Community Health Workers: System Catalysts in Addressing Hypertension

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, we're celebrating American Heart Month by recognizing the efforts and successes of community health workers in Virginia.

KEANDRA HOLLOWAY:
That's what makes the community health workers' job description so unique is because the Richmond City Health District, when they hired community health workers, they wanted to make sure that they could meet those people where they are.

PATRICK WIGGINS:
The more that we're working together across state lines and across communities, the greater likelihood we have for success.

DR. NORMAN OLIVER:
The use of community health workers I think is really an important way for us to make some progress in promoting heart health.

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: a look at two innovative programs in Virginia where community health workers, who often live in the communities they serve, are changing lives one patient at a time—doing so with the support of the state's department of health, insurers, payers, and others.

Where poverty and life challenges are linked to higher rates of heart disease, stroke, and hypertension, community health worker Keandra Holloway is making a difference, drawing on her training and her personal experiences to do her job and help her clients. She joins us later.

Patrick Wiggins is the health systems intervention coordinator at the Virginia Department of Health. He was part of the heart disease and stroke prevention learning collaborative supported by ASTHO and the CDC, and will be along shortly to explain the thinking behind programs like the one supporting Keandra.

But first, Dr. Norman Oliver, Virginia state health commissioner, shares what he learned on his recent statewide listening tour, revealing that residents are indeed connecting socioeconomic conditions with health concerns.

OLIVER:
Everywhere I went, I found that people felt that there were underlying root causes of these problems—everything from heart disease to the opioid epidemic—and those root causes people felt were their conditions in which people live, work, and play; and in many cases, those living conditions are ones that don't really promote health or foster wellbeing, and lead toward increased problems with disease.

And in particular, people talken about the lack of affordable housing in some sections of the commonwealth, such as far soutwest Virginia; from the inner city—urban areas—a lack of jobs, lack of access to nutritious food. These things were pointing toward issues, and we needed to address it, and wanting to seriously move the needle on improving the health of the population.</p<

JOHNSON:
We hear more and more these days about those social determinants of health, and you're a medical doctor, also. Tell us how those connect, especially as it relates to heart disease, which is our focus this month.

OLIVER:
The sorts of protective factors around heart disease would be eating a healthy diet that is does not lead toward increasing plaque in your arteries, for example, taking your cholesterol down. Not smoking, being physically active.

And while those sound like individual behaviors—and they are, obviously—whether or not you can eat a nutritious diet is tied to whether or not you have access to nutritious food.

Here in Richmond, for example, there are areas of this city that are food deserts in that regard, you know; and if you don't have a car to be able to drive two miles out to get to a really good grocery store, what you're left with are convenience stores, gas stations, other things which don't serve the most nutritious foods.Those same neighborhoods would be neighborhoods where there's not a lot of green space, so the idea of being able to go out and active in is harder to do—even from a public safety point of view, they might not be the wisest place to go out for an evening jog after work.

And ironically—maybe not ironically—these are also communities that are real targets of advertising for tobacco use and smoking and pushed and promoted. And these are communities where people find less opportunity to get employment, and educational achievement in those communities is less. And I believe that's in part due to a lack of investment in educational institutions in those areas.

You put all that together, and then it becomes the prime territory for generating the conditions that help to bring on heart disease and make it harder to manage heart disease if you get it. These communities are distressed, not just economically but psychologically distressed, from those living conditions—and I would argue that psychological distress also adds to another risk factor for heart disease.

JOHNSON:
We expect the public health community to be able to make these connections between what's going on in a community and how that affects citizens' health; but what you're saying is, from the listening tour, residents are doing the math as well now.

OLIVER:
Well, yes. They are definitely doing the math. And this one's good because the residents are themselves involved in a lot of different sectors within their community. And it's pretty clear that you can't really affect change in those sorts of living conditions, social and economic conditions, as just one sector group; so public health can't do it alone, or faith-based organizations can't do it alone, employers themselves can't do it alone.

And one of the things that we've been noticing is that there's a lot of people who will now talk about these social determinants of health. And they look at the health condition of the community as it is now and look at where we would like it to be and realize there's a huge gap, and they're doing what they can to try to bridge that gap. But what's occuring is you get lots of people in that gap trying to bridge it, but we're all working independently of one another and we're getting incremental changes.

To really move the needle, all of those efforts need to get aligned; and I believe if they are aligned, we'll get a really powerful impact.

JOHNSON:
Now, one of the projects that is going on in the commonwealth involves working with insurers and others in the community to put community health workers on the ground in places where hypertension, heart disease, stroke are higher than they ought to be.

Can you talk about those projects and how they fit in to this bigger picture?

