Community health workers: A new health-care workforce for the era of health reform

Today's post, by Matt O'Brien, is one in a series of contributions by members of an expert panel intended to expand the breadth of The Public's Health. O'Brien, a primary care physician, is an assistant professor of medicine and public health at Temple University and a founder of Puentes de Salud ("Bridges of Health"), a health center serving the South Philadelphia Latino immigrant community. 

By Matt O'Brien

In the early 1990s, when airline companies were competing fiercely for high-paying, first-class customers, Southwest Airlines developed a radical model that alarmed competitors. Southwest's service model was based on a very simple strategy—targeting the many millions of travelers interested only in finding a cheap and reliable flight. In so doing, Southwest reached a huge segment of customers that the airline giants ignored. By delivering cheaper and more reliable flights to the majority of air travelers, Southwest introduced a "disruptive innovation" that revolutionized the industry.

The current American health-care system, with its focus on delivering expensive treatments to well-insured individuals, is ripe for a similar revolution.

There is a largely untapped workforce with the potential to lead such a revolution in the health-care market — the too-often unheralded community health workers.

Community health workers are lay people trained by medical and public health professionals to provide a range of health-related services in their communities, and who help patients live better by supporting behaviors that impact their health.

Community health workers can, for example, help patients navigate our fragmented health care system by making appointments and accompanying patients to their visits. They can educate community groups about the importance of preventive health services like vaccines and cancer screening tests. Community health workers can recommend ways to improve diets and increase exercise that are based on knowledge of an individual's unique personal situation. Doctors and nurse are cloistered in clinics are given 10-minute visits to address patients' complex health problems and treatments. Anyone who has seen a doctor, or who works as a physician like I do, knows that providing in-depth, tailored guidance about lifestyle behaviors rarely fits into an office visit. This is a problem because these lifestyle behaviors — smoking, physical inactivity, and unhealthy diets — are in fact the leading causes of death in the United States.

A growing body of research demonstrates that community health workers can also help improve control of chronic diseases and promote preventive services, as they have in some other countries for years. Many of these small programs have targeted the medically underserved, who are largely ignored by hospital executives like "coach" travelers were largely ignored by airline executives before Southwest.

Rather than providing much needed health education and support to individuals at the bottom of the market, health systems instead promote lucrative robotic surgeries and valve replacements to the small segment of the population that needs such specialized care and has insurance to pay for it. Health care executives in 2012 are doing exactly what their counterparts in the airline industry did 20 years ago; and they may eventually lose significant market share by focusing primarily on their "first-class" customers.

Last week, 2,217 hospitals were docked millions of dollars under President  Obama's Affordable Care Act for having high rates of readmissions — patients who leave the hospital and return soon thereafter because of infections or other complications from their hospital stays. Obamacare has created other incentives and penalties that challenge our health care system to keep people healthy, rather than provide unnecessary or unsuccessful treatments. With future payment reforms, hospitals will be rewarded for keeping their beds empty. Health systems will get bonuses for preventing expensive procedures. Perhaps in this brave new world of health-care reform, health executives will recognize the value of community health workers as cheap and effective foot soldiers of the health care system, combating the major cause of illness and death — individual health behaviors.

There is a small but growing movement to use community health workers at health centers in Philadelphia. My colleagues and I developed a program at Puentes de Salud in 2007 that has tackled women's health issues, and more recently obesity and diabetes prevention. In the past year, the University of Pennsylvania and Temple University health systems, among others, have also started small community health worker programs.

As such programs are brought to scale nationally, they will help create a high-quality "coach" service in health care that may eventually transform the public's health. Like the airline giants 20 years ago, many hospital executives and doctors may be left wondering what happened to their "first-class" customers who no longer need those lucrative procedures that have dominated the health care market for generations.

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