The Rationale and Logistics for Incorporating Community Health Workers Into the Multidisciplinary Team

Abstract

Community Health Workers (CHWs) have shown value in diabetes care. CHWs are often the individuals who provide behavioral lifestyle intervention to underserved communities and are often the first to assist patients in gaining appropriate access to care. As trusted members of their communities, they have the ability to significantly impact psychosocial and biomedical outcomes, making them important members of the behavioral medicine team. However, lack of recognition of CHWs within multidisciplinary teams (MDTs) gives rise to the issue of the underutilization of their services. Therefore, barriers to including CHWs in MDTs including standardized training and strategies to overcome these are discussed.

Diabetes is a complex chronic disease for which multidisciplinary teams (MDTs) have shown efficacy.^1-3 A systematic review and meta-analysis of 16 studies revealed that MDTs significantly improved HbA1c (P < 0.001) and systolic blood pressure (P < 0.001) for investigations of 3 to 12 months in duration. Humanistic outcomes (patient-reported measures) of MDTs improved or were maintained, and healthcare costs and utilization were comparable to that of usual care. ¹ However, as discussed by Nieto-Martinez et. al. in this issue, strategic plans for lifestyle interventions that include MDTs are well-documented, but the implementation of these plans is needed. ⁴

A critical initial step in implementation is defining key variables and goals. The American Diabetes Association’s (ADA) Professional Practice Committee defines MDTs as primary care physicians, subspecialty physicians, dietitians, mental health professionals, physician assistants, exercise specialists, dentists, podiatrists, nurse practitioners, and nurses. ⁵ They note that other specialists may be included on the team, such as a maternal-fetal medicine specialists for women with preexisting diabetes who are planning pregnancy. ⁵ Other investigators have demonstrated the value of additional specialists, including pharmacists and behavioral health professionals, in improving diabetes outcomes.^6,7 Yet, the ADA recognizes the limitations of this definition, assigning an “E” grade as the level of support for the recommendation where, on a linear scale from “A” to “E”, “A” is clear evidence from well-conducted generalizable randomized controlled trials and “E” is an expert consensus or clinical experience. ⁵ To successfully implement MDTs into diabetes care, the scope of its definition need to be broadened.

Rationale for Community Health Workers (CHWs) as Part of the Multidisciplinary Team

Low-income minority populations encompass the majority of individuals with diabetes but are underrepresented in research.^8,9. The ADVANCE trial (Accelerating Data Value Across a National Community Health Center Network) (n = 952,316) consisted of 97 federally qualified health centers and 744 sites across the US revealed an overall prevalence of diabetes of 14.4%, with whites the lowest (11.4%) and Hawaiian/Pacific Islanders the highest (21.9%), and other minorities ranging from 15.2%-16.5%. ⁹ These individuals often face additional barriers to diabetes care including language, literacy, cultural variations, transportation, and economic hardships compared to other populations. Integrating individuals in the MDT who can understand and address these barriers may be a key component to successful implementation.

CHWs are generally non-medical, lay personnel who are local leaders in their communities who often share similar socioeconomic and cultural characteristics with the patient population at-hand.^10-12 The C3 CHW Core Consensus Project acknowledged 10 major CHWs roles including cultural mediation, providing appropriate health information, case management, social support, advocacy, building capacity, outreach, assessment, research, and evaluation. ¹³ These diverse roles are strongly evident in the literature. A review of CHW roles revealed that more than half of the published studies were from low- and middle-income countries. ¹⁴ Focal points of CHW work varied from system-level/multiple/general to maternal/child health and disease-specific (i.e., diabetes, mental health). ¹⁴ Therefore, CHWs are important members of diabetes care teams for improving diabetes outcomes, particularly in underserved populations as they not only address individual-level but often community-level factors as well.

Barriers for CHWs as Part of the Multidisciplinary Team

CHWs have been in the workforce since the 1960s, but only seven states currently recognize CHWs as a part of team-based care. ³ Underuse of CHWs may relate to ongoing lack of national and international standards for training and certification compared to mainstream medical disciplines, such as medical doctors and registered nurses. The Community Health Training Institute revealed that few US states have CHW training and support: 7 established advisory bodies, 8 have a scope of practice, 5 required certification or training, and 6 authorized a standard curriculum with core skills. ³ Many of these states are duplicated in categories with 12 states representing the national CHW infrastructure, professional identity, and workforce development in the US. Complicating this picture, reimbursement is also variable, such as nine states require state reimbursements for CHW service. With an array of roles, positive patient outcomes, and lower costs for their services compared to other health professionals, it is vital to address these barriers to include them in MDTs.

Logistics to CHWs as Part of the Multidisciplinary Team

There are three key steps to integrating CHWs into the multidisciplinary team:

• (1) Define State Policies. Healthcare Professionals need to be aware of their state laws for reimbursement and certification processes. The majority of states do not have these in place, but sustainability will depend on program leadership and national collaboration involving states with established programs and may require extramural or other mechanisms of financial support.

• (2) Provide appropriate training and support. Even in states with certification processes, training and support specific to CHW roles is needed. For example, state certification will not address disease-specific training. CHWs working with diabetes will need initial and ongoing support to understand diabetes care including medication management and cost, patient privacy, and behavioral strategies in care.

• (3) Determine roles and responsibilities. CHWs need their specific role on MDTs outlined and a medical team member to support them when questions arise. CHWs often bring a broad skill set, have a strong work ethic, and desire to help others. While these are excellent qualities in an employee, these place CHWs at a high risk to be placed in work beyond their capacity, risking frustration and turnover. ²⁹

Conclusions and Next Steps

Diabetes is a disease that affects millions, most of whom are underserved. ³⁰ As front-line workers, CHWs play a critical role in bridging the gap between health services and the community to provide culturally tailored advice, guidance, and support to implement successful behavior changes, with their unique knowledge, cultural competency, and close relationship with the community. Diverse roles combined with the backdrop of culturally sensitive, recognized community leaders make a strong case for including CHWs as part of the MDT. Barriers to including CHWs are largely related variations in national standards for certification and reimbursement, making defining state policies, providing appropriate training and support, and determining roles and responsibilities key to successful implementation.