Training Community Health Workers to Improve Health Equity

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Tom Haederle
Community health workers are a bridge between social and clinical care and serve as an invaluable part of the workforce for hospitals and health systems. They provide essential outreach, education, informal counseling, social support, and advocacy to populations dealing with unmet social needs - vital services that often go beyond the professional scope of clinical care teams. In New York City, Montefiore has taken its appreciation for community health workers to a new level, creating an Institute to standardize their training and ensure that the patients it serves are getting the best possible care in the hospital and beyond.

00;00;46;19 - 00;01;10;26
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Montefiore's Community Health Worker Institute was launched in the summer of 2021 as an expanded investment in how the health system recruits, trains and integrates community health workers into clinical care teams where they offer needed expertise in dealing with social determinants of health.

00;01;10;29 - 00;01;39;16
Tom Haederle
In this podcast, Rebecca Chickey, senior director of Behavioral Health, Clinical Affairs and Workforce with AHA, speaks with two experts from Montefiore about how its Institute is achieving its goals by improving access to health care for disadvantaged populations. Renee Whiskey- Lalanne is director of community partnerships at the Community Health Systems Lab at Montefiore's Albert Einstein College of Medicine, and her colleague, Dr. Kevin Fiore, is vice chair of community health and engagement.

00;01;39;18 - 00;01;41;08
Tom Haederle
Let's join them.

00;01;41;10 - 00;02;07;07
Rebecca Chickey
Thank you, Tom. It's an honor today to be here with two wonderful experts from Montefiore. Kevin and Renee, thank you for your time and most importantly, your willingness to share your expertise. So my first question to you today, can you describe Montefiore's Community Health Worker Institute, specifically why it was created and how long it's been in existence.

00;02;07;08 - 00;02;09;21
Rebecca Chickey
Renee, I think I'll turn that one to you.

00;02;09;23 - 00;02;31;22
Renee Whiskey-LaLanne
Thank you Rebecca. We officially launched in July of 2021, and so our first patient in June 2022. But I think it's important for us to just talk about our history with working with community health workers. Montefiore-Einstein has worked with community health workers since the 1970s. And in various models

00;02;31;25 - 00;03;01;27
Renee Whiskey-LaLanne
mostly in in part working with community-based organizations to employ community health workers and work in partnership with our system to serve our patients. But this institute is really a new approach. This is a new standardized, full investment. And to standardizing how we recruit, train, professionalize and integrate community health workers onto clinical teams to help address health related social needs for our patients.

00;03;01;29 - 00;03;31;28
Renee Whiskey-LaLanne
The model is really a solution to a problem that our health system has. We don't really have expertise or haven't in the past had expertise on clinical teams for how to address these social needs. And we see community health workers as a premium solution, for how we do that, but also as an investment in workforce. It's really working with community members to solve a problem and working alongside them to professionalize them and grow the health care workforce within our system.

00;03;32;00 - 00;03;55;21
Rebecca Chickey
Wow. Not only have you been at this since the 1970s, but now you are refining, enhancing, and expanding the work. That is great, and it's also a heavy lift. So, Kevin, I'm going to turn to you and say, so where did you start on your journey to create this program? What were some of your first steps for those who might want to follow in your footsteps, and how was hospital leadership involved?

00;03;55;23 - 00;04;32;04
Kevin Fiori, M.D.
It's a great question, Rebecca. And I would say you just to follow up a little bit on what Rene mentioned. We've learned a lot as a health system on how to do this well, and also some of the mistakes that we've made in the past. And I think one of the big things that we've learned and really initiated, sort of the genesis of this, this newer version of community health workers within our health system is the idea that, you know, we wanted to think about a workforce that could support a family unit.

00;04;32;06 - 00;04;57;09
Kevin Fiori, M.D.
And what I mean by that, a family unit who doesn't look at our health system as internal medicine, pediatrics, you know, obstetrics and gynecology, but really is coming to our health system. And so we needed a way to have a workforce that could follow families and support families across these silos that we have just by the nature of medicine, of clinical medicine.

00;04;57;11 - 00;05;23;08
Kevin Fiori, M.D.
So what happened was, you know, in the wake of the acute start of Covid in New York City - and the Bronx was a place that got hit particularly hard -we saw an immediate need to do a better job in terms of supporting families who had these unmet social needs. We had social needs before Covid started, of course, in Bronx County, New York.

00;05;23;10 - 00;05;46;11
Kevin Fiori, M.D.
But in the immediate wake of Covid, you know, we just saw a dramatic shift. And so that initiated a conversation with, our health system leadership about, you know, we need a new approach. How are we going to deal with this week? We already have, you know, overwhelmed clinical teams with our nurses, our social workers, our clinicians.

00;05;46;13 - 00;06;13;00
Kevin Fiori, M.D.
And so just adding to the list of things that they do was not an acceptable, you know, solution. And so we really looked at what are the assets that we already have in our community, and you don't have to look very far in the Bronx, you see, because they come into our clinics, patients who have amazing, you know, expertise in how to navigate sort of the existing resource landscape.

