As the United States navigates the uncertainties of Covid-19 and begins a long-overdue process of confronting systemic racism, the communities most affected by poverty, racism, and language barriers and those with the largest populations of immigrants continue to have the worst health outcomes. In the weeks immediately after the pandemic spread to the United States, disadvantaged communities were faced with reduced access to care, a widening digital divide, and inadequate supplies, such as food and diapers. Investing in community health workers (CHWs) and community-based organizations can help address the social determinants of poor health that disproportionately affect low-income, minority populations and that are magnified during times of crisis. These workers and organizations can help improve material conditions, facilitate access to health care systems, and provide psychosocial support.1
CHWs are trusted members of local communities who share lived experiences with their neighbors and peers, and they are experts in navigating complex systems of care, serving as a link between clinical and community-based services and the people who need them most.2 When CHWs are integrated within health care systems, they advocate on behalf of patients and can play a bridging role between patients and clinicians, transferring and interpreting information and ensuring that patients are connected to care. CHWs have been shown to reduce the burden of illness among people with chronic diseases and to improve their ability to manage their own conditions.3 They are also well positioned to address the misinformation, fear, and stigma surrounding Covid-19 by providing timely, accurate information about Covid-19 transmission, precautions that people can take to protect themselves and their families, and tools for obtaining access to care and support.
Examples of Ways in Which CHWs Have Addressed Intermediary Social Determinants during the Pandemic in New York City.
In New York City, where Covid-19 struck early and hard, it didn’t take long for the relationship between infection risk and ZIP Code to be uncovered. The city’s data revealed that 8 of the 10 ZIP Codes with the most deaths from Covid-19 are home to low-income populations that are predominantly Black, Hispanic, and Asian.4 Although the local clinical response to Covid-19 was swift and community-based organizations mobilized to meet rapidly increasing demand, limited access to information, health care, social support, and material resources endangered people in many communities. Our institutions, New York–Presbyterian Hospital and the NYU Grossman School of Medicine, are among the health care organizations that incorporated CHWs into their multidisciplinary response to Covid-19. In collaboration with community-based organizations, CHW teams proactively contacted socially isolated patients, connecting them with sources of critically important care and support. This experience has shown that, during times of crisis, CHWs may be the lone connection between some patients and an ever-changing — and increasingly digital — health care system. Some of the ways in which CHWs have helped identify and address root causes of disparities during the pandemic are described in the table.
For more than 15 years, bilingual and multilingual CHW teams at New York–Presbyterian Hospital and the NYU Grossman School of Medicine have delivered culturally and linguistically tailored health coaching, support, and health system navigation services to underserved communities throughout New York City. The 50 CHWs affiliated with the two institutions and with local community-based organizations move between community and clinical environments. Over periods of several months, CHWs partner with individual patients who have or are at risk for chronic diseases, providing them with education, support, and resources to help them manage their own conditions over the long term. They offer educational sessions, make home visits, and accompany patients to medical appointments and social services agencies. When a clinician identifies a patient as “nonadherent,” CHWs are able to provide insight into the social barriers that may warrant a revised clinical assessment and a plan of care that incorporates both clinical and nonclinical needs. Central to the CHW ethos is a capacity- and community-building approach focused on enhancing patients’ self-efficacy by helping them build their communication skills, empowering them with knowledge about their health care rights, and fostering social support.
CHWs at our institutions started adapting their workflows in early March. Since then, they have conducted more than 9600 wellness checks over the phone, helped nearly 3400 people enroll in online patient portals and prepare for upcoming telehealth appointments, and conducted virtual health coaching sessions with more than 600 patients. Through these efforts, workers uncovered and took action to address social determinants of disparities in Covid-19 infections and outcomes, serving as cultural brokers and navigators between community members and fragmented systems of care and mitigating fear and correcting misinformation in disadvantaged communities. In some cases, wellness checks revealed that patients had run out of medication for chronic conditions, were unable to pay rent, or had recently lost a loved one, for example. Many patients expressed despair associated with an inability to engage in health promotion behaviors, such as physical activity or healthy eating, while also facing lost income, poor job security, and problems obtaining enough food. In these instances, CHWs leveraged their cultural connectedness and shared life experiences to offer practical advice, coaching, and support in navigating the health system to address each challenge. Their efforts included facilitating medication delivery, connecting socially isolated older adults over the phone, and providing a listening ear and reflective empathy.
The effect of the Covid-19 pandemic on disadvantaged communities will be long lasting. Both the health care system and the landscape of social services in the United States have been permanently changed. With deepening food insecurity, increasing housing instability, slow job recovery, and the replacement of many in-person health services with telehealth services, the need for CHWs to bridge communities and systems of care is greater than ever. Investment in community-based organizations that provide critical support, including access to nutritious food and housing, legal, and mental health services, is also essential. A strong body of literature supports the role of CHWs in improving health care utilization and outcomes in a cost-effective manner through the implementation of evidence-based approaches. More research is needed, however. A number of reimbursement mechanisms for CHWs have been explored with varying levels of success, and there is no uniform payment model or consistent reimbursement mechanism for CHW services.5
We believe that CHW programs should be carefully designed, offer adequate training and ongoing supervision of workers, and be integrated into stable systems with sustainable funding. Recruitment should be based on qualities including empathy and cultural connectedness, rather than on academic qualifications, and CHWs should be members of both the health care teams and the communities in which they work. As we define our path forward from the Covid-19 crisis, we should recognize the integral work of CHWs in supporting patients and communities, including the critical role they have played as frontline team members during the pandemic. Now is the time for payers and health care systems to take action to invest in a sustainable CHW workforce.
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September 24, 2020 at 04:07AM
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Community Health Workers and Covid-19 — Addressing Social Determinants of Health in Times of Crisis and Beyond - nejm.org
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