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Background
Payers and public administrators remember
well the unprecedented pressure of the
unusually large "baby boomer generation"
on the educational facilities of the
1950s and 1960s. During the 1970s, the
1980s and the 1990s, boomers' needs
changed and they swayed the political
agenda to address jobs and housing,
reduce taxes, and attain national and
personal economic security. Now that
"the big wave," as some demographers
call the baby boomers, has arrived on
the shores of the 21st century,
its impact has been and will continue
to be large. Recent projections[1]
estimate an elderly population of 87
million people by 2050, a number greater
than the entire U.S. population of 1900.
For the 21st century, the
baby boomer generation has been and
will increasingly be demanding adequate
preventive, acute, and long-term care.
Additionally, in the United States,
the changes in the size and structure
of the population have been accompanied
by unique changes in its diversity,
adding special requirements, such as
cultural competence, to the type and
the quality of health care necessary
to improve health outcomes.[2]
Demographic diversity will fuel population
growth from 2000 to 2050 at a rate that
parallels that of the world population
and is 10 times greater than that of
other developed countries. Seven percent
of that increase will come from Non-Hispanic
Whites. African-Americans will increase
by 71 percent, Hispanics by 188 percent
and Asians by 213 percent. The vitality
of the minority population has added
large cohorts in the youth side of the
age spectrum, requiring a broader range
of health services for entire families
and communities. Cultural understanding,
community health education, and translation
services have been increasingly needed
for delivering effective care to families
and communities that are often isolated
and underserved.[3]
While consumers had high expectations
for the power of medicine and its technical
sophistication, they have been at times
disillusioned at times with the care
they received and criticized the health
system as too complex, impersonal, budget-driven,
and expensive. Empowered by simplified
and easily accessible health information
on the Internet, better-informed patients
have been questioning organized medicine
and have been willing to explore more
economical, accessible, and patient-focused
health assistance outside traditional
providers.[4]
Some health providers have been in
short supply because either not enough
graduates exited the educational pipelines,
or unequal economic and psychological
rewards produced uneven geographic distributions
of practice locations, or both.[5]
Wherever in practice, they have been
caring for increasingly large and diverse
patient populations in regulated environments
that discouraged patient/provider interaction
and continuity of care. Budgetary and
regulatory constraints have led to mostly
short encounters with patients in medical
offices, small clinics, and hospitals.
Studies about the quality of care and
the safety of patients revealed problems
that are currently being addressed by
industry, the organized professions,
and the Federal government.[6]
Science and technology offer encouraging
solutions such as early detection of
illnesses, less-invasive procedures,
shorter hospitalizations, new and better
materials for body parts, transferability
of medical information, and amazing
outreach capabilities through telemedicine.
While the diffusion of many of these
technologies has not yet reached a scale
large enough to outpace providers' shortages
and the escalating cost of care, the
new methods of disseminating scientific
information and telemedicine have been
empowering individuals with less-extensive
clinical training, but strong personal
and community skills, to become valuable
members of established medical teams
to improve access, patient communication
and compliance, outreach, prevention,
and early diagnoses in underserved communities.
Against this backdrop, community health
workers (CHWs) stand out as natural
bridges between providers and underserved
populations in need of care.
Community health workers are lay
members of communities[7]
who work either for pay or as volunteers
in association with the local health
care system in both urban and rural
environments and usually share ethnicity,
language, socioeconomic status, and
life experiences with the community
members they serve. They have been identified
by many titles such as community health
advisors, lay health advocates, "promotores(as),"[8]
outreach educators, community health
representatives, peer health promoters,
and peer health educators. CHWs offer
interpretation and translation services,
provide culturally appropriate health
education and information, assist people
in receiving the care they need, give
informal counseling and guidance on
health behaviors, advocate for individual
and community health needs, and provide
some direct services such as first aid
and blood pressure screening.[9]
CHWs have been a worldwide grassroots
phenomenon of fellowship, self-reliance,
and survival almost as long as communities
have existed as social units of individuals
sharing residence, cultural heritage
and economic conditions.[10]
But only in the 1950s did they begin
to be part of deliberate strategies
for increasing access and delivering
cost-effective and culturally sensitive
care to the underserved. CHWs were employed
in many sectors of social and health
services delivery programs.[11]
In 2002, the Directory of HRSA's
Community Health Workers (CHWs) Programs
included 35 current and nine recently
completed programs that employed CHWs
and were funded directly or indirectly
by the Health Resources and Services
Administration (HRSA). Also, HRSA introduced
"health disparities collaboratives,"
a program that utilized CHWs to improve
care and reduce disparities in Federally
Qualified Health Centers (FQHCs).[12]
About This Study
Content
Chapter 2 chronicles the involvement
of community health workers in the delivery
of health services and summarizes the
legislative process relevant to their
integration into the U.S. health care
system. Chapter 3 provides national
and State estimates of paid and volunteer
workers and describes the CHW workforce.
Chapter 4 addresses their requirements
at hire, training, certification programs,
and career opportunities. Chapter 5
gives an account of the organizations
employing them and of the sustainability
of their programs. Chapter 6 reviews
the extent and nature of current research
and cost-effectiveness studies. Chapter
7 discusses trends in CHW utilization.
Finally, Chapter 8 summarizes the results
of in-depth inquiries on the status
and development of the CHW workforce
in four States: Arizona, New York, Massachusetts,
and Texas.
