November 2019

Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations

Emmett Ruff, Policy Analyst Denisse Sanchez, Policy Analyst Sinsi Hernández-Cancio, Director of the Center on Health Equity Action for System Transformation Eliot Fishman, Senior Director of Health Policy Raven Gomez, Partnerships Coordinator

Evidence for Equity Initiative

The Center on Health Equity Action for System Transformation is the only national entity exclusively dedicated to the development and advancement of patient-centered health system transformation policies designed to reduce racial, ethnic, and geographic inequities. We focus on advancing equity while improving outcomes, increasing value, and lowering costs. We catalyze and coordinate action to develop and implement health equity- focused health care delivery and payment policies. We achieve impact by partnering with and supporting community leaders, health equity experts, and other stakeholders at national, state, and local levels.

The center is made possible by the generous support of the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation.

Evidence for Equity Initiative

The Evidence for Equity Initiative focuses on synthesizing, translating, and disseminating evidence to help community leaders and decision-makers in developing and implementing effective health equity policies and programs, particularly patient-centered outcomes research (PCOR) and comparative effectiveness research (CER). This project is supported by the Patient-Centered Outcomes Research Institute (PCORI).

1 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations

TABLE OF CONTENTS

Executive Summary...... 4 Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations...... 8 Background...... 8 Contextualizing Community Health Workers and Peer Providers within the Health Care System...... 9 New PCORI Research Supports Including Community Health Workers and Peer Providers in Care Teams to Improve Outcomes and Achieve Health Equity for Diverse Patient Populations ...... 10 Effectiveness of Interventions Led by Community Health Workers and Peer Providers Across Different Health Issues...... 11 PCORI's Community Health Worker and Peer Provider Portfolio: Policy Implications...... 20 Conclusion...... 24 Endnotes...... 26

2 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Executive Summary

3 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Executive Summary

As decision-makers seek to transform health care delivery and payment systems to increase value, improve outcomes, and control costs, they need clinical, health systems, and population health research, as well as other scientific evidence, to inform their decisions about what kinds of interventions and treatment to pay for, and how to organize care delivery. Given our nation’s demographic and economic context, health system transformation will succeed and remain sustainable only if it also addresses the long-standing health and health care inequities that affect communities of color and other underserved groups. However, our current evidence base is incomplete and often biased. Strengthening it by making it both transparent about who is included in the research and representative of all of our nation’s communities is imperative.

This report reviews results from nine recent studies chronic diseases, and traumatic physical injury. Study funded by the Patient Centered Outcomes Research participants were of diverse ethnic, racial, linguistic, Institute (PCORI) that provide further support for socioeconomic, and geographic backgrounds, including community health workers (CHWs) and including Black, Latinx, American Indian, monolingual peer providers (PPs) as important components of Spanish-speaking, low-income, and rural patients. health care delivery that are particularly effective in One study focused solely on women. Informed by our addressing health and health care inequities. These analysis of these studies, we developed 12 health studies underscore the enormous value of CHWs system policy recommendations across four broad and PPs, an often overlooked, usually underutilized, policy categories. In addition, we developed four yet highly versatile health workforce, as powerful recommendations to improve health equity-focused health equity change agents. To facilitate scaling and patient-centered outcomes research (PCOR) by making integration of CHWs and PPs across the health care it more diverse, relevant, and transparent. system, we translate this evidence into equity-focused policy recommendations for advocates to promote A. Payers and providers should include CHWs and decision-makers to adopt. and PPs in care teams to improve outcomes while reducing costs. Community Health Worker and Peer 1. Payers and providers should include CHWs and Provider Policy Recommendations PPs in care teams to improve outcomes and Based on Research Funded by PCORI reduce hospital and emergency department (ED) We reviewed nine PCORI-funded studies that utilization to potentially generate savings. examined the effectiveness of interventions led 2. Health systems should ensure effective integration by different types of CHWs and PPs across health of peer mentors into health care teams to conditions such as serious mental illness (SMI), maximize positive outcomes.

4 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers These studies underscore the enormous value of CHWs and PPs, an often overlooked, usually underutilized, yet highly versatile health workforce, as powerful health equity change agents.

3. Payers and providers should take advantage of C. Payers and providers should include the different Medicaid reimbursement pathways CHWs and PPs in care teams serving diverse to provide an integrated, sustainable funding communities affected by health inequities. mechanism for CHW and PP services. 8. Payers and providers should use CHWs and PPs 4. Payers and providers should incorporate to improve health outcomes in communities CHW utilization into well-designed advanced and patient populations that experience health alternative payment models. inequities based on racial, sexual, geographic, linguistic, or economic characteristics.

B. Payers and providers should include 9. Payers and providers should prioritize recruiting CHWs and PPs in care teams to improve and training community members as CHWs or outcomes for a variety of health conditions. similar roles to serve as critical trust brokers and 5. Payers and providers should use CHWs and PPs bridges between communities and health systems. to improve outcomes for people with physical and This is especially important in communities with mental health conditions. shortages of licensed clinicians and a need for chronic disease management. 6. Payers and providers serving people with SMI should prioritize peer navigators’ abilities to 10. The federal government should specifically invest leverage their shared experiences in recruitment in the health and health care of American Indians and patient assignments. and Alaska Natives. It must honor its trust and treaty obligations and increase funding for the 7. Payers and providers should use CHWs and PPs Indian Health Services (IHS), including dedicated to help patients with multiple chronic conditions funding for community health representatives engage with primary care providers and prevent (CHRs). their chronic disease symptoms from worsening, thereby reducing the need for costly emergency 11. Payers and providers should implement CHW care. interventions to mitigate the negative effects of the shrinking safety net in urban and rural communities.

5 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers D. Payers and providers should include 15. Researchers should design studies that measure CHWs and PPs in care transition teams. not only whether patients were rehospitalized, 12. Payers and providers should include CHWs and but also how many days they spent in the hospital PPs in care teams to improve patients’ self- once readmitted. efficacy and prevent avoidable hospital utilization 16. Researchers should make efforts to design studies as they transition from inpatient to community that will not exclude participants with limited settings. English proficiency.

E. Research on CHWs and PPs should be Overall, this research adds to the existing evidence of improved to strengthen the evidence base the power of CHWs and PPs as valuable health equity for equity. change agents. Advocates, decision-makers, and other 13. Researchers should design CHW and PP health care stakeholders must prioritize the inclusion intervention studies to include follow-up with of this workforce in care delivery teams as a standard patients to assess the longer-term impact of practice that health care payment systems support these interventions on outcomes. fully and sustainably.

14. Researchers should design studies that include diverse populations with sufficiently large sample sizes to power subgroup analysis.

