By: Patricia Flowers-Coulson, MHS, MCHES, Latish Walker, MA, Julius Ho, MD, MPH, Cheryl Finney, PhD, Katie Shaw, MD and, Panagis Galiatsos, MD
Program Context: Baltimore City, Maryland (USA) is home to renowned healthcare systems and patients come from around the world to receive advanced quaternary care at the cutting edge of biomedicine. Yet the city faces a multitude of social concerns, with over 1.5 times the rates of poverty and unemployment of the US as a whole and 2.8 times the rate of incarceration. Many communities in Baltimore City experience long-standing lack of economic opportunity, mistrust in public institutions including hospitals, and failure of the criminal justice system. The inequities that stem from such social determinants can be illustrated by health indicators in two of Baltimore City’s neighborhoods: Greenmount East (adjacent to the Johns Hopkins Hospital) and Roland Park (an affluent area where many of its faculty live) are two miles apart. There is an alarming difference in average life expectancy between the two (67.9 years vs. 83.9 years, respectively) and health outcome disparity as reflected in age-adjusted mortality from chronic conditions: the rate of heart disease in Greenmount East is more than three times that of Roland Park, and the rates for cancer and diabetes are double.
Due to payment reforms in Maryland where all hospitals have moved to value-based global budgeting, healthcare institutions have a renewed interest in reducing costs by expanding their role beyond acute care delivery to addressing root causes of illness. Through the employment of community health workers (CHWs) from and based in distressed communities, we see an opportunity to create a new blueprint for investing in health: helping community members navigate systems of employment and healthcare, building their confidence and self-efficacy, and increasing institutional awareness of biases experienced by those they serve.
Program Design: In 2015, several hospitals in Baltimore City joined together to call for the creation of jobs to improve population health, funded by a small increase in annual reimbursement from the state. Beginning in 2017, individuals from the most distressed ZIP codes in the city were actively recruited to train as CHWs, peer substance recovery specialists, outreach specialists, or nursing assistants. The CHW job pathway was created with cohorts of 15 people trained over a 3-month period, without stipends, in a work readiness and leadership development program called Turnaround Tuesday. Turnaround Tuesday is run by BUILD (Baltimoreans United In Leadership Development), a network of neighborhood, religious, and civic leaders with a decades-long history of organizing around housing, education, policing, and other social determinants of health. Turnaround Tuesday started in 2014 when a listening campaign with young men engaged in the street corner drug trade revealed employment as their most important need. Together the community and BUILD member institutions began addressing barriers to employment.
Housed in community institutions, Turnaround Tuesday’s weekly leadership and workforce training sessions are open sessions offered 48 weeks per year. Individuals that choose the CHW job pathway must first pass The Adult Basic Education (TABE) Test at an 8th grade level or higher, and then complete 12 hours of leadership training, 30 hours of Essential Skills training, 120 hours of CHW technical training through a workforce training partner, and 40 hours of field practicum shadowing a fellow CHW. Candidates are then interviewed and, if hired, offered full-time positions with competitive compensation and benefits.
CHW positions vary depending upon the hiring institution. Some are embedded with Care Coordination Teams in hospitals in the emergency department or on an inpatient unit; others work with treatment programs or health education centers. A CHW’s scope of work includes assessing needs of the whole clienti and meeting with clients in the clinic or in the home, with the primary focus to research and connect clients to healthcare, insurance, and daily living resources. CHWs also educate and engage individuals to utilize preventive health services; participate in health fairs, conferences, and training; and volunteer time with local service organizations.
CHWs are supervised by multiple people within their assigned unit and receive external supervision from individuals with oversight of community outreach programs. Internal unit supervisors hold regular meetings with CHWs to discuss professional development, institutional and other relevant policy updates, and facilitate brainstorming about difficult cases. External supervisors approve pertinent training and volunteer opportunities found by CHWs and pair incoming CHWs with established CHWs for the shadowing mentioned earlier. Doctors, nurses, case managers, social workers, and/or supervisors refer clients, mostly by phone call or in-person introduction, to CHWs.
