Community health workers, when properly integrated with clinical staff, can help people in under-resourced communities prevent and manage diabetes.
Community health workers (CHWs) can help people prevent and manage diabetes through education, coaching, and other support. By building trust with people who have diabetes, CHWs often identify barriers to care that help health care professionals better understand and respond to patients’ needs. Elizabeth M. Vaughan, DO, associate professor at the University of Texas Medical Branch at Galveston, explains who CHWs are, how they are trained, and how health care professionals can successfully integrate CHWs into diabetes care.
Q: Who are community health workers?
A: Community health workers (CHWs) are frontline public health workers who are trusted members of the communities they serve. I often call them “the bridge”—the bridge to help people get the health and social services they need. Other names are “promotores de salud” (who work with Spanish-speaking individuals), coaches, lay health advisors, and community health representatives.
CHWs are not social workers. Social workers do amazing things, and they have an important role in patient care. But an individual serving a community who doesn’t live there, have a close relationship to the population, understand their cultural practices and barriers, or speak their language is not a CHW.
Being on the front line, being part of the community, and having trusted relationships distinguish CHWs from social workers and other health care professionals. CHWs usually share race or ethnicity, language, geographic area, socioeconomic status, and even life experiences with the community members they serve. They’ve often walked in patients’ shoes, which helps them to understand their problems. These community members are typically disproportionately affected by social determinants of health.
On a much higher level, CHWs have the potential to be a key part of the U.S. health care system’s movement to reduce health disparities and increase health equity. Growing evidence shows that CHWs are effective in chronic disease management and other areas. And each dollar spent on a CHW intervention will result in a $2.47 return on investment, one study shows.
I’ll add that demand for CHWs is expected to grow at least 12% (PDF, 200 KB) from 2016 to 2030.
Q: How do CHWs work with people to manage and prevent diabetes?
A: First of all, it’s important to recognize diabetes’ disproportionate impact on people of color. Some of these people live in communities where CHWs work.
People in under-resourced communities may be more open with CHWs about their health than with other health care professionals. Here’s a common scenario we’ve faced: A doctor asks a patient with an A1C level of 12%, “Are you taking your pills?” The patient says, “Oh, yes.” Then 2 days later, the patient tells a CHW, “I haven’t had any pills.” Patients are not trying to lie to their doctors, but it may reflect a cultural desire to please health care professionals. In contrast, CHWs can find out what’s really going on. For example, maybe the person has trouble paying for their pills but is too embarrassed to admit it. It’s a holistic approach.
Most individuals with diabetes have low or middle incomes. If they lose a leg or eyesight or are placed on dialysis due to diabetes complications, they might lose their jobs. In populations that depend on manual labor for income, this also affects their families and communities. CHWs may help prevent diabetes complications by helping people attend medical appointments, get and take medications, and adopt or strengthen lifestyle changes.
CHWs also help people navigate a complex health care system. They get people prescription drug cards and help them apply for prescription assistance programs. They help people who don’t read English understand health information and work through application processes. A lot of it is communication.
CHWs can also help with primary prevention of diabetes. They meet with people one-on-one in their homes or in group sessions at community centers and the like. CHWs provide education and materials about diet and exercise as well as informal coaching. They also help people find health care providers and sign up for health insurance and other benefits they may be eligible for.
There are so many possible cracks to fall through. That’s why it’s great to have CHWs be part of the health care system. In a randomized controlled trial of an intervention called TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access), we found that more than half of participants reported at least one barrier to care, mostly involving medications, appointment access, and eligibility to attend a clinic. CHWs identified nearly 88% of these barriers, making it more likely that health care professionals can address these problems.
Q: Can working with CHWs improve health outcomes for people with diabetes?
A: Absolutely! The research on CHWs and their impact (PDF, 280 KB) has grown over the years. Numerous randomized controlled trials, systematic reviews, and meta-analyses show that CHWs are valuable in diabetes care and prevention. For instance, one systematic review showed that CHWs engaged in diabetes prevention can help improve health outcomes, including improved blood glucose management, weight loss, and reduced rates of new-onset diabetes in people at increased risk of developing diabetes. In people with diabetes, CHW interventions were associated with modest reductions in A1C levels when compared with usual care, according to a systematic review and meta-analysis.
The TIME program that my colleagues and I developed led to lower A1C and blood pressure levels (but no changes in body mass index or weight) in Latino adults with type 2 diabetes, compared with usual care, in a 6-month intervention. A follow-up study found that the improvements in A1C and blood pressure levels were sustained 2 years after TIME ended.