6 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations

7 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations

Background CHWs and PPs at scale in our health care system has been limited. However, ongoing efforts to transform As decision-makers seek to transform health care the health care system to emphasize and reward value delivery and payment systems to increase value, by changing the way we pay for and deliver care offer improve outcomes, and control costs, they need an important opportunity to fund CHWs sustainably clinical, health systems, and population health and adopt their use more widely. Payment models research, as well as other scientific evidence, that hold providers and health care organizations to inform their decisions about what kinds of financially accountable for their patients’ health interventions and treatments to pay for, and outcomes or for population health are leading some how to organize care delivery. Given our nation’s to include CHWs as an effective workforce to meet demographic and economic context, health system such value-based payment incentives, especially those transformation will succeed and remain sustainable concerning the social determinants of health. only if it also addresses the long-standing health and health care inequities that affect communities of PCORI strengthens the evidence base for effective color and other underserved groups. However, our health equity interventions by funding research that current evidence base is incomplete and often biased. focuses on patients’ expressed needs and includes Strengthening it by making it both transparent about diverse populations. It has funded 70 studies of CHWs who is included in the research and representative of and PPs (currently at different stages of completion) all our nation’s communities is imperative. to help patients, clinicians, and other health care stakeholders determine how best to deploy this The evidence supporting the effectiveness of workforce for maximum impact.3 CHWs and PPs in improving health outcomes for underserved and underrepresented communities is This report reviews nine PCORI studies of CHWs and PPs strong.1 For example, the Centers for Disease Control that provide new evidence supporting the value of this and Prevention recommended that states use CHWs workforce in advancing health equity among different to prevent chronic disease in high-risk communities. communities, in various settings, and across a number The Institute of Medicine recommended using CHWs of health conditions. We translate this evidence into to reduce hypertension. And the Affordable Care equity-focused policy recommendations for advocates Act encouraged use of CHWs to improve health to promote and decision-makers to adopt. It is the outcomes for the medically underserved through third in a series from the Evidence for Equity Initiative, health promotion.2 Nevertheless, deployment of a project launched by Families USA’s Center on Health Equity Action for System Transformation.

8 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Contextualizing Community Health outcomes, especially for people from underserved Workers and Peer Providers within the communities struggling with inequities. Health Care System Community Health Workers Many job titles are included under the U.S. Department of Labor's Standard Occupational CHW is an umbrella term that encompasses a wide Classification of Community Health Workers. These variety of job descriptions. Generally, CHWs are include CHWs, peer mentors, peer navigators, community-based and share a sociocultural background 6 promotores, community-based doulas, PPs, and with their clients. They serve as bridges between their others.4 Each has specific roles and training or communities and the health care system, fostering certification requirements, as well as different levels greater trust and enhancing the health system’s ability of recognition by health care systems and payers. to provide higher quality, culturally centered care. CHWs However, they share some key characteristics: also have an intimate knowledge of their communities’ needs and available resources, making CHWs particularly »» They share a key life experience with their clients effective at addressing the social determinants of health, — such as cultural background, experience with and they are skilled advocates for their clients and their specific conditions, recovery, or reentry — which communities more broadly. Growing evidence supports facilitates trust. CHWs’ effectiveness in improving health outcomes such »» They provide non-clinical supports for their clients. as medication adherence, quality of life, disease self- management, and lowering health care costs.7, 8, 9 »» They are based in or originate from the same communities as their clients. Peer Providers »» They work both in clinical and non-clinical While PPs are often considered a subset of CHWs,10 settings. for purposes of this analysis, some important differences distinguish them from that broader group. Arguably, the most important characteristic of all PPs typically work in behavioral health settings, types of CHW is shared experience with their clients,5 where they may hold job titles such as peer support which may take many forms. For example, it could specialists, peer navigators, and peer mentors.11 Their be based on living in the same community, the defining characteristic is a shared lived experience of shared experience that results from living with certain recovery from mental illness and/or substance use demographic characteristics (for example, institutional disorder rather than a sociocultural affinity with their racism and sexism, language barriers, etc.), or having clients.12 Importantly, the Centers for Medicare and been a patient (for example, similar diagnosis or Medicaid Services (CMS) reimburses PPs as a provider recovery goals, or navigating the same health system). type distinct from CHWs, and states have separate This shared experience, along with their specific certification processes for PPs and CHWs.i, ii roles and unique relationships with patients, make many CHWs particularly effective in improving health i PPs have a well-established pathway and history of Medicaid reimbursement. As described in 2007 Centers for Medicare and Medicaid Services guidance, peer support services delivered directly to Medicaid beneficiaries with mental health and/or substance use disorders are Medicaid-reimbursable. See CMS guidance at https://www.integration.samhsa.gov/workforce/CMS_letter_with_date.pdf. ii Many states have developed processes for training and certifying peer providers. Some, like California, do not have a statewide certification process, but PPs can still be reimbursed by Medicaid for certain services. For state-specific information on reimbursement, seehttps:// copelandcenter.com/peer-specialists.

9 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers New PCORI Research Supports 6. Collaborative Goal Setting With or Without Including Community Health Workers Community Health Worker Support for Patients and Peer Providers in Care Teams to With Multiple Chronic Conditions (Long et al.)18 Improve Outcomes and Achieve Health 7. Using One-on-One Peer Mentors to Help Patients Equity for Diverse Patient Populations With a Spinal Cord Injury Transition From For this report, we reviewed new PCORI–funded studies Rehabilitation to Home (Jones et al.)19 with published results and synthesized their findings, showing that using CHWs and PPs are powerful 8. Using Home Coaching to Support Older Adults interventions to advance health equity. Given the With Chronic Illness After an Emergency Room 20 sometimes loosely applied term CHW, we selected only Visit (Carden et al.) studies that used CHWs and PPs with a core attribute 9. Is a Patient Navigation Program More Helpful of this workforce: a shared cultural affinity or lived Than a Referral Program for Reducing Depression experience with clients. These studies were: and Improving Quality of Life Among Women 1. Can People Who Have Experience with Serious Living in Neighborhoods with Few Resources? 21 Mental Illness Help Peers Manage Their Health (Poleshuck et al.) 13 Care? (Brekke et al.) The nine studies we selected examined the 2. Peer-Navigator Support for Latinx Patients With effectiveness of interventions led by CHWs and Serious Mental Illness (Corrigan et al.)14 PPs across different health issues such as SMI, chronic disease, and traumatic physical injury. Study 3. Working with Bilingual Community Health Worker participants represented diverse ethnic, racial, linguistic, Promotoras to Improve Depression and Self-Care socioeconomic, and geographic backgrounds, including Among Latino Patients with Long-Term Health Black, Latinx, American Indian, monolingual Spanish- Problems (Ell et al.)15 speaking, low-income, and rural patients. Some worked exclusively with a single group — women, Latinx, and 4. Impact of Community Health Representative-Led Zuni Indians. However, some studies were limited Patient Activation and Engagement on Home- by the statistical power of the sample size to provide Based Kidney Care (Shah et al.)16 disaggregated results, or by general research design 5. Does a Program that Focuses on Lifestyle issues. The following tables are an overview of each Changes Reduce Heart Disease Risk Factors in study. Taken as a group, the studies provide substantial a Rural Community in Appalachian Kentucky? evidence that use of CHWs and PPs contributes to (Moser et al.)17 valuable, effective health equity interventions.

