Boston, Mass., July 31, 2013 – Members of the New England Comparative Effectiveness Public Advisory Council (CEPAC) recently convened in Portland, ME to review evidence and make best practice recommendations on the use of community health workers (CHWs). With state Medicaid programs, private payers, and health care provider organizations all poised to consider how best to introduce or expand existing CHW programs, now is a critical time for objective review of the evidence and for guidance on how to maximize the potential for CHWs to impact health care outcomes and value. This meeting brought together policy experts from around the country to inform a deliberation on this issue, leading to the production of a final report that will guide decision-making at the policy and practice level in New England, and nationally.
“CEPAC’s goal remains providing evidence-based, actionable information to key decision makers in the healthcare system. The final meeting report highlights some of the paths forward for implementation of CHWs based on what the best available evidence and expert experience suggests as best practice,” stated Steven D. Pearson, MD, MSc, FRCP, President of the Institute for Clinical and Economic Review (ICER). “This meeting marked the first time that CEPAC broadened the scope of its work to address a delivery system intervention. Expanding the focus of its meetings to include non-clinical intervention topics will only improve upon CEPAC’s ability to tackle the questions most important for healthcare decision makers, and provide new solutions for how evidence can be moved into action.”
The Council’s recommendations address a broad range of considerations important to deploying CHWs, including the integration of CHWs into the health care team, standards for certification and training, and strategies for CHW recruitment, evaluation, and funding. In addition, CEPAC voted on which aspects of CHW programs are most associated with improved patient health outcomes. CEPAC based its votes and recommendations on the published evidence, findings from interviews with expert stakeholders, new survey results benchmarking the use of CHWs in New England, and public testimony.
Summary of Key Results from CEPAC’s Votes and Deliberation
Votes on Effectiveness
- A majority of CEPAC (11 out of 14 members) voted that pairing CHWs to patients by a shared community, ethnicity/race, or disease/condition is highly likely to contribute to improved patient health outcomes.
- A majority of CEPAC voted that following components are likely to contribute to improved patient health outcomes:
- In-person interaction in the patient’s own home or environment (9 out of 14 members)
- 40+ hours of training focused on the development of core competencies and/or specialized, condition-specific curriculum (7 out of 14 members)
- In-person interaction that lasts at least 60 minutes in duration (6 out of 14 members)
Votes on Value
CEPAC received information on 2 distinct types of CHW interventions with published data on program costs and cost offsets: a disease-specific approach (for low-income children with persistent asthma) and a generalist approach (for complex, high-risk adults). Data from these analyses suggested that the asthma intervention, while associated with reductions in urgent healthcare services, increased net costs to the system in the first program year. This program did have the potential for downstream net cost savings, however, if cost offsets continued after the program stopped. CEPAC voted that such an intervention represented a “reasonable” value.
In contrast, the “high risk” intervention produced substantial reductions in emergency-room visits, hospitalizations, and pharmacy usage, resulting in net cost savings in the first program year. Analyses suggested that savings would persist in future years even if the program were half as effective for future “high-risk” patients. CEPAC voted that this type of intervention represented a “high” value.
Selected Best Practice Recommendations
- Certification: Policy makers should encourage certification as a means to standardize the training and skills of CHWs and increase the recognition of the workforce. The process for certification should not pose such a high barrier to entry that ideal candidates are deterred from entering practice.
- Funding: Collaboration between payers and providers to sustain CHW initiatives is essential. New models for funding CHWs should explore the creative restructuring of existing budgets for home visits and case management.
- Integration: A clear plan for CHW integration onto the care team is needed and should include role definitions for all team members, allow for CHW involvement in the creation of the care plan, and provide the power necessary for CHWs to marshal care team resources as needed for the patient.
- Training: Training for CHWs should focus on the development of core competencies and skills, and be community-based in nature, highlighting the local environment in which CHWs work.
For the complete list of Best Practice Recommendations and Votes, please refer to the final report.
CEPAC is a regional body whose goal is to provide objective, independent guidance on the application of medical evidence to clinical practice and payer policy decisions across New England. Initially supported by a federal grant from the Agency for Healthcare Research and Quality (AHRQ), and with backing from a consortium of New England state health policy leaders, CEPAC holds public meetings to consider evidence reviews of medical tests and treatments and provide judgments regarding how the evidence can best be used across New England to improve the quality and value of healthcare services. CEPAC consists of practicing physicians with experience in evaluating and using evidence in the practice of healthcare, methodological experts, as well as patient/public members with experience in health policy, patient advocacy and public health. ICER manages the day-to-day operations of CEPAC with the input of a multi-stakeholder Advisory Board. A list of CEPAC members and Advisory Board members, as well as other information about the project, is available online at cepac.icer-review.org.
The Institute for Clinical and Economic Review (ICER), based at the Massachusetts General Hospital’s Institute for Technology Assessment (ITA) and an affiliate of Harvard Medical School, provides independent evaluation of the clinical effectiveness and comparative value of new and emerging technologies. Structured as a fully transparent organization, ICER seeks to achieve its ultimate mission of informing public policy and spurring innovation in the use of evidence to improve the value of health care for all.