Picture: first cohort graduating
Program Impact: From January 2017 to July 2018, more than 600 community members – the majority of whom live in the most distressed ZIP codes in Baltimore – attended Turnaround Tuesday leadership training sessions. There were 283 people who chose the CHW job pathway and took the TABE test. Fifty-four percent (n=152) passed the TABE and were eligible for CHW training, with 17% at the remedial level, many of whom took the free 12-week remedial classes offered and subsequently passed. Of those that passed, 130 participants began Essential Skills and CHW technical training with 74% (n=96) completing the full training. (Figure 1)
Figure 1
Seventy percent (n=67) of the 96 participants who completed the full training were hired as CHWs at nine Baltimore City hospitals. An additional 16% (n=15) who were not selected for CHW positions were further supported to find employment in other capacities. Hiring decisions were made based upon candidate preparation, regardless of criminal background and previous educational attainment.
Ninety-five percent hired since the beginning of the program (in 2015) are still working and live in Baltimore City (as of early 2019). For many, this job is the first career experience that pays a living wage and provides benefits. Through a grassroots process that arose from local needs and uniquely leverages local resources, our program has deployed CHWs across a range of sites and institutional partners. Healthcare systems benefit from a better-trained and supported workforce, improved relationships with the communities they serve, and more effective community-based care. CHWs state that they bring natural skills to their jobs such as acting as a resource person and describe their jobs as life-changing. One CHW said with enthusiasm, “My job makes me never want to leave it!” The difference a CHW makes in the life of a client is clear from the stories they share (Figure 2).
Figure 2: CHW Stories
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“My client with a heart condition was told she had to have a procedure in Washington, D.C. She can barely get to appointments around the corner; how is she going to get to D.C? I looked up local hospitals that do the procedure and now she is getting care at one of those hospitals. The doctor here wasn’t so happy with me because its not a hospital in our health system. But the next patient was referred locally. I’d like to think that was because of me.” |
“My client was referred to me with issues of homelessness. It turns out her son was murdered two months prior and she wasn’t living in the house due to people coming in and out. I knew from my own experience that it was probably drug activity and she needs to be moved to another home. The doctors and nurses didn’t take the time to listen to her. We talked for an hour and at the end she was sitting up straighter and looked brighter and told me she felt better.” |
Lessons Learned: Many health inequities are driven by a relative lack of engagement both of individuals in their healthcare and of healthcare institutions in their communities. It is possible for organizations to successfully employ a local hiring strategy that is rooted in the community and produces fully trained, “ready to employ” CHWs that make a positive impact on their clients’ lives.
In this first year of program implementation, regular listening sessions with CHWs have increased cooperation and understanding of their work and their clients’ experience in healthcare. CHW recommendations include:
- Clarify the role of the CHW with medical institutions and/or program supervisors; describe how the intersection of expertise and lived experience is designed to serve populations from distressed neighborhoods;
- Provide opportunities for CHWs to educate members of the healthcare team about their clients’ lives and challenges to reduce bias and labeling of patients;
- Ensure that the CHW is viewed as an important member of the care team to achieve health outcome goals and objectives;
- Provide chances for CHWs to meet regularly to collaborate on ways to address challenges, share successes, and discuss best practices.
Sustainability and Scale-up:Ensuring both the healthcare and local community understand the value added by CHWs is key to sustainability. Significant reduction in health inequities requires that community members themselves recognize the value of a CHW program, their own agency in their health outcomes, and drive the systemic change necessary to eliminate barriers to equity. Community organizing that builds relationships, surfaces and trains leaders, and brings pressure to bear on those who have the power to make systemic change is the best hope for sustaining a positive impact.
Using principles of community organizing, we are currently beginning a “listening campaign” for CHWs to identify personal, community-level, and healthcare system barriers in our served communities. Along with process data and the qualitative experiences of our CHWs, the listening campaign will inform plans to utilize our leaders and request additional funding from the state to scale up the project.
i In the CHW program, the term “client” is used versus “patient.” The term patient implies that individuals undergoing care have to bend to whatever “we” (those of us in the healthcare field) say. It therefore diminishes client voice. The term client, on the other hand, promotes mental control, involvement and self-awareness about overall health.
Authors
Patricia Flowers-Coulson, MHS, MCHES (1), Latish Walker MA (1), Cheryl Finney, MPH, PhD (1), Julius Ho, MD, MPH (2), Katie Shaw, MD (2) Panagis Galiatsatos, MD (2)
Author affiliations:
(1) Baltimoreans United in Leadership Development (BUILD)
(2) Medicine for the Greater Good and the Johns Hopkins Medical Institutions
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