10 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations limited to female/male female/male to limited due Latinx/non-Latinx and participant the small to population. participation, for criterion the limits which findings of generalizability limited with patients for proficiency. English • Subgroup• analysis was a was fluency • English

Results intervention increased their intervention increased health care primary of use services. intervention participants reported improved primary with relationships increased providers, care care, primary for preference preference decreased and care or urgent emergency for services health or avoiding altogether. were no more participants who patients than likely visit to care usual received the ED after and care urgent after 12 months. However, six interventionmonths, Bridge routine increased participants ED decreased and screenings visits. care urgent and reported also participants of a better understanding problems, health current in health confidence greater and self-management, care pain. physical less • Participants in the Bridge in the Bridge • Participants months, Bridge six • After intervention• Bridge intervention• Bridge primary care provider care primary activities medications status Outcomes Measured Outcomes • Health service use service • Health care with satisfaction • Global with relationship of • Quality self-management • Patient screenings • Health diagnoses • Medical symptoms • Health • Pain ratings health • Global daily with • Interference health physical • Prescribed functional and health • Mental medications • Psychiatric habits • Health stigma • Internalized stigma • Provider-level life satisfaction • General and Peer Providers Across Different Health Issues Issues Health Different Across Providers Peer and health care plus the Bridge the Bridge plus care health intervention. Patients a peer navigator with worked develop to months six for set and plan care a health navigators Peer goals. health to patients accompanied the appointments, medical assisted pharmacy; and lab, appointments; securing with on patients coached and management care health skills. on while care health list; wait a six-month the received patients interventionBridge six after months. Interventions Tested Interventions • Group 1: Usual mental mental 1: Usual • Group mental 2: Usual • Group Effectiveness of Interventions Led by Community Health Workers Workers Health Community by Led Interventions of Effectiveness Participants 1. Can People Who Have Experience with Serious Mental Illness Help Peers Manage Their Health Care? (Brekke et al.) et (Brekke Care? Their Health Manage Help Peers Illness Mental Serious with Experience Who Have People 1. Can 8% Black, and 8% other or and 8% Black, multiracial Medicaid; through coverage insurance 3% received CalWORKS through coverage Patients with SMI who SMI with Patients a large through care received health mental community Southern California. in agency white, 25% • 60% Latinx, female • 54% 47 age was • Average insurance received • 97%

11 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations not follow up with with up follow not measure to participants after the outcomes intervention ended, so whether known not is it to continued patients improved experience after they outcomes a with working stopped peer navigator. in differed groups two as such characteristics birth, of place gender, and language, preferred level. education were ethnically no homogenous, analysis subgroup other considered as such characteristics, age, preferred gender, of or place language, birth. • Researchers did did • Researchers in the • Participants participants • Although Results navigator program program navigator intervention scheduled more doctor attended and appointments. intervention participants reported improved more personal recovery, better and empowerment, life. of quality • Participants in the peer • Participants program • Peer navigator appointments Outcomes Measured Outcomes • Scheduled and achieved achieved and Scheduled • • Recovery • Empowerment life of • Quality integrated usual care plus plus care usual integrated who met a peer navigator least at participants with identify to weekly once their health address and concerns. care. Interventions Tested Interventions • Group 1: One-year trial of of trial 1: One-year • Group usual 2: Integrated • Group 2. Peer-Navigator Support for Latinx Patients With Serious Mental Illness (Corrigan et al.) et (Corrigan Illness Mental Serious With Patients Latinx for Support 2. Peer-Navigator Participants continental U.S. continental Spanish Latinx patients with SMI living living SMI with patients Latinx Illinois. in Chicago, • 58% female 46 age was • Average born outside • 72% speak to preferred • 63%

12 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers and Patient- and Limitations

implementation implementation Hand A Helping of promotoras Home Medical Centered the ability limits CHWs positive attribute to solely outcomes patient Hand the A Helping to intervention because in both participants groups had access to CHWs. were ethnically no homogenous, analysis subgroup other considered as such characteristics age, preferred gender, of or place language, birth. • The concurrent The concurrent • participants • Although Results to Improve Depression Depression Improve to activation and self-efficacy self-efficacy and activation their chronic in managing conditions. help for professional seek to be prescribed their depression, medication, antidepressant the treatment. to adhere and health. psychological improved increased had admissions slightly. implemented: intervention was self-efficacy and activation of their chronic in managing conditions. professional seek to likely and their depression help for to adhere and be prescribed medication. antidepressant improved significantly health. psychological decreased had admissions significantly. Six months after the intervention months Six months (1.5 implemented was after the intervention ended): reported increased • Both groups were more likely • Both groups reported slightly • Both groups ED and hospital • Both groups’ after the months Twelve levels maintained • Both groups were even more • Both groups reported • Both groups ED and hospital • Both groups’ Promotoras treatment improvement Outcomes Measured Outcomes • Depression care and and care • Depression symptom • Depression health • Psychological activation • Patient condition • Physical support social and Stress • • HbA1C visits • Clinic also assisted assisted also in Department in Department once a week a week once A Helping Hand intervention. Hand A Helping depression received Patients self-management care and a bilingual, from support community-based promotora Sessions weeks. six for face-to-face were primarily home, in the patient’s These telephone. or by three by were followed sessions. booster monthly Promotoras and food with patients transportation clinic health needs. County Angeles the Los Health of Department Patient-Centered Services’ Home. Medical the Patient-Centered care Home made Medical including improvements, and CHWs utilizing promotores clinics. Services Health of Interventions Tested Interventions • Group 1: Usual care plus the plus care 1: Usual • Group through care 2: Usual • Group the study, during However, and Self-Care Among Latino Patients With Long-Term Health Problems (Ell et al.) et (Ell Problems Health Long-Term With Among Latino Patients Self-Care and in

3. Working with Bilingual Community Health Worker Worker Health Community Bilingual with Working 3. Participants 68% born in Mexico 68% born in Mexico speakers Spanish coverage insurance received Medicaid through Latinx patients with depression depression with patients Latinx and/ diabetes concurrent and three from disease or heart clinics community net safety California. Angeles, Los female • 85% 57 age was • Average the U.S., • 91% born outside • 50% were monolingual participants of • 30%–35%

13 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations care utilization data was was data utilization care collected. not participants with up patient measure to after outcomes activation the intervention ended. were ethnically nohomogenous, analysis subgroup other considered as such characteristics age. and gender the time at published not writing. this of • Hospitalization and health and • Hospitalization follow not did • Researchers participants • Although was • analysis A subgroup

Results who received usual care, care, usual who received in the HBKC participants BMI, lower intervention had high- and levels, HbA1c protein C-reactive sensitivity after the intervention, which of risk reduced to translates CKD. improved significantly had activation, patient of levels with associated is which and ED utilization lower improved and hospitalization outcomes. health significant a statistically between improved correlation lower and activation patient BMI. A reduction in other CKD with coincided also factors risk activation. patient improved in usual those than more likely in the participating stop to care the that indicates which study, received well intervention was patients. by • Compared to patients patients to • Compared intervention participants • HBKC identified • Researchers were no participants • HBKC protein level protein score mental Outcomes Measured Outcomes • Patient activation • Patient (BMI) index • mass Body pressure • Blood • HbA1c • Cholesterol ratio • Urine albumin/creatinine C-reactive • High sensitivity • survey Short-form 12 health analyses • Sensitivity life of • quality Health-related Engagement on Home-Based Kidney Care (Shah et al.) et (Shah Care Kidney on Home-Based Engagement the Home-based Kidney the Home-based intervention (HBKC) Care visited 12 months. CHRs for every homes participants’ and engaged and other week them on healthy educated of management and lifestyles also Patients factors. risk CKD at sessions group attended every three months. the clinic the by provided care usual IHS. Interventions Tested Interventions 4. Impact of Community Health Representative-Led Patient Activation and and Activation Patient Representative-Led Health Community of 4. Impact • Group 1: Usual care plus plus care • 1: Usual Group received • 2: Patients Group Participants Zuni Indians residing in the residing Indians Zuni New in rural Pueblo Zuni risk multiple with Mexico kidney chronic for factors (CKD). disease •male 58% 21–80 • from Age ranged 47 • age was Average

