Higher Quality at Lower Cost: Community Health Worker Interventions in the Health Care Innovation Awards

Background: Published evidence regarding cost savings, reduced utilization, and improved quality associated with employing community health workers (CHWs) is largely lacking. This paper presents findings from the Centers for Medicare & Medicaid Services Health Care Innovation Awards (HCIA), with a focus on six diverse programs that employ CHWs. We examine outcomes associated with programs incorporating CHWs into care teams for a broad age range of patients with various health issues such as cancer, asthma, and complex conditions. Methods: This mixed-methods study used data from claims and site visits to assess the effectiveness of CHW programs. In difference-in-differences analyses of Medicare fee-for-service and Medicaid claims, we compared utilization and spending for beneficiaries participating in each CHW program with propensity score matched non-participant beneficiaries for baseline (2010 – 2012) and post-intervention (2013 – 2016). We adjusted for geographic area, prior utilization, and clinical and sociodemographic characteristics. We assessed changes in care quality through beneficiary focus groups and interviews with program leadership and staff. Results: Five of the six programs saw a significant reduction in utilization and/or spending relative to a comparison group, and all programs had positive qualitative findings regarding quality of care. In three of the six programs, the adjusted total cost of care was significantly reduced (-$143 to -$2,044 per beneficiary quarter). We hypothesize that some reductions in spending can be attributed to CHWs’ provision of enhanced access outside of regular clinic hours, which facilitated patient adherence to evidence-based treatment pathways and averted unnecessary ED visits and hospitalizations. Culturally competent CHW encounters engaged patients in health care decisions, generated confidence in their decisions, encouraged adherence to treatment pathways, and mitigated social barriers to care. Conclusions: Programs were associated with improved quality and reductions in health care utilization and spending up to $20,000 per patient over the three-year period. Findings suggest a strong business case for the use of CHWs as part of interdisciplinary teams as CHW programs can provide a significant return on investment for payers. Reimbursement policies that do not account for the services of non-clinical staff such as CHWs impede the sustainability and spread of these interventions, despite mounting evidence of CHWs’ effectiveness. Organizations looking to integrate CHWs into care delivery may conduct feasibility assessments of available workforce and the capacity for clinical oversight, physician buy-in, and funding sustainability. Established programs could be leveraged for mentorship

Lessons from the Health Care Innovation Awards: Productively Engaging Vulnerable Populations to Address Social Determinants of Health

Objectives: This paper examines productive interactions—a cornerstone of the Chronic Care Model—between health care providers and vulnerable populations with chronic illnesses and/or disabilities. Methods: We conducted qualitative analysis of 16 focus groups and 29 interviews with patients and/or caregivers and 195 interviews with program leadership and providers across 15 Health Care Innovation Awards that targeted vulnerable populations. We analyzed how awardees addressed health concerns and social determinants of health (SDOH), and identified key components of productive interactions. Results: Providers achieved productive interactions through four primary strategies: establishing trust and showing respect; solving problems; building accuracy in health information exchange; and sharing accountability and responsibility. While providers sought cooperation from patients and caregivers for medical goals, they often addressed SDOH priorities. Discussion: Strategies tailored to vulnerable populations can enable shared decision-making and effective self-care. A nonjudgmental engagement style, accurate information, and consistent communication are important for patient engagement