Care coordination and the community health worker (CHW) – The time has come

October 7th, 2015 / By Steve Delaronde

Improving care coordination for the sickest, most vulnerable and highest cost patient segments remains an important component of population health management and achieving the goals of the Triple Aim – better outcomes, lower costs and improved patient satisfaction. Yet, even as we acknowledge the importance of care coordination and devote considerable resources to this effort, the next question is whether these resources are being diverted to the right places to make a meaningful difference in health outcomes, cost and patient satisfaction.

Commercial payers are hiring more nurses to focus on care coordination. Additionally, CMS now incentivizes primary care physicians to coordinate care for Medicare patients who have two or more chronic conditions and will pay doctors $42 per month to offer 24/7 patient access, medication monitoring, appointment tracking, and attempts to smooth transitions between home, hospital and other facilities.

While there is certainly a care coordination role for physicians, nurses and other medical professionals, there are some factors which do not necessarily make them the best choice:

  1. Medical professionals do not typically have sufficient training or understanding of the environmental, social and community factors that influence the health of their patients, and remain exclusively focused on the coordination of medical services.
  2. Access to medical professionals may be challenging for patients in rural areas, as well as those patients who lack transportation or the means to make regular visits to a medical office.
  3. Reimbursement for care coordination provided by medical professionals is high relative to non-medical workers, since it is aligned with their medical training and not the more elemental services of care coordination.

Enter the community health worker (CHW). CHWs are frontline public health workers who understand the community, use their understanding and experience of the community to build trusting relationships with patients, and serve as a link between the healthcare system and the community to facilitate access to services that improve health outcomes. CHW-based interventions have proven to be effective in improving post-hospital outcomes, and reducing overall medical costs and utilization in high risk populations.

Since 2014, CMS has allowed reimbursement for preventive services by professionals that are not within a state’s clinical licensure system (e.g., CHWs), as long as those services are initially recommended by a physician or other licensed practitioner. Even prior to 2014 many states, including Alaska, Minnesota, Montana, New Mexico, Oregon and Texas have led efforts to formalize and endorse CHW programs. Minnesota has been a leader in promoting the CHW role by offering a CHW curriculum in higher education.

Patient-centered medical homes and accountable care organizations that consider the impact of the social determinants of health will have the greatest impact on improving overall health outcomes. The CHW is an effective, economical and efficient resource for achieving the goals of the Triple Aim and should be a key part of any care coordination effort.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.


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