OLIVER:
The use of community health workers, I think, is a really important way for us to progress in promoting heart health. If you are having someone tell you, "You need to stop smoking, or you need to drink less, or you need to be more physically active," and that someone from outside in your community who doesn't really know your community, doesn't really know you, it's a message that doesn't get heard as well.

Having a peer talk with you, work with you, help you to change their behaviors to more of health-promoting behaviors, help you manage your disease if you already have heart disease, they're much more effective. And we've seen that in this initiative where community health workers were able to really have an impact on helping people to manage their disease.

Some of the work we've done around hypertension in particular, as you note—before I came to the health department, I was involved in a clinic I worked in in Charlottesville, and we were able to get the patients who were cared to work with our community health worker. We were able to have them get real good control of their blood pressure—many of them also had diabetes, and they have much better control over their diabetes.

Medication adherence was astronomical. If you talk to most clinicians and look at the studies around this in adherence to medication regimens, if you get it to 50–60%, then you're knocking it out of the park. And with our community health workers, we were having adherence rate in the 90s. It was astronominal, and it had an impact on how well these patients were doing in managing their disease.

I'm a real big fan of community health workers.

JOHNSON:
So, it sounds like those two projects are going well?

OLIVER:
Very well. And I think if more insurance and hospitals systems were to utilize this resource, I think that it would have a big impact.

I have been talking a lot about social determinants of health, and one of those social determinants is how is your healthcare system and how effective it is? I think we have a long way to go to improve the clinical service delivery of our healthcare system, and I think the use of the community health workers is a really important way to do that.

The insurance payers also are among those who are beginning to realize the importance of these social determinants of health. So, not only are some of them utilizing things like community health workers, but they are finding ways to deal with some of those living conditions that impact the health of their covered lives of people they insure. And I think that's a hopeful sign as well.

JOHNSON:
Patrick Wiggins coordinates state and local partnerships for the Virginia Department of Health. He explains the two collaborations underway in Richmond.

WIGGINS:
For one payer-provider model, we have Anthem Blue Cross and Blue Shield—which is a commercial insurer—and we have Commonwealth Primary Care, which is a large primary care practice with a patient panel size of over a hundred thousand patients all across Virginia. And then, we have the Richmond City Health District, which is our local health department located in Richmond.

And then on the other side, our second model that we have, those partners are Anthem Health Keepers Plus, which is a Medicaid-Medicare insurer. We have Fairfield Court, which is a public housing community. And then, we also have the Richmond City Health District who works closely in that community.

So partners—you know, it depends on the model and who is the target population, who will be implementing the services, who are your conveners, and just, you know, stakeholders; so, as you expand and scale these types of models, who are the other key players that can really move the needle on hypertension and cholesterol.

JOHNSON:
Are you having success so far?

WIGGINS:
Yes. We implemented from June 2017 to June 2018 both payer provider models here in Richmond through a great funding opportunity from ASTHO, and we have had significant success, both in our public housing community in Richmond and then also Commonwealth Primary Care. So, we are able to see clinical outcomes and success through Commonwealth Primary Care because we were able to hire a community health worker that was embedded in the two primary care practices.

So, she was actually able to have access to their eClinicalWorks EHR system; and from there, she was able to track patients, she could update medical providers through the patient charts on the portal and the EHR. So, the community health worker was able to really follow closely and be really integrated into the clinical workflow.

And then conversely, our community health worker that was already hired and working in Fairfield Court, for the public housing community, they have one of the units that was built as a community resource center for that community. And so, Keandra—who you'll speak with soon, and she can speak more to her role—she saw tremendous success.

Because in both models we provided, or the community health workers provided, blood pressure self monitors in addition to the pedometers and other heart health and educational materials. And the community health workers trained the residents and patients how to monitor their own blood pressure. They were able to record it consistently and meet back with the community health worker who was able to monitor. If blood pressure readings were looking more elevated, then that person would be referred to a primary care doctor or to additional services in the community. If there were issues with access to fruits and vegetables for a healthy diet, or maybe they needed yoga mat or a pedometer to help them exercise more often, we provided many of those different materials also as incentives to help them monitor their own blood pressure.

And so, I think that success, we could see it through clinical outcomes with improved blood pressure readings. In terms of patient satisfaction, we conducted a patient satisfaction survey; and the majority of patients and residents loved their community health worker, loved the additional support that they were receiving through the community health worker, but also through their primary care practice and also through their insurer. So, it boosted satisfaction for the services that they were providing just to have more of an interaction outside of your doctor visits.

JOHNSON:
And all of this is the result of a partnership at a higher level between the provider, the insurer, the commonwealth, right?

