By Erin Cristales, Vizient
Ask Sarah Arthur of Novant Health to pinpoint one example of how the system's community health workers have transformed the lives of local patients, and it proves to be a surprisingly tricky task.
"To be honest," said Arthur, director of community health, "there are just so many stories to tell."
Take, for instance, the patient who connected with a community health worker (CHW) after a visit to the emergency department. A Mexican native and domestic violence survivor, she fled her home country to escape her abuser. The CHW assigned to her case recognized that, as a victim of a violent crime, she was eligible for a visa and supported her through the process of securing one.
Then there are the expectant mothers whose lives — and the lives of their unborn babies — have been saved through community health workers' efforts to address food insecurities, as well as anxiety and depression disorders that often affect high-risk maternal populations.
Add to that the hundreds of patients with diabetes, heart failure and COPD who, thanks to CHW interventions, now have access to life-changing resources, and it's easy to see why there's no single example that encapsulates the significance of the work that's occurring.
"A lot of times, it's basic services that fall through the cracks for patients who have complex needs," Arthur said. "Community health workers are ambassadors for patients — allowing them to have more of a voice within healthcare, which has traditionally been exclusionary for minority groups and those with low health literacy."
Since the formal launch of its Community Health Worker program in 2019, Novant Health — a not-for-profit system that consists of nearly 800 locations, 19 hospitals and more than 1,900 physicians and 36,000 team members across the Carolinas — has strived to close healthcare disparities by removing barriers to care and helping patients navigate the many challenges that affect their wellbeing. Arthur and her colleague Kimberly Dull, director of performance, community health and social determinants of health, detailed the successes and challenges of Novant Health's program as part of a recent Vizient Diversity, Health Equity and Inclusion (DHEI) Network webinar titled "Community Health Worker Models to Improve Health Equity."
The CHW model has picked up steam in recent years as a way to help providers improve quality of care and reduce ED utilization and length of stay. According to a report from the Centers for Medicare & Medicaid Services, a systematic review of CHW interventions determined they were cost effective for cardiovascular disease prevention as well as preventing and managing Type 2 diabetes. One study published by the Society for Public Health Education found that every $1 invested in CHW interventions provides a return on investment (ROI) of more than $2.28, mostly by shifting inpatient and urgent care to primary care.
The CHW model also enables providers to build stronger relationships within their communities, particularly with patients who have historic distrust of healthcare institutions. It helps that community health workers typically share ethnicity, language, socioeconomic status and life experiences with the community members they serve.
"Community health workers are instrumental in addressing patients' clinical and nonclinical needs, especially those from the most vulnerable populations," said Laura Hoffman, Vizient PI program director, who has written about the importance of CHWs in improving health literacy and patient outcomes.
In 2022, Novant Health served more than 1,200 patients through its Community Health Worker program and enabled more than 5,700 connections to community resources that aided in access to care. Here, Arthur and Dull discuss some of the major considerations for healthcare organizations who want to launch or expand a community health workers program.
Think about how you define ROI — and how you will effectively communicate it.
In Novant Health's program, ROI is largely illustrated through cost reduction versus revenue generation (although, Arthur and Dull note, that may change with the new CMS guidelines allowing for CHW reimbursement). Much like case management teams, community health workers reduce utilization, length of stay and readmissions while also building deeper connections with patients to address the socioeconomic issues that contribute to poor health.
It's key, they said, to communicate those successes with data.
"Emphasize improvements in health outcomes like percentage of reduction in A1C, hypertension or PHQ-9 scores," Dull said.
Some of Novant Health's key performance indicators include:
- Improved health, such as in PHQ-9 scores and medication adherence.
- Improved system efficiency and effectiveness, including reduced ED and inpatient utilization and an increase in perceived quality, coordination and access to care.
- Improved social determinants, such as a decrease in unmet social needs and an increase in confidence to improve health.
Embrace simplicity for better health literacy.
Everything from discharge summaries to the incorporation of health and wellness recommendations into everyday life can be overwhelming for the average patient. But Novant Health is all about keeping it simple by utilizing the "Ask Me 3" educational program, which centers on three simple questions patients should ask their doctors:
- What is my main problem?
- What do I need to do about it?
- Why is it important for me to do this?
"Often, patients are so intimidated to talk to their doctor that they forget what they want to ask," Arthur said. "When it comes to any health behavior change, you have to translate the information in a way that's understandable and easy to follow and allows patients to feel more in control of their health — which is exactly what our community health workers do."
Determine the appropriate models and roles within your program.
Currently, Novant Health structures its Community Health Worker program based on community, hospital and physician group needs, as well as the trends that are revealed through the system's social determinants of health (SDOH) screenings.
"For some CHWs, their work is based on a population health approach with specific disease states, while others are focused on high-utilization populations coming out of the ED and the inpatient setting," Arthur said.
Novant Health's program lives within the Office of Health Equity, which helps to inform the initiative's approach and culture through:
- Working closely with Novant Health's Community Engagement team, which helps in identifying and collaborating with referring partners (including police and fire departments, senior centers and other nonprofits) as well as community placement.
- Connectivity with the social work intern program, which is also housed under the Office of Health Equity.
- Close partnerships with system leadership (Heart & Vascular Institute, Women's and Children's Hospital, Behavioral Health) and referring teams (case management and acute navigators).
"These types of partnerships help us leverage resources for our patients," Arthur said. "We look holistically at how the patient can be successful, whether that means improving health to prevent readmission after discharge or focusing on the prevention side. How do we give them the tools to really manage their chronic disease and create a culture shift around how they think about the connection between their health and what they eat or the neighborhoods they live in?"
Look at SDOH through both a quantitative and qualitative lens to bolster your interventions.
Beginning this year, CMS requires providers to collect SDOH information (including food, housing and transportation insecurity, utilities and interpersonal safety) on all adult patients. It's important data for CHW programs, both for targeting patient needs and then assessing the success of chosen interventions.
"When you have team members who are saying, 'I know that we're making a difference because my patients tell me that we are every day' — that's one thing," Dull said. "But when you can marry those qualitative stories with real-time data that segments our patients' experiences by dimensions of diversity and calls out pre- and post-change, that really puts fuel behind the fire. It brings stakeholders on board who might not naturally be inclined to support the program."
Tools like the patent pending Vizient Vulnerability Index™ — which identifies social needs and obstacles to care in neighborhoods that may influence a person's overall health — also help make the case for necessary interventions.
"The ability to overlay geographic areas that we know have vulnerabilities with areas where patients are experiencing disparate quality outcomes helps us make the argument that this work is really important, and it needs to be prioritized in specific places," Dull said.
Never lose sight of your mission.
It may sound simple, but sometimes the heart of your work can be obscured by the seemingly endless onslaught of challenges currently facing healthcare providers. But by always striving to keep your core mission front and center, you can truly stay focused on achieving ideal patient outcomes.
"Our team has a vision that every unique individual can achieve their highest level of health," Arthur said. "And all our work is pointed toward that vision."
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