14 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations

were white, so the results were white, so the results have may the study of applicability limited who non-whites to in disparities experience CVD. • 96.9% of participants participants of • 96.9% Results improvements in patient in patient improvements to adherence satisfaction, quality and recommendations, life. of their CVD meet to more likely to related reduction goals risk HbA1c, levels, lipid reducing body and pressure, blood number increasing weight, and walked. steps of in blood improvements and cholesterol, pressure, walked steps of number months four from continued after the 12 months to implemented. intervention was quality physical and mental lifestyle to life, adherence of recommendations, change their with satisfaction and was providers and care health after the 12 months highest implemented. intervention was interventionthe HeartHealth regardless effective was gender, participants’ of or level symptoms, depressive Participants’ literacy. health of was background race/ethnic the analysis, into factored not participants study most as were white. • Both groups showed showed • Both groups • were participants HeartHealth • participants, HeartHealth For participants’ • HeartHealth proved analysis • Subgroup blood pressure, lipid profile, profile, lipid pressure, blood symptoms, BMI, depressive activity physical Outcomes Measured Outcomes • CVD risk factors: tobacco use, tobacco factors: • CVD risk • life of Quality satisfaction • Participant the intervention to • Adherence in a Rural Community in Appalachian Kentucky? (Moser et al.) et (Moser Kentucky? in Appalachian Community in a Rural screening, primary care care primary screening, plus referral, physician intervention.HeartHealth six attended Patients sessions group interactive dedicated CHWs by taught factors CVD risk managing to self-care. promoting and care primary and screening referral. provider Interventions Tested Interventions • Group 1: CVD risk factor factor • 1: CVD risk Group factor CVD risk • 2: Only Group 5. Does a Program that Focuses on Lifestyle Changes Reduce Heart Disease Risk Factors Factors Risk Disease Heart Reduce Changes on Lifestyle Focuses that a Program 5. Does Participants Patients from Appalachian Appalachian from Patients for risk who were at Kentucky (CVD) disease cardiovascular a regular have not did and provider. care primary white • 96.9% female • 76.9% 43 • age was Average

15 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations measure persistent persistent measure intervention of effect ended. after it effective proven was care in three primary settings: a veterans’ a federally hospital, center, health qualified family an academic and However, clinic. practice size sample the small researchers’ limited detect to ability sites. across differences • Limited follow-up to • follow-up Limited • intervention The IMPaCT

Results who received usual care, care, usual who received in the IMPaCT participants intervention reported better spent care, primary of quality in the hospital, fewer days fewer hospital had and readmissions. months, and six lasted measured researchers of the end at outcomes the intervention three and some For later. months patient including measures, chronic and activation patients’ control, disease to continued outcomes in the three months improve after the intervention ended. health physical self-rated in the between participants interventionIMPaCT and usual who received those for improved ratings but care, after in both groups patients nine months. patients for effective proven or age, gender, of regardless disease. chronic specific • Compared to patients patients to • Compared • intervention The IMPaCT in no difference • There was • The intervention was care Outcomes Measured Outcomes • Patient-rated physical health health physical • Patient-rated health mental • Patient-rated activation • Patient control disease • Chronic • patient-centered of Quality admissions • Hospital for Patients with Multiple Chronic Conditions (Long et al.) et (Long Conditions Chronic Multiple with Patients for disease management goals goals management disease in a then participated and intervention standardized Individualized as known Patient- for Management (IMPaCT) Targets Centered provided CHWs in which as such support tailored social coaching, navigation, advocacy. and support, then connected CHWs long-term with participants the intervention as support ended. disease chronic set without goals management CHW support. Interventions Tested Interventions • Group 1: Patients set chronic chronic set • 1: Patients Group • 2: Patients Group 6. Collaborative Goal Setting With or Without Community Health Worker Support Support Worker Health Community Without or With Setting Goal 6. Collaborative Participants Patients from three primary three primary from Patients in Philadelphia, facilities care in lived Patients Pennsylvania. were codes, zip high-poverty insured, or publicly uninsured chronic multiple had and conditions. Black • 94.3% female • 62.5% 53 • age was Average

16 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations

peer mentors based on based peer mentors and age, sex, level, injury on race/ not but interests, ethnicity. white males, young analysis subgroup and on the level only focused the limits which injury, of results. of applicability published not report was writing. this the time of at • Patients were assigned • were assigned Patients were• patients Most research final • The PCORI Results peer mentor interventionpeer mentor and usual who received patients number a similar had care visits, hospital unplanned of in the peer mentor patients time in less spent program these during the hospital visits. care, usual who received in the peer participants a intervention mentor had in self- increase greater efficacy. patients with working ceased after their discharge 90 days the settings, community into in patient increase largest six recorded was self-efficacy after discharge. months improved with associated less and outcomes health utilization. avoidable • in the participants Although patients to • Compared • peer navigators Although was • self-efficacy Greater Outcomes Measured Outcomes • Self-efficacy • Rehospitalization From Rehabilitation to Home (Jones to al.) et Rehabilitation From connected with peer with connected with who met mentors throughout them weekly and stay their inpatient for them weekly phoned post-discharge 90 days to and discuss address Peer concerns. patient patients provided mentors on other information with and resources community them encouraged strongly in monthly participate to the by sponsored activities peer team. peer mentors. assigned with were connected They peer and peer mentors activities team–sponsored request. upon only Interventions Tested Interventions • Group 1: Patients were• 1: Patients Group were not • 2: Patients Group 7. Using One-on-One Peer Mentors to Help Patients with a Spinal Cord Injury Transition Transition Injury Cord Spinal a with Help Patients to Mentors One-on-One Peer Using 7. Participants Patients from the spinal cord cord the spinal from Patients a private, at program injury specialty not-for-profit rehabilitation inpatient Georgia. in Atlanta, hospital • 73% were white • 77% were male 37.5 age was • Average