00;06;13;03 - 00;06;31;07
Kevin Fiori, M.D.
And so the idea was, well, how can we better integrate them within our health system. And we knew to be able to do that, we had to have a centralized structure. That was an idea that we pitched to our chief medical officer, Andrew Racine. And, you know, his response was, what do you need? You know, how can we do this?

00;06;31;08 - 00;06;53;28
Kevin Fiori, M.D.
How do we invest in this? And so that, you know, that journey started in 2021. And the other thing I'll say about where our journey started is we were thinking about this as we needed to develop a program that could be scaled across our enterprise. So we were not looking to set up a one clinic, one practice, one hospital solution.

00;06;54;01 - 00;07;08;20
Kevin Fiori, M.D.
But how does a health system integrate this workforce across our enterprise, in hematology, in pediatrics? And so to do that, we knew we needed a centralized structure.

00;07;08;23 - 00;07;37;08
Rebecca Chickey
You just said several phenomenal words: scalable, coordination, pushing down silos. And I think you used it that the term integration of this individual who is going to support the family unit. All of those are, I think, things that every hospital and health system aspires to. So each of us may approach it in a different way, but this community health worker training program sounds phenomenal.

00;07;37;10 - 00;07;58;24
Rebecca Chickey
You also mentioned the term investment. And so my next question and Kevin, I'm going to stick with you for a moment: Is this program, this training program of community health workers, is it financially viable? Because the reality is no margin, no mission. And so, how have you been able to support and begin to scale this work?

00;07;58;27 - 00;08;26;24
Kevin Fiori, M.D.
It's a great question, Rebecca. And I think it is probably a central question. And it was the first question that we asked when we started. Just to take one step back, I have been involved with setting up a community health worker programs across the globe for the past 20 years. And my observation is that what we usually do is we just try to put the program into place and think about, like, how are we going to pay for it afterwards? There's immediate need,

00;08;26;24 - 00;09;03;20
Kevin Fiori, M.D.
there is a fire. Let's grab a bucket of water and put it out. And we didn't do that this time around. And so, what we did was we thought through, okay, what are the kinds of things that we think our CHWs will help our health system do better? And our initial focus was looking at missed primary care appointments. We had seen in our data that patients who endured health related social needs, they were missing more appointments than patients that did not.

00;09;03;22 - 00;09;22;23
Kevin Fiori, M.D.
And that missed appointment is a fixed loss for our health system. It's bad for the patient. They don't get the care that they need. In addition, another patient doesn't get the care that they need as well because we usually can't rebook that appointment right away and we lose, you know, $200 or $300 every time that happens because of our fixed costs.

00;09;22;26 - 00;09;50;12
Kevin Fiori, M.D.
So we model the program thinking through how many missed appointments could a community health worker program, a high functioning community health worker program...could it avert? And we started developing the business case for CHW's. So this is in 2021. And then we had some great policy changes that happen in New York State this year, whereby CHW services are now reimbursable under Medicaid.

00;09;50;15 - 00;10;17;28
Kevin Fiori, M.D.
And there's also a program within Medicare. And so we are now because these reimbursement options are new, we are not putting that into our business model as well. And thinking through both in terms of just the reimbursement revenue that we could anticipate from this, the services that CHWs are providing, but also the reduction in waste and costs and improvement in care that the CHW workforce could provide as well.

00;10;18;01 - 00;10;38;24
Kevin Fiori, M.D.
So we're looking at all these things, and we actually believe that CHW programs are viable. And not only they're viable, they're probably essential because whether we like it or not, our patients are coming to us with these health related social needs. So the question becomes, well, it's affecting our ability to take the best care of a patient. Who on are our team

00;10;38;24 - 00;11;05;09
Kevin Fiori, M.D.
do we want doing this? Do we want the MD to take up the little bit of time that they have, to do this, or do we want to take someone who already has expertise because of the shared lived experience with patients? Because they've navigated some of these services themselves. Bring that onto our team. And it's just a much better business option.

00;11;05;12 - 00;11;16;13
Kevin Fiori, M.D.
So it checks both boxes. It's both in our what we think is the most effective strategy for navigating social service services, but it's also the most cost effective.

00;11;16;15 - 00;11;40;05
Rebecca Chickey
That's exceptional. You are singing a song that I love. You know, you planned, you looked at the cost avoidance opportunities. And there probably many more that you didn't mention, reduced readmissions, reduced visits to the emergency department, and then even reaching out improved productivity for that individual or their family members in their own workplace.

00;11;40;07 - 00;11;51;24
Rebecca Chickey
The savings can abound with this type of work. It's just often hard to quantify. Renee, can you share some of the other key success factors to making this training program work and grow?

00;11;51;26 - 00;12;04;02
Renee Whiskey-LaLanne
There are a couple critical key elements that we have to think about. And one was really making sure that we had a clear, established, standardized workflow, one that would be easy to implement.

00;12;04;04 - 00;12;25;20
Renee Whiskey-LaLanne
One that we could clearly establish who's doing what and how and how best to work with your community health worker on your clinical team. And those workflows can really be adapted based on the clinical setting. And so if you're working in the cancer center or you're working in primary care, you know, you can make adaptations based on the clinical context.