WIGGINS:
Yes. Oftentimes, the recognition isn't really seen at that level—you see it more at the interpersonal level. But behind the scenes, our payers, our providers, our health departments are working together, taking into account feedback from patients and residents about things that they would like to help improve their hypertension and educational resources that they would like to receive. But we are strategizing behind the scenes and are working hard to provide more opportunities.

JOHNSON:
And you're creating a model, it sounds like, that could be used in other places where these health problems are running rampant.

WIGGINS:
Yes, absolutely. And the good thing about working with state insurers like Anthem Blue Cross and Blue Shield—the commercial insurer—and also the Healthcare Workers Plus for Medicare or Medicaid is they have member networks across Virginia.

So, what we did in Richmond is to really look at where those members generally live—you know, in which general area do they live. We identified—you know, they just kind of provided us with the mapping or the information so that we can map using GIS mapping—and were able to find hotspot communities of where those numbers might be located, identify primary care practices within those hotspot areas, and then replicate and scale the same type of model in Richmond to other parts of the state.

JOHNSON:
You must be pleased with the outcomes so far. Are you willing to share this model with others in the public health field if they hear this podcast and want to know more?

WIGGINS:
Absolutely. We have already begun to share the previous gathering of grantees through ASTHO. With other states, we were able to share our surveys for provider and patient satisfaction, EHR protocols that we have developed, the model itself. And I would, of course, be happy to speak with anyone to help share this model.

Public health is something where we're all in this together, and what's working in one state could benefit another state or another community. And so, the more that we're working together across state lines and across communities, the greater likelihood we have for success in terms of moving the needle on heart disease and stroke.

JOHNSON:
Keandra Holloway's job as a community health worker means working face-to-face with people in need, often watching them choose between food, rent, and healthcare. She plays a major role in helping her clients get the resources necessary to navigate these challenges.

HOLLOWAY:
It's very hard when you live in an impoverished community where you're really at low-income—the majority of the residents where I work only make $10,000 a year. So, their first priority is not really their health so much, it's really more their social determinants of health, really.

And so, what I've gotten from those in the community, it's moreso if you are worried about feeding your children or, you know, getting diapers or formula, you're not really concerned about your health, you know. And so, the high blood pressure would come from the stress of not knowing where your next meal is going to come from, or, you know, if you have money for diapers or even your rent. So yeah, it's a major concern. And also, because they lack the knowledge of their health, they don't utilize their primary care doctors as they should.

And so, with me being in the community, I'm able to assist them and give them that knowledge and help to say, "Hey, you know, I can help you find a primary care doctor, I can get you to this specialist, or even I can get you signed up for insurance so we can get your blood pressure controlled, you know, so it doesn't lead to heart failure," and things like that.

JOHNSON:
Your office is right in the middle of the public housing project that you serve.

HOLLOWAY:
Yes, it is. It's right in the heart of it. We actually rented one of the one-bedroom apartments, and we made it into an office slash clinic. And so, we have a waiting room—just like a doctor's office—we have a front desk person like a doctor's office, and you have a triage room and then the exam room.

But that's the best part about it—they can actually walk right outside their door and get, you know, medical care or attention that they would need.

JOHNSON:
Describe your typical day for me. Tell me what that day at work in that clinic looks like for you.

HOLLOWAY:
A typical day for me is pulling up to my office and not even being able to get inside my office before I'm stopped. My clients know my cars, they are excited when I'm here; when I'm not here at all, they are like, "Where are you?"

So, a typical day looks like, you know, I come in and—I mean, this could go from anywhere. It could be, "I need my blood pressure checked," "I need, you know, medical insurance, I need help finding a primary care doctor." You can go any way—we have no regulations on what a person can come in and be seen for.

So, I see a good amount of people a day. I would say on average I could see maybe 15–20 people a day, and that's in office. But I'll reach out as well, which is door-to-door outreach, where I go out and actually knock on the doors to introduce myself, or to just check on the members in the community to see if they need anything.

JOHNSON:
You're right in the middle of it, then. You're part of the community.

HOLLOWAY:
Yes, yes, we are very well a part of the community and we're well-known in this community. So, that does make it great. We are a part of the community, yes we are.

JOHNSON:
How does that help in terms of delivering the care?

HOLLOWAY:
I would say it's a tremendous help. I know the numbers we have—you know, teen pregnancy has dropped, so it's awesome that they can be in their community and come to the center and get birth control and, you know, talk to a doctor or talk to the community health worker. They say, "Hey, I need assistance with filling my prescription. I don't have the money for my prescription," and they don't have to get on a bus to do that. They can actually walk out their door and get that assistance.

JOHNSON:
Have you been with this project since the day of the office opened?

HOLLOWAY:
I have not been with the project since the office has opened. The office that I'm actually located at, which is in Fairfield Court public housing, it's been up and running for 10 years now. I've been a part of the team for four years, but the community health worker's position, yes, I have been a part of that since it got started.

