Community health workers

Community health workers (CHWs), sometimes called lay health workers, promotores de salud, community health representatives, or community health advisors, serve a variety of functions including providing outreach, education, referral and follow-up, case management, advocacy, and home visiting services. CHWs may work autonomously in the community or as part of a multi-disciplinary team in primary or specialty care; training varies widely with intended role and location. CHW services are usually provided to underserved communities and to individuals at high risk of poor health outcomes. CHWs often work with individuals at risk for or suffering from chronic diseases such as diabetes or cardiovascular disease. They also work with women at high risk for poor birth outcomes, providing pregnant women and new mothers with emotional and practical support and education on topics such as family planning, pregnancy, childbirth, breastfeeding, and vaccination.

Expected Beneficial Outcomes (Rated)

  • Increased patient knowledge

  • Increased access to care

  • Increased healthy behaviors

  • Increased preventive care

Other Potential Beneficial Outcomes

  • Reduced low birthweight births

  • Increased breastfeeding rates

  • Improved mental health

Evidence of Effectiveness

There is some evidence that community health workers (CHWs) improve patient knowledge, access to health care, and healthy behaviors (AHRQ-Viswanathan 2009), especially for minority women (Andrews 2004*). Health effects appear strongest for interventions to prevent cardiovascular disease (CG-CVD) and preventive health behaviors such as cancer screening (Kim 2016*, Wells 2011*, AHRQ-Viswanathan 2009). Such interventions can improve health in minority or underserved communities, reducing disparities in health outcomes and enhancing health equity (CG-CVD), and can be effective among Blacks (Cochrane-Lewin 2010*, Andrews 2004*), Hispanics (Verhagen 2014*), Asian Americans, Native Hawaiians, and Pacific Islanders (Islam 2015). Additional evidence is needed to confirm effects.

By reaching and mobilizing populations within their communities, CHWs have been shown to improve access to care for patients that may not otherwise receive care (Andrews 2004*), such as older adults from ethnic minority populations (Verhagen 2014*). CHWs can also increase health care utilization for interventions such as screening mammography (Kim 2016*, Wells 2011*, AHRQ-Viswanathan 2009) and cervical cancer screening (Kim 2016*, AHRQ-Viswanathan 2009). Effects are stronger when the CHW and patients have the same racial or ethnic background (Wells 2011*).

CHW interventions can help reduce the risk of cardiovascular disease (CVD) (CG-CVD, Kim 2016*). Interventions that engage CHWs as part of team-based care improve blood pressure and cholesterol in patients at increased risk for CVD (CG-CVD). When engaged as health educators and outreach, enrollment, and information agents, CHWs appear to increase healthy behaviors in patients at increased risk for CVD and may also help reduce morbidity and mortality related to CVD (CG-CVD).

CHW interventions appear to reduce A1c levels in diabetic patients, with larger effects among patients with higher baseline levels (Palmas 2015*). CHWs may also improve diabetes-related self-management behaviors, knowledge, and self-efficacy in Latino patients (Little 2014*). In some instances, CHWs can increase physical activity among those at risk for or diagnosed with chronic disease (Costa 2015*).

CHWs implementing the Pathways Model, which incorporates expert-created care plans and protocols toward specific measureable outcomes, appear to enhance access to prenatal services and reduce the incidence of low birthweight births among their at-risk clients, including both white and black women (Urban-Eyster 2013, AHRQ HCIE-Redding, AHRQ HCIE-Roberts). Community health workers can also increase breastfeeding initiation and exclusivity among low income women and black women (Cochrane-Lewin 2010*, Andrews 2004*) and may decrease the severity of post-partum depressive symptoms (Cochrane-Lewin 2010*).

CHWs can increase childhood immunization rates and improve TB treatment outcomes (Cochrane-Lewin 2010*). CHW interventions may also reduce symptoms and urgent care use among children with chronic conditions (Raphael 2013*).

Experts suggest establishing a comprehensive policy for formalization of CHW roles that incorporates occupational regulation (CDC-CHW 2015), a more defined scope of practice (Allen 2015*, Pittman 2015, CDC-CHW 2015), and more standardized workforce training (CDC-CHW 2015, Pittman 2015) and certification (CDC-CHW 2015, Pittman 2015). Experts also stress the importance of identifying sustainable funding mechanisms for CHW services (Allen 2015*, CDC-CHW 2015, Pittman 2015), such as Medicaid payment (CDC-CHW 2015).

Cost analyses suggest that integrating CHWs in the health care system can be cost-effective for certain conditions (Kim 2016*).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

Community health workers practice across the country, providing a variety of services in diverse settings. Training and certification requirements vary. As of 2015, 8 states have defined CHW scope of practice (Alaska, Massachusetts, New Mexico, Ohio, Oregon, Rhode Island, Texas, and Washington), 6 states have a standard core competency curriculum (Massachusetts, New Mexico, Ohio, Oregon, Rhode Island, and Texas), and 5 states also require core competency certification (Massachusetts, New Mexico, Ohio, Oregon, and Texas) (Barbero 2016*).

The Affordable Care Act (ACA) of 2010 includes provisions supporting the implementation and evaluation of CHW programs. However, reimbursement for CHWs remains limited; few private insurers and state Medicaid programs pay for CHW services, and most programs are supported by grant funding (Urban-Bovbjerg 2013). CHWs are authorized to be part of multidisciplinary health care teams by Medicaid or private insurance models in 6 states (California, Minnesota, New Mexico, Oregon, West Virginia, and New York) and to provide chronic disease care services in 4 states (New Mexico, Oregon, Rhode Island, and West Virginia). In 4 states, Medicaid payment is provided for CHW services (Alaska, Minnesota, New York, and Washington; Alaska and Minnesota require certification for payment) (Barbero 2016*).