17 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Limitations focused on patients on patients focused from discharged recently ED measure not did ED, it post-discharge. utilization limited and patients 69 in in-person participation the following interviews intervention. on study information population participant analysis. no subgroup and published not report was writing. this the time of at • the study Although of size sample • Small demographic • Limited research • final PCORI Results received usual care, patients patients care, usual received were coaching who received a follow- attend to more likely four within appointment up visit. an ED of weeks decreased levels activation they but discharge, following patients for less decreased in the who participated intervention. patients. coached for increase Black with interviews their detailed participants in care seeking for reasons the belief the ED, including receive would they that a and care comprehensive or same-day urgent for need This demonstrates treatment. barriers address to a need Black prevent may that quality receiving from patients facilities. in appropriate care • Compared to patients who patients to • Compared patient • patients, all For not did visits • Follow-up from • data Qualitative Outcomes Measured Outcomes • Patient activation activation • Patient visits doctor • Follow-up discharge from the ED, from discharge two from coaches trained on agencies community patients helped aging doctor follow-up schedule disease recognize visits, reconcile worsening, communicate medications, set and providers, with Coaches goals. achievable homes patients’ visited ED of three days within three called and discharge one month of within times discharge. the ED, leaving patients written of consisted which discharge verbal and to advice and instructions a provider. with up follow Interventions Tested Interventions • Group 1: Following • 1: Following Group for care • 2: Usual Group 8. Using Home Coaching to Support Older Adults With Chronic Illness After an Emergency Room Visit (Carden et al.) et (Carden Visit Room an Emergency After Illness Chronic With Adults Older Support to Home Coaching Using 8. Participants white Patients age 60 or older age 60 or older Patients in northern EDs two from were Patients Florida. and Medicare by insured low have to were considered literacy. health • were non- patients 77% of female • 57%

18 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers

Limitations accounts for accounts patients’ of heterogeneity psychological and social for not but barriers, as such characteristics age. and race/ethnicity participation, for criterion the limits which findings of generalizability limited with patients for proficiency. English • Subgroup analysis • analysis Subgroup a • was fluency English Results experienced improvement in improvement experienced depression. of symptoms satisfaction, patient increased navigator the patient but more intervention was of subgroup for the effective perceived lower with patients resources. financial more intervention was social in improving effective the subgroup life for of quality higher levels with patients of anxiety. and pain of months, four only lasted reported less some patients improved and depression life three months of quality after the months or even six interventions ended. • Participants in both groups • in both groups Participants reported• Both groups navigator • The patient • intervention each Although (anxiety, alcohol abuse, alcohol (anxiety, health physical pain, function) Outcomes Measured Outcomes • Patient satisfaction • Patient • Depression • life of Quality • barriers Social barriers • Physiological comorbidities • Health with patient navigators navigators patient with them through who guided tool a computer-based identify to and designed their concerns. prioritize on responses patient’s Each create to were used the tool plan. care a personalized to up provided Navigators outreach of months four implement to support and After plan. care the personal months, the patient four reviewed navigator and plan, care the personalized steps, next determined additional considered and to resources and supports progress. sustain identify to tool screening their prioritize and were Patients concerns. information then offered community about in assistance resources; appointments, making an and needed; if an onsite with appointment worker. social Interventions Tested Interventions • Group 1: Patients met • 1: Patients Group a used • 2: Patients Group 9. Is a Patient Navigation Program More Helpful than a Referral Program for Reducing Depression and and Depression Reducing for Program a Referral than Helpful More Program Navigation a Patient 9. Is Improving Quality of Life Among Women Living in Neighborhoods With Few Resources? (Poleshuck et al.) et (Poleshuck Resources? Few With in Neighborhoods Living Women Among Life of Quality Improving Participants 19% Latinx 19% per $20,000 than less of year the of the start at pregnant study Women with depressive depressive with Women in care receiving symptoms in clinics health women’s New York. Rochester, white, and • 21% Black, 57% 30 • age was Average income • household 73% had • were women 30% of

19 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers PCORI’s Community Health Worker A. Payers and providers should include and Peer Provider Portfolio: Policy CHWs and PPs to improve outcomes while Implications reducing costs. As Families USA has previously noted,22 the use of Four of the research studies (Brekke et al., Ell et al., CHWs serves as a powerful intervention to address Jones et al., Long et al.) measured the effects of CHW inequities. These studies provide valuable evidence and PP interventions on hospital and ED utilization. In that CHW- and PP-related interventions are effective all four studies, the CHW and PP interventions reduced in a variety of settings across health conditions and avoidable utilization. For some (Brekke et al., Ell et al.), in diverse communities. To address health inequities, the reduction in the number of hospital and ED visits policymakers, industry decision-makers, and other was observed 12 months after the intervention was health care stakeholders must prioritize the effective implemented, demonstrating the lasting impact of the inclusion of CHWs and PPs into health care delivery intervention. Successful CHW and PP interventions teams broadly and ensure sustainable financing for that reduce avoidable utilization can produce net their valuable services. To support these objectives, we savings for health systems and payers,23, 24, 25 resulting translated our findings into 12 policy recommendations in a positive return on investment.iii, iv In addition, to guide advocates and decision-makers in achieving CHWs can improve patients’ perception of primary these goals, and four research recommendations to care, which can benefit providers and health systems strengthen the evidence base for CHWs and PPs as that are incentivized to report on and improve patient providers of valuable equity interventions. experience.

States should explore alternative payment models To address health inequities, (especially those that reward reduced utilization) and Medicaid reimbursement pathways to finance CHWs policymakers, industry decision- and PPs to generate savings or, at least, contain cost makers, and other health care growth. For example, state Medicaid programs should stakeholders must prioritize the use the rehabilitation services option to reimburse PPs for post-acute care. State Medicaid agencies have effective inclusion of CHWs and the option of covering remedial services in a facility or PPs into health care delivery teams in the home to reduce physical disability and restore broadly and ensure sustainable function.26 These services can be provided by a PP rather than a physician.27 financing for their valuable services.

iii Families USA, in collaboration with the Center for Health Law and Economics of the University of Massachusetts Medical School, published two tools for estimating the impact of two specific CHW programs—one for diabetes and one for childhood asthma—in specific geographies. These tools allow users to apply local data and measure return on investment and social impact to help make the business case for paying for CHW services and including CHWs in care teams. To view these tools, see Community Health Worker Impact Estimator Tools: Asthma and Diabetes on our website. iv Penn Medicine calculated a positive return on investment for the CHW intervention tested in the study by Long et al. The savings generated from reduced hospitalizations resulted in a return investment of $2 for every dollar spent on the intervention. For more information, see https://www.pennmedicine.org/news/news-releases/2017/august/community-health-workers-lead-to-better-health- lower-costs-for-medicaid-patients and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055768/pdf/AJPH.2016.303366.pdf.

20 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Recommendations their ability to connect and foster trust with patients 1. Payers and providers should include CHWs and and improve outcomes, particularly for patients with PPs in care teams to improve outcomes and SMI. CHWs and PPs can help patients understand reduce hospital and emergency department the important role their primary care providers plays utilization to potentially generate savings. in managing their chronic conditions; those with an improved perception of primary care may rely on their 2. Health systems should ensure effective primary care provider instead of the hospital or ED to integration of peer mentors into health care manage their chronic conditions. teams to maximize positive outcomes. For example, Brekke et al. demonstrates that, for 3. Payers and providers should take advantage patients with SMI, a peer navigator intervention of different Medicaid reimbursement pathways improves relationships with primary care providers, to provide an integrated, sustainable funding enhances patients’ preference for primary care over mechanism for CHW and PP services. the ED, increases the number of routine screenings 4. Payers and providers should incorporate they undergo, and decreases their visits to the ED CHW utilization into well-designed advanced and for urgent care. Long et al. demonstrated that alternative payment models. CHWs improve patients’ perception of primary care, which can play a role in reducing hospital admissions. B. Payers and providers should include Corrigan et al. demonstrated that peer navigators help CHWs and PPs to improve outcomes for a patients understand and engage more efficiently with variety of health conditions. the health care system, resulting in increased access Several studies tested CHW and PP interventions to to preventive care and improved understanding of the treat a variety of health conditions, including SMI health system. (Brekke et al., Corrigan et al.), depression (Ell et al., Recommendations Poleshuck et al.), spinal cord injury (Jones et al.), CKD 5. Payers and providers should use CHW and PP (Shah et al.), CVD (Moser et al.), and other chronic services to improve outcomes for people with conditions (Carden et al., Ell et al., Long et al.). either physical or mental health conditions.