References to the relevant literature
are made throughout the study and a
selected annotated bibliography has
been assembled into a companion volume.[13]
Approach
The study employed four research strategies:
- First, a comprehensive list of articles,
books, and published and unpublished
reports was compiled. These items,
including nine published literature
reviews from 2002 to 2006, summarized
in Chapter 6, were examined for supporting
evidence in addressing the topics
of the study. Forty-five of the articles
judged to be of particular significance
because they were published in reviewed
journals, seminal, highly quoted,
and/or of noteworthy methodology were
selected and summarized in an annotated
bibliography published separately
from the report.[14]
- Second, national and State estimates
of the number of CHWs currently engaged
in paid and volunteer positions were
made using both the Public Use Microdata
Sample (PUMS) of the Census Bureau
and the Bureau of Labor Statistics'
annual survey of industry "staffing
patterns."
- Third, a survey of programs utilizing
CHWs, referred to in this report as
the "CHW National Employer Inventory"
(CHW/NEI), was conducted in partnership
with the Center for Sustainable Health
Outreach of The University of Southern
Mississippi. For each of the 50 States,
contact information for programs currently
employing CHWs was verified and individuals
familiar with the programs and community
health workers were invited to participate
in a Web-based questionnaire - hard
copies were made available on request
- about the type, health goals, and
sustainability of the programs as
well as the characteristics, education,
skills, type of job held, salary,
and career potential of the employed
and volunteer community health workers.
- Fourth, in-depth accounts of CHW
status and development in the States
of Arizona, Massachusetts, New York,
and Texas were assembled after discussions
with local experts, unstructured interviews
(referred to as the "CHW National
Workforce Study Interviews" or
CHW/NWSI throughout this report) with
employers and active CHWs, and reviews
of published and unpublished reports.
A national technical advisory group
was assembled in consultation with the
HRSA project officer to review the research
plan and its subsequent revisions. The
members' names are listed in Appendix
A.
Data sources
The study used both original and extant
data. Original data were collected from
approximately 900 responses from across
the United State[15]
and from 48 unstructured interviews
with employers and community health
workers in Arizona, Massachusetts, New
York, and Texas.[16]
Existing data were gathered from available
reports, comprehensive literature reviews,
informative Web sites, literature searches
that used both librarians' protocols
and citations from reviewed articles,
and from two national databases: the
Public Use Microdata Sample (PUMS) of
the Census Bureau and the Bureau of
Labor Statistics' annual survey of industry
"staffing patterns."[17]
[1] Murdock SH, Hoque
N, McGehee M. Population Change in the
United States: Implications of an Aging
and Diversifying Population for Health
Care in the 21st Century. In: T Miles;
A Furino, editors, Annual Review of
Gerontology and Geriatrics: Aging Health
Care Workforce Issues. New York (NY):
Springer Publishing Company, Inc.; 2005;
p. 19-63.
[2] Smedley BD, Stith
AY, Nelson AR, editors. Unequal Treatment:
Confronting Racial and Ethnic Disparities
in Health Care. Washington (DC): Institute
of Medicine, National Academies Press;
2003.
[3] Murdock et al.
(2005).
[4] National Fund for
Medical Education. Advancing Community
Health Worker Practice and Utilization:
The Focus on Financing. San Francisco
(CA): Center for the Health Professions,
University of California at San Francisco,
2006.
[5] Davis K, Schoen
C, Schoenbaum SC et al. Mirror, mirror
on the wall: an update on the quality
of American health care through the
patient's lens. New York (NY): The Commonwealth
Fund, April 2006 Report No.: 915.
[6] Kohn LT, Corrigan
JM, Donaldson MS, editors. To Err Is
Human: Building a Safer Health System.
Washington (DC): Institute of Medicine,
National Academies Press, 2000; Committee
on Quality of Health Care in America.
Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington
(DC): Institute of Medicine, National
Academies Press, 2001; Adams K, Corrigan
JM, editors. Priority Areas for National
Action: Transforming Health Care Quality.
Washington (DC): Institute of Medicine,
National Academies Press; 2003.
[7] The term “community”
is used in a geographic sense describing
people living together in a particular
area as small as, but not necessarily
limited to, a neighborhood, who have
some common characteristics and are
unified by common interests.
[8] The terms promotores
and promotoras are used in Mexico,
Latin America and Latino communities
in the United States to describe advocates
of the welfare of their own community
who have the vocation, time, dedication
and experience to assist fellow community
members in improving their health status
and quality of life. Recently, the
term has been used interchangeably,
despite some opposition, with the term
community health workers.
[9] Definition of CHWs
used in this study. More details on
the role of CHWs in the U.S. Health
Care System are provided in Chapter
3.
[10] Pew Health Professions
Commission. Community Health Workers:
Integral Yet Often Overlooked Members
of the Health Care Workforce. San Francisco
(CA): University of California Center
for the Health Professions, 1994; Rosenthal
EL, Wiggins N, Brownstein JN et al.
The Final Report of the National Community
Health Advisor Study. Tucson (AZ): University
of Arizona, 1998.
[11] See Chapter 2
for an account of the evolution of the
CHW workforce and Chapter 6 for an overview
of studies on CHW utilization.
[12] Brownstein JN,
Bone LR, Dennison CR et al. Community
health workers as interventionists in
the prevention and control of heart
disease and stroke. Am J of Prev Med
2005; 29 (5S1):128-33.
[13] Health Resources
and Services Administration. Community
Health Worker National Workforce Study:
An Annotated Bibliography. U.S. Department
of Health and Human Services, Health
Resources and Services Administration,
Bureau of Health Professions, March
2007.
[14] Ibid.
[15] The protocol
and the questionnaire employed in conducting
the CHW/NEI are included in Appendices
C and D, respectively.
[16] Copies of the
interview protocols are provided in
Appendices E1 and E2. Results from
the interviews are included throughout
the report as appropriate.
[17] The databases
used to make National and State estimates
of paid and volunteer community health
workers are described in Appendix B
together with the methodology used for
the estimates.
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