The Pathways Model of care delivery, developed by the Community Health Access Project in Mansfield, OH, has been implemented in at least 16 communities across the country (AHRQ HCIE-Redding).

Implementation Resources

CDC-CHW 2015 - Centers for Disease Control and Prevention (CDC). Addressing chronic disease through community health workers (CHW): A policy and systems-level approach. National Center for Chronic Disease and Health Promotion. 2015.

CDC-CHW 2014 - Centers for Disease Control and Prevention (CDC). Policy evidence assessment report: Community health worker (CHW) policy components. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2014

CHW Central - CHW Central. A global resource for and about community health workers.

RHIhub-CHW - Rural Health Information Hub (RHIhub). Community health workers toolkit.

Georgetown-Scott 2008 - Scott J, Dunning L. Community health worker code of ethics toolkit. Washington, DC: Harrison Institute for Public Law, Georgetown University Law Center for the American Association of Community Health Workers (AACHW); 2008.

UAZ Rural and public health - University of Arizona Rural Health Office and College of Public Health. Community health worker evaluation tool kit: Increasing the quality and quantity of community health care worker program evaluations.

Citations - Evidence

* Journal subscription may be required for access.

AHRQ-Viswanathan 2009 - Viswanathan M, Kraschnewski J, Nishikawa B, et al. Outcomes of community health worker interventions. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2009 Jun. (Evidence Report/Technology Assessment, No. 181).

Andrews 2004* - Andrews JO, Felton G, Wewers ME, Heath J. Use of community health workers in research with ethnic minority women. Journal of Nursing Scholarship. 2004;36(4):358-65.

CG-CVD - The Guide to Community Preventive Services (The Community Guide). Cardiovascular disease (CVD).

Kim 2016* - Kim K, Choi JS, Choi E, et al. Effects of community-based health worker interventions to improve chronic disease management and care among vulnerable populations: A systematic review. American Journal of Public Health. 2016;106(4):e3-e28.

Wells 2011* - Wells KJ, Luque JS, Miladinovic B, et al. Do community health worker interventions improve rates of screening mammography in the United States? A systematic review. Cancer Epidemiology, Biomarkers & Prevention. 2011;20(8):1580-98.

Cochrane-Lewin 2010* - Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews. 2010;(3):CD004015.

Verhagen 2014* - Verhagen I, Steunenberg B, de Wit NJ, Ros WJG. Community health worker interventions to improve access to health care services for older adults from ethnic minorities: A systematic review. BMC Health Services Research. 2014;14:497.

Islam 2015 - Islam NS, Zanowiak JM, Riley L, et al. Characteristics of Asian American, Native Hawaiian, and Pacific Islander community health worker programs: A systematic review. 2015;26(20):238-268.

Palmas 2015* - Palmas W, March D, Darakjy S, et al. Community health worker interventions to improve glycemic control in people with diabetes: A systematic review and meta-analysis. Journal of General Internal Medicine. 2015;30(7):1004-1012.

Little 2014* - Little TV, Wang ML, Castro EM, Jimenez J, Rosal MC. Community health worker interventions for Latinos with type 2 diabetes: A systematic review of randomized controlled trials. Current Diabetes Reports. 2014;14:558.

Costa 2015* - Costa EF, Guerra PH, dos Santos TI, Florindo AA. Systematic review of physical activity promotion by health workers. Preventive Medicine. 2015;81:114-121.

Urban-Eyster 2013 - Eyster L, Bovbjerg RR. Promising approaches to integrating community health workers into health systems: Four case studies. Washington, DC: Urban Institute; 2013.

AHRQ HCIE-Redding - Redding M, Redding S. Program uses 'pathways' to confirm those at-risk connect to community based health and social services, leading to improved outcomes. Rockville: AHRQ Health Care Innovations Exchange.

AHRQ HCIE-Roberts - Roberts A. Urban healthy start program offers support at each stage of childbearing cycle, leading to fewer low- and very low-birthweight babies. Rockville: AHRQ Health Care Innovations Exchange.

Raphael 2013* - Raphael JL, Rueda A, Lion KC, Giordano TP. The role of lay health workers in pediatric chronic disease: A systematic review. Academic Pediatrics. 2013;13(5):408-420.

CDC-CHW 2015 - Centers for Disease Control and Prevention (CDC). Addressing chronic disease through community health workers (CHW): A policy and systems-level approach. National Center for Chronic Disease and Health Promotion. 2015.

Allen 2015* - Allen C, Brownstein JN, Jayapaul-Philip B, Matos S, Mirambeau A. Strengthening the effectiveness of state-level community health worker initiatives through ambulatory care partnerships. Journal of Ambulatory Care Management. 2015;38(3):254-262.

Pittman 2015 - Pittman M, Sunderland A, Broderick A, Barnett K. Bringing community health workers into the mainstream of U.S. health care. National Academy of Medicine. 2015:1-8.

Citations - Implementation Examples

* Journal subscription may be required for access.

Barbero 2016* - Barbero C, Gilchrist S, Chriqui JF, et al. Do state community health worker laws align with best available evidence? Journal of Community Health. 2016;41(2):315-325.

Urban-Bovbjerg 2013 - Bovbjerg RR, Eyster L, Ormond BA, Anderson T, Richardson E. Integrating community health workers into a reformed health care system. Washington, DC: Urban Institute; 2013.

AHRQ HCIE-Redding - Redding M, Redding S. Program uses 'pathways' to confirm those at-risk connect to community based health and social services, leading to improved outcomes. Rockville: AHRQ Health Care Innovations Exchange.

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