Abstract

Excerpted From: John V. Jacobi, Community Health Workers and the Dilemma of Integrated Care, 23 Houston Journal of Health Law & Policy 5 (2024) (132 Footnotes) (Full Document)

Community Health Workers (CHWs) form an emerging profession that has the promise of helping to fix some of the most significant faults of our health care system. CHWs are of the community of largely poor, often of-color population alienated from and sometimes poorly served by our technically sophisticated but increasingly distant institutions of care. One of the strengths of CHWs is that they can assist in a shift in care for the underserved from fragmentation to integration allowing medical services and social services to relate in recognition of the complex causes of the poor health status of the poor, including social determinants of health (SDOH) effects as much as or more than medical conditions. Improving their communities' health status can involve the creation and support of integrated care systems that knit together medical and behavioral care with social services. Much has been written about such team-based care, including by this writer. CHWs can be contributors to the success of such ventures.

This paper's modest goal is to describe and propose solutions to two difficulties that can arise when CHWs are used to further the largely admirable effort to create whole-person, integrated health care systems in part by recognizing the need to address social, as well as medical, barriers to good health status. The first difficulty is that the absorption of CHWs into large health enterprises can threaten to undermine an important source of CHWs' value: their independence to act as of-the-community advocates and bridge-builders for people experiencing a gulf between themselves and established health and service systems (and community members' recognition of CHWs' independence). Second, such absorption can foster or further the medicalization of socially-created problems, such as inadequate housing stock, food deserts, and inadequate schools--that is, it can contribute to the sweeping into health systems' range of authority social services provision that has historically been the purview of separate, hopefully expert, social service providers and advocates.

How can these two dangers--the loss of an essential value of CHWs and the medicalization of social care--be avoided? Carefully, and with thoughtful planning. This paper will suggest a possible structural response to these dangers, drawing on the work of organizations that support CHWs by connecting them to health and social service organizations while preserving their range of independent action on behalf of their communities. This proposed solution is not meant to suggest an exclusive professional path for CHWs. CHWs are members of an emerging profession, and some may choose to become integrally related to health care systems and participate in a clinically-oriented workplace with the attendant hierarchies. But some CHWs may prefer a role distinct from (although conversant with) the health care delivery system as a community representative and, importantly, as an intermediary between communities often alienated from health systems and those systems' clinical services. Both paths should be open to CHWs, and both serve important social functions.

The first part of this paper will describe who CHWs are, their roots as a profession, the roles they perform in today's health and social service context, and the work underway to create sustainable funding paths for their work in their communities. Second, this paper will briefly review the integrated care models that have emerged to combine health and social services for the benefit of underserved communities and the place CHWs have found within those models. Third, it will describe two problems the absorption of CHWs into health systems can create: the possible weakening of the community-centric nature of CHW work and the dangers of medicalizing socially-generated determinants of poor health status. Fourth, it will describe a model for connecting some CHWs to health and social service organizations that can both preserve the integrity of the CHW model and provide an alternative or counterweight to a dominant model in which services directed to ameliorating the non-clinical problems created by SDOH are channeled through health systems in part through the work of CHWs. The model described in the fourth part of this paper inevitably adds complexity to already very complex medical and social service systems. But the structures described can serve an important function by permitting community-based organizations (CBOs) employing CHWs to deliver care in a way that is fiscally and managerially independent of health systems, but that maintains linkages to assure that funding flows to the CBOs for CHW services; information flows from the CBOs to payers for the services (including insurers and health systems); and professional independence is maintained for those CHWs who choose to remain community-based in local CBOs.

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This paper recognizes the importance of both CHWs and integrated primary care teams as means to address the effects of social determinants of health on historically underserved populations. Both CHWs and integrated care practices are essential in remediating the historic injustices in both health care and the broader society that have served as barriers to the improvement of the health status of communities of color, the poor, and other underserved and alienated populations.

CHWs and integrated primary care teams are often linked because the community-based skills of CHWs can bridge the gap between underserved populations and the health care delivery system, including integrated primary care teams. This paper suggests two cautions: First, the complete absorption of CHWs into health systems risks degrading or neglecting the unique skills they bring to health equity efforts. A model for facilitating the independence of CHWs from health systems while facilitating their service to the goals of integrated care exists in the form of community nonprofits serving as intermediaries between CHWs and clinical care. These intermediaries can perform “back office” work for CHWs, allowing CHWs maximum independence of action while serving the needs of patients of integrated care practices. Second, for those CHWs who prefer to be employed by and integrated into health care entities, there is a danger that CHWs' essential value will be degraded if they are treated as just one more category of clinician or clinical helper within a health care practice. The integration of CHWs into health care entities should be accomplished through thoughtful clinical protocols and CHW supervision to protect the unique value of CHW work. CHWs are not simply additional clinicians; rather, they best function as a bridge between clinicians and skeptical communities.

CHWs can be important forces in improving care for poor and vulnerable populations--a goal shared by integrated care practices. The meshing of clinical work and CHW practice must be done delicately and with forethought. The payoff for communities if care is taken can be substantial.

Dorothea Dix Professor of Health Law & Policy, Seton Hall Law School.