Patients with SMI and/or multiple chronic conditions 6. Payers and providers serving people with SMI often struggle to access appropriate care in a should prioritize peer navigators’ ability to fragmented health care system in which mental leverage their shared experiences in recruitment health, physical health, and social supports are and patient assignments. separate from one another, both in treatment methodology and geography. This is particularly 7. Payers and providers should use CHWs and PPs challenging for people who have comorbid physical to help patients with multiple chronic conditions and mental conditions and those with limited engage with primary care providers and prevent English proficiency. PPs’ shared experiences with their chronic disease symptoms from worsening, similar diagnoses and treatment plans enhance thereby reducing the need for costly emergency care.

21 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers C. Payers and providers should include Health Representative Program. Today, more than CHWs and PPs in care teams serving diverse 1,600 CHRs serve 250 tribes, but this program is communities affected by health inequities. at risk because the president’s budget calls for the The studies we reviewed also measured the elimination of funding. One study (Shah et al.) tested effectiveness of CHWs and PPs among diverse a CHR intervention to reduce risk factors for CKD, communities and patient populations, many of which disproportionately affects American Indians whom experience disproportionate negative health (who also face barriers to accessing the national 28,29,30 outcomes based on racial, geographic, linguistic, and transplant waiting list). In the early stages of CKD, economic characteristics. Populations included Black, treatment options are available that can prevent the Latinx, American Indian, Appalachian, limited English need for dialysis and transplants. However, dialysis proficient, and low-income participants. CHWs and and transplants are the only viable options for patients PPs leverage their shared experience to address the with late stage CKD or end stage renal disease. This health inequities within these communities. study showed that CHRs improved patient activation and reduced CKD risk factors such as high BMI and CHWs serving as promotores de salud have a long HbA1c levels. By addressing risk factors and engaging history of providing care, support, and education patients, CHRs can help prevent CKD from advancing across Latin America. The CHWs and PPs in three of to a stage that, in addition to being increasingly hard the studies discussed in this report (Brekke et al., on patients, is more costly to treat.31 Corrigan et al., Ell et al.) continue this tradition in the U.S., working in Latinx communities to provide CHWs’ ability to improve risk reduction and self-care culturally centered care that addresses social is especially important in both rural and urban core determinants of health. These studies provide further areas, given the high rate of hospital closures and 32, 33, 34, 35 evidence that promotores and other CHWs and PPs shrinking workforce. Multiple studies showed acting in similar roles can improve patients’ health successful outcomes for patients in rural (Moser et al., and help them navigate the health care system to get Shah et al.) and urban settings (Corrigan et al., Long et the care they need. al., Poleshuck et al). In particular, CHW interventions that leveraged the strengths of rural patients and their For women with low socioeconomic status who communities can give patients the skills to reduce the rely on women’s health clinics to address a variety risk of chronic conditions while keeping them close to of health concerns, including depression, anxiety, home, preventing health complications that require chronic pain, and intimate partner violence, peer inpatient treatment. navigation interventions such as the one tested by Poleshuck et al. can eliminate non-clinical barriers to Recommendations good health by providing care that addresses social 8. Payers and providers should use CHWs and PPs and environmental factors. to improve health outcomes in communities and patient populations that experience health CHRs are a type of CHW who have worked for inequities based on racial, sexual, geographic, decades in American Indian communities that linguistic, and economic characteristics. started receiving federal funding through the IHS in 1968, when Congress established the Community 9. Payers and providers should prioritize recruiting and training community members as CHWs or

22 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers similar roles to serve as critical trust brokers Recommendation and bridges between communities and 12. Payers and providers should include CHWs and health systems. This is especially important in PPs in care teams to improve patients’ self-efficacy communities with shortages of licensed clinicians and prevent avoidable hospital utilization as they and a need for chronic disease management. transition from inpatient to community settings.

10. The federal government should specifically invest E. Research on CHWs and PPs should be in the health and health care of American Indians improved to strengthen the evidence base and Alaska Natives. It must honor its trust and for equity. treaty obligations and increase funding for the Our review of these studies surfaced methodological IHS, including dedicated funding for CHRs. recommendations to make research more 11. Payers and providers should implement CHW representative and transparent and to help support interventions to mitigate the negative effects health equity-centered delivery and payment of the shrinking safety net in urban and rural transformation. These recommendations have the communities. potential to strengthen the evidence base so that treatments, therapies, and interventions are optimally D. Payers and providers should include effective for diverse patients and can accelerate CHWs and PPs in care transition teams. improvements in persistent health and health care Transitions from inpatient to community settings inequities. are points in care delivery where patients can be Recommendations especially vulnerable to negative outcomes.36 Two 13. Researchers should design CHW and PP of the research projects implemented CHW and intervention studies to include follow-up with PP interventions in ED and inpatient settings that patients to assess the longer-term impact of focused on critical care transitions. In one study these interventions on outcomes. Many of the (Jones et. al), peer mentors improved the self-efficacy studies we reviewed followed up with patients to of patients with spinal cord injuries, increased their measure changes in quality of life and engagement use of primary care services, and reduced the number in their health care. If an intervention improves of unplanned days they spent in the hospital after patients’ quality of life or activates them to pursue leaving an inpatient rehabilitation center. In another effective treatment for their health conditions, study (Carden et al.), health coaches helped patients then patients have the potential to improve their schedule and attend follow-up visits with primary care health outcomes long after the intervention ends. providers and prevented sharp declines in patient However, this potential can only be understood activation following discharge from the ED. Both if researchers follow up with patients to measure studies demonstrate how using CHWs and PPs in care outcomes after the intervention ends. transition interventions can improve outcomes and reduce costly avoidable health care utilization in post- 14. Researchers should design studies that include acute treatment settings. diverse populations with sufficiently large