I’ll note that A1C levels are challenging to measure in groups experiencing disadvantage. The levels fluctuate significantly because people sometimes lose medication access. In some cases, it’s not that the CHW program wasn’t helpful; it’s because our health care system has some cracks that even CHWs can’t always fill. But even with these variable levels, we’re still seeing significant differences between intervention and control groups.
Q: What kind of education, training, and certification do CHWs typically have?
A: In terms of education, CHWs may have anything from primary education to bachelor’s degrees and beyond. They often do not have a medical background. On-the-job training is common.
There are no national standards for CHW education, training, and certification. That’s a major challenge. Large variations in CHWs’ knowledge and roles may result in health care professionals being reluctant to work with them. A study of the knowledge and attitudes of primary care doctors and nurses showed they were interested in working with CHWs but also were concerned about adequate training and added workload. Providing appropriate CHW training and support and educating health care professionals about CHWs’ roles and limitations is critical.
Currently, 13 states have state-run CHW programs. Their training and certification requirements vary widely. In Texas, where I train CHWs, people take a 160-hour class to become certified and recertify every 2 years with another 20 hours of training. That’s probably one of the more stringent programs in the United States. Several states have private certification programs, and the rest have CHW programs in development or nothing at all.
Some states have no CHW certification, but they do have CHW training. It’s important to look at who’s conducting the training. In Texas, for example, nonprofits, universities, and others can apply to operate state certified CHW training programs. I hope that as time goes on, we’ll have more uniformity in CHW training and certification programs nationwide. That will help pave the way for more robust demand for CHWs and longer-term funding.
Q: Where do CHWs work?
A: CHWs typically work with under-resourced and often minority populations who face barriers to adequate health care. They work in hospitals and community health clinics, as well as in community-based settings such as community organizations and houses of worship. CHWs also visit people in their homes.
CHWs may work directly for health care systems or for nonprofits contracted by health care systems. They are not usually found in private medical practices.
What CHWs work on can be broad—like COVID-19 vaccination campaigns or cancer screening programs—or narrow, such as helping an individual with a chronic disease. In both cases, they offer the ability to form close, trusting relationships with people in the community.
Q: How can clinicians integrate CHWs into their practice and pay for their services?
A: The first step is recruitment. To find CHWs, we go to the community—our patients, clinic volunteers, houses of worship, and community centers. Health care professionals are so careful about hiring for clinical positions. We should show the same care for CHWs.
Next comes training, starting with a state certification or program if available. We also train CHWs in the specific disease and environment they’ll be dealing with. For our diabetes CHWs, we use a four-step training program that includes
- teaching skills and common clinic legal requirements for privacy, such as personal health information
- basic education about diabetes, including identifying patients who are in danger, have trouble with medication adherence or side effects, or have comorbidities
- on-the-job training, such as how to do a foot exam
- ongoing education with opportunities for CHWs to ask questions about cases
CHWs are frontline workers who often have the most contact with patients but the least medical knowledge and training. Our job is to make sure they have the knowledge to be effective.
Sometimes CHWs get thrown out there with no clearly defined role and little support. They are told to “fix something,” but without the right training and integration with the health care team. It can be frustrating for both the employer and CHW and lead to high turnover rates. It’s important to clearly define your needs. For example: “Patients’ A1C levels are higher than we’d like. We want CHWs to improve communication between patients and the medical team about their medications and coming to appointments to help lower those A1C levels.”
The next part is support. CHWs need to know who to call when they have a question or concern. I’ve seen programs in which the CHWs are doing their own thing and the medical staff is doing their own thing, but they’re not connected. Health care professionals need to connect the CHW to the system. We have done this through a weekly virtual meeting with a designated staff member.
The most common sources of CHW payment are grants, charity, and government funding. The challenge with grants is that they’re great for conducting studies, but they’re not a sustainable mechanism. After the study is over, how do you get CHWs to stay? I hope that one day we’ll see CHWs as an important part of a multidisciplinary care team, not just a nice add-on.
Currently, nearly 30 states allow Medicaid payment for CHW services. Medicare does not specifically cover CHWs, and most private health plans do not reimburse for CHW services.
The goal is to recognize the return on investment for CHWs. If they can help prevent diabetes-related amputations and dialysis or help uninsured and undocumented people get care, that will save hospitals and the rest of the health care system a lot of money.