community health workers are there on the job today?

OHLY:
You know, there is a lack of information nationally about how many community health workers there are in the country. And many brilliant minds are working together to determine how many CHWs are in our country. And one of the reasons for this is CHWs often go by hundreds of different names, not each one, but overall CHWs go by hundreds of different names from outreach worker to, well, even within the CHW workforce, primarily folks who work with, in their community, the Spanish speakers, community health representatives, work in tribes.

They're also doulas. They also sometimes go under this category of also being co trained as community health workers. And so because there's so many different titles, it's very difficult to get a tap on how many there are.

JOHNSON:
Absolutely. Thousands of additional workers were hired during the pandemic. What kind of impact would you say they had?

OHLY:
Over the course of the last three years, these individuals have both worked in their communities and impacted thousands of lives in assisting folks to get better health care, to improve the quality of their life through addressing things like hunger and homelessness. You know, when Medicaid unwinding happened, so they not only walked people through the initial crisis of the pandemic and what to do and who to trust and how to go about keeping your family and yourself safe.

They also continued to walk with them as things shifted. And when the pandemic was declared not to be an emergency anymore and Medicaid unwinding was taking place that represented a whole other crisis for communities as they had to adjust to the shifting rules again and lack of awareness of was their Medicaid or food stamps at risk.

And so the community health workers jumped in again and they continue to jump in again. To support that, you know, as climate change impacts us and while this was going on, there was also fires and there was also tornadoes and there was also hurricanes. There's also extreme heat and the community health workers walk alongside in their community with folks and guiding them as to where to find solutions.

And so they have maintained that presence and support throughout this. And as many of us are now have moved past crisis mode. They're once again thrown into crisis as they face a fiscal cliff, and they still stay there and work on the behalf of their communities, and people trust them, and they know that they can go to them as a reliable source for information.

JOHNSON:
Many of these workers came online during the pandemic to address COVID 19, but they really did more than that. And I'm guessing that if they really do go away now because the funding is drying up, communities will feel that, won't they?

OHLY:
Most definitely. There is a lot that happens within communities, and there's lots of causes for why certain communities felt the impact of the pandemic more than others, and many of those causes are so insidious.

They're still there. They haven't changed, and the community health workers was simultaneously working on both. Pandemic response as well as food and housing insecurity, which we all know is only getting increasingly worse and more difficult to find stable and low housing as costs rise and such. So you take that away from the community and it is very destabilizing.

JOHNSON:
Everyone agrees that community health workers are on the front lines of public health. So given that, what do you think we take away from this experience with them over the last three years?

OHLY:
To start with exactly that, that community health workers are first frontline public health professionals that are a necessary ingredient to systems change that involves those that are most impacted with the solutions.

Right from the start. That CHW leadership in developing programs and in supporting the community is needed in design, in implementing, and in evaluation.

JOHNSON:
So the goal right now really is to try to figure out how to extend their tenure one way or another, right?

OHLY:
That's right. And Envision has worked from the beginning to sustain these positions. Knowing that this day would come that, you know, the funding would end as it does grant funding positions ended and we have put considerable effort into creating resources that support health departments and community based organizations and healthcare systems to sustain community health workers, both from a fiscal perspective of financing and where do ongoing funds come from.

Reimbursement strategies around Medicaid and Medicare, also budgeting and creating stable positions from within health department and health system budgets that honor community health workers and lift up their lived experience. And we've created a toolkit that helps folks to assess these strategies, which one is the best that would work for them? And then how do you go about implementing those including influencing decision makers as needed to create more policies to fund and better policies to fund community health workers at an equitable pay rate and that. We've created a website where we share the resources. Envision has been creating monthly webinars since the beginning of this program, as well as gathering resources that are available to support anyone who's working on implementing a quality community health worker program.

JOHNSON:
Thank you for listening to Public Health Review. If you like the podcast, please share this episode with your colleagues on social media and if you have comments or questions we'd like to hear from you, email us at PR at ASTHO. org. That email address again, PR at ASTHO. org. You can also follow us using the follow button on your favorite podcast player.

Also, stay up to date on everything happening at ASTHO by tuning in every morning for Public Health Review Morning Edition. We cover news like this every day. Look for a link in the show notes and let us know what you think. This podcast is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.