JOHNSON:
How much progress have you seen in the course of the four years you've been at this with the health of people? Have you seen improvements?

HOLLOWAY:
Yes. So, I've seen a big improvement. I actually did a pilot on a project where I worked with those in the community only with hypertension. And so, I was able to go to their doors and go in their homes and help them with, you know, different barriers they were facing. I'm able to give them even free blood pressures cuffs and booklets to keep track of their blood pressures and things like that. So, it's been a tremendous help for those in the community.

JOHNSON:
Now people don't know yet, but they're about to find out—you actually lived in this community at one point yourself, right?

HOLLOWAY:
Yes. And that's what makes the community health worker job description so unique is because the Richmond City Health District, when they hired community health workers, they wanted to make sure that they could meet those people where they are. So, they wanted people who either lived in public housing or previously living in public housing.

And I myself, at the time, when I got the job, I was living in public housing. I actually lived in the same community where I worked for seven years. I mean, it's going on three years since I have moved out. And so, it's awesome being able to meet them where they are, and they know and understand that I have been in your shoes, I know where you're coming from, I know it's hard to kind of get out of here and also take care of your health at the same time.

And so, they watched me grow tremendously. And so, being an example for them as a community health worker is awesome.

JOHNSON:
When you are trying to help folks, does that credibility make it easier?

HOLLOWAY:
Oh, it does. It very well does because I built that trust and rapport, and that's very important with a community health worker. It's so important that you have that trust and rapport. And so, being that I was a great role model and example during the seven years that I did live out here, the people already knew who I was. So that made a great deal, a great big deal—you know, it made a difference.

JOHNSON:
Well, you're not an outsider.

HOLLOWAY:
That's exactly right. That's exactly right. And that is something that goes on a lot in public housing.

We have a lot of people and partners who want to help and, you know, they come from the outside kind of looking in. And so, they really don't know the depth of what goes on after five o'clock—you know, nothing is open, everything is shut down. And so, they come from on the outside wanting to come in and do things. And so, there's been a little trust issue for outsiders.

But they know here at the resource centers and the clinics that they can trust us.

JOHNSON:
What do you think would be the health of the community were this project not part of their daily lives?

HOLLOWAY:
I don't think that people would have the knowledge of knowing how important their health is—not just their social determinants of health, but their physical health. So, I truly believe that if this project or if this center was not here, we would see a definite increase in, you know, ER visits, heart attacks, you know, things of that nature. People just not knowing how to take care of themselves.

JOHNSON:
I assume that you've become fairly attached to many of the people that you see every day.

HOLLOWAY:
Oh, gosh, it's funny that you say that. Yes, I definitely have to, you know, create some barriers and draw some lines between me and a few clients because, you know, to be honest, with a few of them I am their only support system. And so, you can get attached to those clients.

But you also—we're not here to really hold their hand. We're here to help them be able to become stable, to have stability and to be able to take care of themselves, you know, on their own, you know. So yes, we do get attached, but I also know that I don't want to enable any of my clients.

JOHNSON:
At the same time, if they believe you, if they trust you, if they respect you, the guidance you're giving them is more likely to stick with them.

HOLLOWAY:
Yes, we help with that. And like I said, we help with the social determinants of health as well. So, we've helped some people move out of public housing and they still come back and it does stick with them. So, I do have people come back and say, "I remember what you said, you know, I didn't forget." You know, they come back. And so yes, it definitely sticks with them.

JOHNSON:
Why do you think this approach has worked so well?

HOLLOWAY:
I truly believe it has worked so well, like I said, because of that rapport and that choice that the community has with the community health worker, which is myself. So, I know that was a tough barrier, that was something that was really heavy in a poverty rate community, which is health. You know, most of the people that I've served, you know, have a lot of ER visits, have, you know, high blood pressure and hypertension.

JOHNSON:
This sounds like the perfect job for you and for the community.

HOLLOWAY:
Yes, it is. It's perfect together. I tell a lot of clients, you know, "Without you, you know, I wouldn't be here at my job," you know, and they tell me, "Without you, I wouldn't be motivated to, you know, keep my blood pressure down." Or, you know, I had a client who has had open heart surgery, and so it was even the little things as, you know, covering up, you don't want to get an infection, you know? And so, yeah, they need me as much as I need them.

JOHNSON:
For more information, visit ASTHO's Heart Disease and Stroke Prevention Tools For Change webpage. It's full of useful resources and examples of programs across the states and territories. Find it on the ASTHO website, www.astho.org, or click on the page link in the show notes for this episode.

Thanks for listening to Public Health Review.

If you like the show, please share it with your colleagues. And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

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