HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Defeating COVID-19 Locally: The Community Health Worker Ground Game

June 10th, 2020

The Problem

While COVID-19 is a novel virus, its devastating impact on public health has shone a spotlight on longstanding failures of our healthcare and social services systems. Thus far in the United States, the virus has claimed over 100,000 lives, dramatically reduced access to healthcare, and reinforced disparities in health. Beyond the healthcare sector, COVID-19 has shut down schools and even triggered a global economic depression.

COVID-19’s effects on U.S. health extend far beyond direct infection rates. In terms of healthcare access, patients who depend on routine care have deferred essential appointments for primary care, behavioral health, and specialty care. Because the majority of nonelderly Americans receive health insurance from their employers, many unemployed individuals have lost coverage at the time when they need it the most. Poor disease management today will lead to harmful consequences in the future.

COVID-19 has also brought economic and social devastation. Widespread school closures exceed what was observed during the 1918 Spanish Flu. Furthermore, nearly 40 million Americans have lost their jobs, leaving them financially vulnerable and overwhelming our unemployment benefit system’s ability to provide relief. The stress of the pandemic is creating a mental health crisis as well.

All of these effects have been felt most by disadvantaged communities and racial and ethnic minority groups. In Chicago and Louisiana, African Americans account for 70% of COVID-19-related deaths while representing only 30% of the population. Latinx communities have also been disproportionately burdened by the pandemic.

Community Health Workers

The diverse impacts of COVID-19 on our health, education, and economy necessitate an equally multi-faceted response. Community health workers (CHWs)—trusted individuals who are members of the communities they serve—are uniquely qualified to address a range of socio-behavioral, economic, and preventive health needs. As recently outlined by Smith and Wennerstrom, CHWs are well-positioned to contribute to the COVID-19 response. This cadre of workers can support or conduct contact tracing, while also addressing needs beyond COVID-19. For example, CHWs can connect patients to community-based resources, battle eviction notices, and reduce social isolation through the provision of emotional support.

In recent decades, global and domestic community health experts have identified core components of successful community health worker programs, including sound hiring guidelines, work practices that enable a holistic and longitudinal patient relationship, adequate supervision, and manageable caseloads. In the U.S., significant evidence has emerged demonstrating that CHWs can address social determinants of health, improve chronic disease management, and reduce hospitalizations. IMPaCT, a standardized model for hiring, training, and implementing CHWs, has been demonstrated across three randomized controlled trials to improve health care quality and health outcomes, leading to reductions in hospital stays. In turn, this model delivers $2.47 in savings for every dollar invested, saving Medicaid $4,626 per beneficiary.

A Comprehensive Workforce Approach

The national public health dialogue has thus far focused on contact tracers—not CHWs —as the frontline interface with communities impacted by the virus. Contact tracers are an established cornerstone of pandemic response. These public health workers call infected individuals, identify a list of people they may have exposed, and encourage exposed individuals to self-quarantine.

In our country’s response to the COVID-19 pandemic, contact tracing efforts have been centered within public health departments. However, the needs of contacted individuals will often extend far beyond the scope of contact tracing. An individual exposed to COVID-19 may also be struggling to manage chronic hypertension, suffering from recent domestic abuse, and worrying about bills she is unable to pay due to illness. These struggles may also impede her ability to isolate effectively. This is where a CHW can step in to provide advocacy with employers, connections to social services, and a referral for high-quality primary care. For instance, in a recent case study, a CHW supported a group of Latinx immigrant warehouse workers by successfully advocating for them to receive COVID-19 tests paid for by their employer.

Together, CHWs and contact tracers can transform the community-based response to the current pandemic. A comprehensive approach that harnesses the skills of CHWs and contact tracers begins with population stratification according to COVID-19 risk factors. These factors include high poverty, population density, and racial demographics. For high-risk communities, place-based community health worker programs should be deployed with CHWs hired from within these same communities. These programs should be implemented according to key program elements, including hiring guidelines, supervision, integration into the clinical workflow, and holistic psychosocial support. Additionally, embedding CHW programs within local public health departments, community-based organizations, or health systems builds lasting infrastructure and capacity to address the longer-term consequences of COVID-19 and broader social determinants of health.

Lower-risk communities may only require a temporary workforce of contact tracers who perform light-touch calls. These tracers could be a combination of volunteer and paid individuals with minimal training and supervision by public health professionals, with referrals to CHWs as needed.

Policy and Financing Levers

The major prerequisite to widespread implementation of CHW programs is to enact key funding levers. A Public Health Infrastructure Fund and Emergency Supplemental Funding, as called for by the Association of State and Territorial Health Officers, could provide short-term funding for local COVID-19 contact tracing. To sustain these programs and drive long-term health impact, Congress should designate CHW services as a Medicaid optional benefit and increase Federal Medicaid Assistance Percentage (FMAP) rates for states and territories providing this service. Centers for Medicare & Medicaid Services (CMS) should then approve reimbursement for CHWs and align payment with evidence-based standards, such as those currently being developed by the National Committee for Quality Assurance.

We will know that we are responding well to COVID-19 when our most vulnerable communities are protected. A two-pronged strategy of CHWs and contact tracers, adequately funded by CMS, can provide this defense. Moreover, using COVID-19 as an impetus to invest in impactful CHW programs will pay dividends in preventive care in a post-COVID America.

**Feature photo obtained with standard license on Shutterstock.

 

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pranay nadella revised

Pranay Nadella, MPhil, is a medical student and Gamble Scholar at the University of Pennsylvania as well as an Associate Scholar at the Center for Global Health. In 2019, he received his Masters in Epidemiology from the University of Cambridge, as a Gates Cambridge Scholar, where he researched community health worker programs in India. Prior to his Masters, he completed his undergraduate degree in biology at Harvard. Follow him on Twitter @Pranay_Nadella

 

elena butler pic

Elena Butler is a medical student at the University of Pennsylvania. She has worked as a healthcare consultant at Bain & Company and a strategy advisor at the Boston Medical Center Health System. She was a Fulbright Scholar to Malaysia. Follow her on Twitter @elena_butler

 

shreya kangovi picShreya Kangovi, MD, is the Founding Executive Director of the Penn Center for Community Health Workers and is an Associate Professor of Medicine at the University of Pennsylvania Perelman School of Medicine. Follow her on Twitter @ShreyaKangovi 

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