23 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers sample sizes to power subgroup analysis. diverse communities, studies should measure the Instead of making assumptions based on effect of CHW and PP interventions on patients the aggregated results of research based on whose primary language is not English. Two homogenous populations that often excludes studies (Brekke et al., Poleshuck et al.) included certain communities, policymakers must have English fluency as participation criterion to avoid transparent evidence to better tailor, target, the administrative burden and cost associated and fund strategies that address inequities with translating for participants with limited experienced by specific groups. Five studies English proficiency. Research funding must be (Brekke et al., Jones et al., Long et al., Moser made available to account for costs associated et al., Poleshuck et al.) conducted subgroup with including linguistically diverse participants analyses, which were often limited to certain to ensure the evidence generated is more patient characteristics. Other studies (Corrigan representative. et al., Ell et al., Shah et al.) focused on ethnically homogenous populations and therefore did not Conclusion require subgroup analyses for race and ethnicity, The nine PCORI-funded studies reviewed in this report but also did not conduct subgroup analyses for expand the evidence base for policies and clinical other patient characteristics. Many researchers approaches that include CHWs and PPs as unique and noted that they were unable to conduct subgroup valuable members of the health workforce. Taken as analyses given the small number of participants a group, the successes of the interventions tested in in their studies. these studies demonstrate that CHWs and PPs can 15. Researchers should design studies that measure improve patient outcomes, increase access to primary not only whether patients were rehospitalized, care, reduce avoidable hospital and ED utilization, but also how many days they spent in the and generate savings for payers and providers across hospital once readmitted. In addition to number a wide variety of patient populations, conditions, and of rehospitalizations, the number of days spent settings. By leveraging shared lived experiences and rehospitalized is an especially valuable measure. enhancing trust, CHWs and PPs engage and activate In measuring health and quality of life, there is patients in their health and health care, which helps to a strong relationship between the severity of reduce their chronic disease risk and enable them to a patient’s condition, recovery time, and the remain healthy in their own communities. CHWs and number of days spent in the hospital due to that PPs can be funded sustainably through Medicare and condition.37 Moreover, the number of days spent Medicaid and integrated effectively into health care in the hospital has a direct relationship to the cost delivery models that incentivize value-based care. of care. Although these studies demonstrate that CHWs and 16. Researchers should make efforts to design PPs improve outcomes for patients who experience studies that will not exclude participants with inequities based on their race and ethnicity, sex or limited English proficiency. Given the value gender identity, language, location, and diagnoses, of CHW and PP interventions in addressing there is room to improve the evidence base. Issues communication barriers among linguistically with study design limit our understanding of these

24 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers The successes of the interventions tested in these studies demonstrate that CHWs and PPs can improve patient outcomes, increase access to primary care, reduce avoidable hospital and ED utilization, and generate savings for payers and providers across a wide variety of patient populations, conditions, and settings.

successful interventions, particularly in terms of the CHWs and PPs continues to grow, we hope to learn policy implications for addressing health inequities. more about the long-term effectiveness of their use for The lack of available disaggregate data in some of certain subgroups that experience inequities. the research studies limited evidence on how their Despite these limitations, this research adds to the interventions addressed specific inequities. This existing evidence of the power of CHWs and PPs as limitation highlights the need for an explicit focus valuable health equity change agents. Advocates, on equity that includes disaggregate outcomes decision-makers, and other health care stakeholders data as a central research objective. Additionally, must prioritize inclusion of this workforce in care the lasting impact of these interventions cannot delivery teams as a standard practice that is fully be demonstrated unless researchers follow up to and sustainably supported by health care payment measure patients’ outcomes after the intervention systems. ends. As the evidence base to support utilization of

25 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Endnotes www.bls.gov/careeroutlook/2017/youre-a-what/peer-support- specialist.htm?view_full. 1 Catherine Franklin et al., “Interprofessional Teamwork and 11 Collaboration Between Community Health Workers and Health Daniels et al., Defining Peer Roles and Status Among Community Care Teams,” Health Services Research and Managerial Health Workers and Peer Support Specialists in Integrated Systems Epidemiology (March 2015), accessed September 13, 2019, of Care.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5266454/. 12 Cheryl Gagne et al., “Peer Workers in the Behavioral and 2 Franklin et al., “Interprofessional Teamwork and Collaboration Integrated Health Workforce: Opportunities and Future Directions,” Between Community Health Workers and Health Care Teams.” American Journal of Preventive Medicine 54, No .6 (June 2018): S258–S266, accessed September 13, 2019, https://www. 3 Community Health Workers, Patient-Centered Outcomes sciencedirect.com/science/article/pii/S0749379718316374. Research Institute, accessed September 13, 2019, https://www. 13 pcori.org/topics/community-health-workers. J Brekke, Kelly E, Duana L et al., Can People Who Have Experience with Serious Mental Illness Help Peers Manage Their Health 4 Bureau of Labor Statistics, U.S. Department of Labor, Care? (Patient-Centered Outcomes Research Institute, 2019), Occupational Outlook Handbook, Health Educators and accessed September 13, 2019, https://doi.org/10.25302/4.2019. Community Health Workers, accessed October 3, 2019, https:// AD.13046650. www.bls.gov/ooh/community-and-social-service/health- educators.htm. 14 P Corrigan, Sheehan L, Morris S et al., Peer-Navigator Support for Latinx Patients with Serious Mental Illness, (Patient-Centered 5 Allen S. Daniels et al., “Defining Peer Roles and Status Among Outcomes Research Institute, 2019), accessed September 13, Community Health Workers and Peer Support Specialists 2019, https://doi.org/10.25302/8.2019.AD.130601419. in Integrated Systems of Care,” Psychiatric Services 68, no. 15 12 (December 2017): 1296–1298, accessed September 13, K Ell, Aranda M, Wu S. et al., Working with Bilingual Community 2019, https://ps.psychiatryonline.org/doi/full/10.1176/appi. Health Worker Promotoras to Improve Depression and Self-Care ps.201600378. among Latino Patients with Long-Term Health Problems, (Patient- Centered Outcomes Research Institute, 2018), accessed September 6 Daniels et al., “Defining Peer Roles and Status Among 13, 2019, https://doi.org/10.25302/3.2018.AD.13047364. Community Health Workers and Peer Support Specialists in 16 Integrated Systems of Care”. V Shah, Nelson R, Faber T. et al., Impact of Community Health Representative-Led Patient Activation and Engagement on Home- 7 Regina Otero-Sabogal et al., “Physician-Community Health Based Kidney Care, (Patient-Centered Outcomes Research Institute, Worker Partnering to Support Diabetes Self-management in 2019), September 13, 2019, https://doi.org/10.25302/4.2019. Primary Care,” Quality in Primary Care 18, no. 6 (2010): 363–372, AD.12115532. accessed September 13, 2019, https://www.ncbi.nlm.nih.gov/ 17 pubmed/21294977. D Moser, Feltner F, Biddle M et al., Does a Program that Focuses on Lifestyle Changes Reduce Heart Disease Risk Factors in a Rural 8 Kim B. Kim et al., “Community Health Workers Versus Nurses Community in Appalachian Kentucky? (Patient-Centered Outcomes as Counselors or Case Managers in a Self-Help Diabetes Research Institute, 2019), accessed September 2019, https://doi. Management Program,” American Journal of Public Health 106, org/10.25302/4.2019.CER.850. No. 6 (June 2016): 1052–1058, accessed September 13, 2019, 18 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860100/. J Long, Kangovi S, Mitra N, et al., Collaborative Goal Setting with or without Community Health Worker Support for Patients with 9 Anna Spencer, Integrating Community Health Workers into Multiple Chronic Conditions, (Patient-Centered Outcomes Research State and Local Chronic Disease Prevention Efforts: Program Institute, 2019), accessed September 13, 2019, https://doi. and Financing Considerations, (Academy Health, Robert Wood org/10.25302/7.2019.AD.131007292. Johnson Foundation, Nemours Children’s Health System, 19 February 2018), accessed September 13, 2019, https://www. Jones et.al., Using One-on-One Peer Mentors to Help Patients movinghealthcareupstream.org/wp-content/uploads/2018/06/ with a Spinal Cord Injury Transition from Rehabilitation to integrating-community-health-workers-into-domain-3d-projects. Home, (Patient Centered Outcomes Research Institute, 2019), pdf. accessed September 13, 2019, https://www.pcori.org/research- results/2013/using-one-one-peer-mentors-help-patients-spinal- 10 You’re a What? Peer Support Specialist, Bureau of Labor cord-injury-transition. Statistics, October 2017, accessed September 13, 2019, https:// 20 Carden et al., Using Home Coaching to Support Older Adults with