00;12;25;22 - 00;12;51;20
Renee Whiskey-LaLanne
But it really helps set the guidelines and baseline for how we're going to do the things that we say we're going to do. The other is we're working very closely with identified provider champions who really help us push this work forward. They help us as problem solvers on the clinical care team. Most of our clinical teams are not really familiar with how to work with community health workers, or what the community health worker role is.

00;12;51;23 - 00;13;12;13
Renee Whiskey-LaLanne
And so we identify these provider champions. We educate them first, and they help us pass the message and really endorse why we're doing this and how best to work with this new member of the team. The other things I think are really important are one, we use data to inform what we're doing. So we want to know of all the data we're collecting

00;13;12;13 - 00;13;44;10
Renee Whiskey-LaLanne
how does this data tell us what we're doing well and what areas we need to improve in. And we use that as a springboard to help improve our program as we grow and we continue to implement. And last but certainly not least, is our work around partnerships. From the very beginning we're thinking about how can we work with community-based organizations, health care training organizations and pipeline programs to really help us identify how we recruit the right types of community members to fill these roles.

00;13;44;13 - 00;14;05;12
Renee Whiskey-LaLanne
How do we best train our community health workers? How do we optimize what they're doing? And how do we provide the best service delivery? And so partners are really working with us from the inception, straight through implementation. And I think that is the really critical part of this, is to have that feedback and continuous improvement mindset.

00;14;05;15 - 00;14;28;08
Kevin Fiori, M.D.
If I can, I just want to add to something that Rene said. We were very deliberate and are still very deliberate about taking a learning health system approach, knowing that, you know, we we're not going to get this perfect at the start. And we still don't have a perfect implementation. And we know that there's always an opportunity for improvement.

00;14;28;11 - 00;14;43;04
Kevin Fiori, M.D.
But the way that one does that, you know, in our our teams mind is we need data. We need data to understand where we're doing things well. But more importantly, we need data to understand where we're not doing well.

00;14;43;07 - 00;15;03;10
Rebecca Chickey
So I think in your own words, you just described, a sort of a performance improvement process, because there are going to be mistakes. And, and that's actually a good thing because, I can't remember who said at first, but apparently we learn more from our mistakes than our success. And that's what science is all about.

00;15;03;10 - 00;15;28;08
Rebecca Chickey
So thank you for, reinforcing the value of data, and taking action from the data when you identify something that can be better than it was. As we, go to the last question and wrap up today's podcast, I want to focus in on what do you want for all of those people listening to this podcast. If there were three things to take away

00;15;28;10 - 00;15;34;17
Rebecca Chickey
what would you want them to remember to leave with the listeners as we close this out?

00;15;34;20 - 00;15;57;09
Renee Whiskey-LaLanne
So three things is hard. But I will start with, I think the first is, you know, integrating community health workers into clinical teams is really critical. That's number one. It's also very challenging and it requires the appropriate amount of investment. So I think that would be my first takeaway.

00;15;57;11 - 00;16;32;16
Renee Whiskey-LaLanne
The second is there are some things that we've learned that are key elements of success, that are agnostic of setting. So it doesn't matter whether you have a community health worker here at Montefiore-Einstein or at another institution down the road. I think you have to think about one, clearly defining what the role is, establishing clear guidelines and workflows around how you're going to, utilize your community health workers and integrate them into teams and establish that communication between them and everyone else on the team so that this works well.

00;16;32;18 - 00;16;48;22
Renee Whiskey-LaLanne
Setting up a foundation for appropriate training, supervision, mentorship and coaching, and making the business case for why it is a valuable investment to have a community health worker, a local expert on clinical care teams.

00;16;48;24 - 00;17;16;24
Kevin Fiori, M.D.
I think as health systems, we need to just think about there is enormous potential with this workforce and actually acknowledging the expertise that our communities bring to health service delivery. But it's not a just, you know, let's put out a job description for CHWs ...community health workers...and some kind of magic happens once you hire them. Really takes some investment and take structures

00;17;16;26 - 00;17;22;06
Kevin Fiori, M.D.
and that's something that we're absolutely committed to. And we're seeing the benefits of that.

00;17;22;08 - 00;17;45;00
Rebecca Chickey
Thank you so much, Kevin and Renee. This was exceptional. For those listening in, I just want to let you know, of course this will be on AHA's Advancing Health channel. And, we will do our best to embed a couple of stories, which is where I learned about this wonderful program because they've been recognized as leaders in this field.

00;17;45;00 - 00;18;10;09
Rebecca Chickey
And I want any of the listeners who want more information on this wonderful program that you have to have the most available. So we'll get that posted with. So thank you for listening today. Thank you Kevin and Renee for sharing this journey. And best of luck as you continue to invest, train and mentor this important component of whole person care.

00;18;10;11 - 00;18;11;20
Rebecca Chickey
Thank you.

00;18;11;23 - 00;18;20;02
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.