26 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers Chronic Illness After an Emergency Room Visit, (Patient Centered 29 Marina Scavini et al., “The Burden of Chronic Kidney Disease Outcomes Research Institute,2019), accessed September 12, Among the Zuni Indians: The Zuni Kidney Project,” Clinical Journal 2019, https://www.pcori.org/research-results/2013/using-home- of American Society Nephrology 2, (2007): 509–516, accessed coaching-support-older-adults-chronic-illness-after-emergency- September 13, 2019, https://cjasn.asnjournals.org/content/ room. clinjasn/2/3/509.full.pdf. 21 E Poleshuck, Juskiewicz I, Wittink M et al., Is a Patient Navigation 30 Meghan Jernigan et al., “Knowledge, Beliefs, and Behaviors Program More Helpful than a Referral Program for Reducing Regarding Organ and Tissue Donation in Selected Tribal College Depression and Improving Quality of Life among Women Living in Communities,” Journal of Community Health 38, no. 4 (August Neighborhoods with Few Resources? (Patient-Centered Outcomes 2013): 734–740, accessed September 13, 2019, https://www.ncbi. Research Institute, 2019) accessed September 13, 2019, https:// nlm.nih.gov/pmc/articles/PMC3706512/. doi.org/10.25302/5.2019.AD.12114261. 31 “Healthcare Expenditures for Persons with ESRD,” in 2018 USRDS 22 Community Health Worker Sustainability Collaborative (Families Annual Data Report, Volume 2: ESRD in the United States, accessed USA), accessed October 10, 2019, https://familiesusa.org/our- September 13, 2019, https://www.usrds.org/2018/download/ work/c-h-w/. v2_c09_ESRD_Costs_18_usrds.pdf. 23 Kimberly R. Enard and Deborah M. Ganelin, “Reducing 32 Hospitals Closings Likely to Increase (Health Resources Preventable Emergency Department Utilization and Costs by and Services Administration, September 13, 2019), accessed Using Community Health Workers and Patient Navigators,” Journal September 13, 2019, https://www.hrsa.gov/enews/past- of Healthcare Management 58, no. 6 (2013): 412–428, accessed issues/2017/october-19/hospitals-closing-increase.html. September 13, 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/ 33 Alex Kacik, “Nearly a Quarter of Rural Hospitals Are on the Brink PMC4142498/pdf/nihms616520.pdf. of Closure,” Modern Healthcare, February 20, 2019, accessed 24 Sanjay Basu et al., “Benchmarks for Reducing Emergency September 13, 2019, https://www.modernhealthcare.com/ Department Visits and Hospitalizations Through Community article/20190220/NEWS/190229999/nearly-a-quarter-of-rural- Health Workers Integrated into Primary Care: A Cost-Benefit hospitals-are-on-the-brink-of-closure. Analysis,” Medical Care 55, no. 2 (February 2017): 140–147, 34 Darrell J. Gaskin et al., “Residential Segregation and the accessed September 13, 2019, https://insights.ovid.com/ Availability of Primary Care Physicians,” Health Services Research pubmed?pmid=27547954. (April 2012), accessed September 13, 2019, https://onlinelibrary. 25 Mitchell H. Katz, “Interventions to Decrease Hospital wiley.com/doi/abs/10.1111/j.1475-6773.2012.01417.x. Readmission Rates: Who Saves? Who Pays?,” JAMA Internal 35 Joseph P. Williams, “Code Red: The Grim State of Urban Medicine 171, no. 14 (2011): 1230-1231, accessed September 13, Hospitals,” U.S. News and World Report, July 10, 2019, accessed 2019, https://jamanetwork.com/journals/jamainternalmedicine/ September 13, 2019, https://www.usnews.com/news/healthiest- article-abstract/1105805. communities/articles/2019-07-10/poor-minorities-bear-the-brunt- 26 Jeffrey S. Crowley and Molly O’Malley, Medicaid’s Rehabilitation as-urban-hospitals-close. Services Option: Overview and Current Policy Issues (Washington, 36 Janice L. Clarke et al., “An Innovative Approach to Health Care D.C.: Kaiser Family Foundation, August 2007), accessed Delivery for Patients with Chronic Conditions. Population Health September 13, 2019, https://www.kff.org/wp-content/ Management, 28, no. 1(2017), accessed September 13, 2019, uploads/2013/01/7682.pdf. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5278805/. 27 Jeffrey S. Crowley and Molly O’Malley, Medicaid’s Rehabilitation 37 Julie Gassaway et al., “Effects of Peer Mentoring on Self-Efficacy Services Option: Overview and Current Policy Issues. and Hospital Readmission After Inpatient Rehabilitation of 28 Joseph M. Yracheta et al., “Diabetes and Kidney Disease in Individuals With Spinal Cord Injury: A Randomized Controlled Trial,” American Indians: Potential Role of Sugar-Sweetened Beverages,” Archives of Physical Medicine and Rehabilitation 98, no 8. (August Mayo Clinic 90, no. 6 (June 2015): 81-823, accessed September 2017): 1526-1534, accessed September 13, 2019, https://www. 13, 2019, https://www.ncbi.nlm.nih.gov/pubmed/26046414. ncbi.nlm.nih.gov/pubmed/28342829.

Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers 27 This publication was written by: Emmett Ruff, Policy Analyst, Families USA Denisse Sanchez, Policy Analyst, Families USA Sinsi Hernández-Cancio, Director of the Center on Health Equity Action for System Transformation, Families USA Eliot Fishman, Senior Director of Health Policy, Families USA Raven Gomez, Partnerships Coordinator, Families USA

The following Families USA staff contributed to this publication (in alphabetical order): Kimberly Alleyne, Senior Director of Communications Nichole Edralin, Senior Manager of Design and Publications Noelle Thompson, Former Health Equity intern

To download a PDF of this report, visit FamiliesUSA.org/CHWs-Mounting Evidence-And-Policy-Recommendations

Publication ID: HEV101519 29 Center on Health Equity Action at Families USA | Advancing Health Equity through Community Health Workers and Peer Providers 1225 New York Avenue NW, Suite 800 Washington, DC 20005 202-628-3030 [email protected] FamiliesUSA.org 1225 New York Avenue NW, Suite 800 | Washington, DC 20005 | 202-628-3030facebook | / [email protected] FamiliesUSA.org | facebook / FamiliesUSA | twitter / @FamiliesUSAtwitter / @FamiliesUSA

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