By Treating Obstacles to Health, Community Health Workers Also Treat a Troubled System
Welcome to the world of community health workers. The job, part medical aide and part social worker, is a tradition in poor and rural communities around New Mexico and well established elsewhere around the country. But institutional recognition has come slowly.
Lidia Regina was just starting a new job at the University of New Mexico Health Center in Albuquerque a decade ago when the full weight of the unfamiliar work fell on her, hard. The new job was to check in with poorer patients, find out about the problems they faced every day, and ensure that poverty, unemployment or family obstacles did not prevent them from keeping pace with the health regimen their doctors prescribed.
Her first assignment was monitoring care of clients’ new babies. “The first case I get, I’m just going to see if she wants to participate,” she said. Within five minutes, a shower of bureaucratic problems rained down. The baby had no birth certificate. Or social security number. Neither did the mother. The father was suspected of drug abuse.
Ms. Regina said she excused herself, went into an adjoining room, and screamed. Then she returned, said, “Do you want to work with me?” When the patient agreed, Ms. Regina began to assembled the data needed to get the identity cards that would make health care payments possible. She ended up working with the family for years.
Welcome to the world of community health workers. The job, part medical aide and part social worker, is a tradition in poor and rural communities around New Mexico and is well established in similar places around the country. There are now 80,000 in the United States, and 700 or more in New Mexico. But institutional recognition for these workers, who often have only a high school degree — their main asset is being trusted by communities that are isolated from the workaday world — has been slow to come.
Now, after decades or more during which these people helped remedy social obstacles to medical care and healthy living, their work is increasingly recognized by the institutional structures at the core of modern healthcare. More than 10 states, including New Mexico, either train and certify these workers or plan to do so. Hospitals, clinics and insurance companies pay them, to identify and ameliorate what are called “social determinants.”
In rural communities around New Mexico, community health workers are the link to a medical world that can seem alien to local cultures.
“Primary care providers experience a sinking feeling when, after a clinical encounter, their hand on the doorknob to leave the examination room, the patient adds one more reason for the visit — perhaps they lost their job, are unable to afford their medicine or are about to be evicted from their home,” wrote the authors of a report on health workers and their new tools. Since 2014, the state has offered a formal certification to newly trained workers, and has certified seasoned hands under a grandfathering program.
Now, after decades or more during which these people helped remedy social obstacles to medical care and healthy living, their work is increasingly recognized by the institutional structures at the core of modern healthcare. More than 10 states, including New Mexico, either train and certify these workers or plan to do so. Hospitals, clinics and insurance companies pay them, to identify and ameliorate what are called “social determinants.”
“Primary care providers experience a sinking feeling when, after a clinical encounter, their hand on the doorknob to leave the examination room, the patient adds one more reason for the visit — perhaps they lost their job, are unable to afford their medicine or are about to be evicted from their home,” wrote the authors of a report on health workers and their new tools. Since 2014, the state has offered a formal certification to newly trained workers, and has certified seasoned hands under a grandfathering program.
In rural communities around New Mexico, community health workers are their link to a medical world that can seem alien to local cultures. One-third of the state’s population lives in rural areas; the vast majority of those areas have a shortage of primary-care physicians. Poverty is everywhere. Of the state’s 2 million-plus citizens, about 550,000 people currently receive their health care through Medicaid. The bill is $3.8 billion a year.
Health care workers “are usually family members and friends, and can have talks about chronic diseases and their care,” said Lynn Gallagher, New Mexico’s Secretary of Health. “They can go into the community because they know the traditions.” Secretary Gallagher spoke in March at the Rural West Conference run by Stanford University’s Bill Lane Center for the American West. (The Center also publishes this “…& the West” blog.)
About 48 percent of the population is Hispanic; 10 percent is Native American. A health-care worker might belong to a Native American community that is aloof to outsiders.
Health indicators in New Mexico are troubling, especially for those earning less than $20,000 a year. According to statistics from 2015, 35 percent of the people in this income range suffer from obesity, about 18 percent have diabetes, and more than 26 percent have mental diseases. Many people at this income level are concentrated in rural counties, where doctors practice what the medical community calls “frontier medicine” Two-thirds of the state’s 33 counties have a shortage of primary-care physicians;
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Dr. Arthur Kaufman, the vice chancellor for community health at the University of New Mexico, has long been an ardent advocate of community health workers. “A significant change in the financing of health care has now enshrined the work of community health care workers as a ‘tangible economic benefit,’” he said. Federal Medicaid payments to insurers are now made per patient, rather than per procedure.
New Mexico’s four approved managed care providers — Molina Healthcare, United Healthcare, Blue Cross/Blue Shield, and Presbyterian Health Plan — all pay for community health workers; salaries range from less than $10 an hour to more than $25; median pay is about $17. Their work can reduce what insurers pay in medical bills.
Such workers — Molina’s title is ‘community connection workers’ — “are kind of a door” into the homes of poor clients, said Laura Ortega, healthcare services manager for Molina. “When you see a member’s hierarchy of needs, when you see they have no food, place to live or transportation — well, if you don’t move them from that level, they don’t have self-esteem.” Self-esteem, she believes, “improves a member’s willingness to work with Molina.”
A small 2012 study showed a reduction in emergency-room visits. Patients without resources often rely on the emergency room for primary care, leading to large and often unnecessary expense. Dr. Kaufman and several colleagues followed 448 Molina patients over a six-month period, measuring their use of emergency rooms before and after they worked with community health workers. The $650,875 Molina paid for emergency room visits before the change dropped to $225,324.
More studies are in progress to show the economic impact as this traditional approach to health care, in areas that are poor or rural or both, is integrated into the health-care system. But behind the studies are encounters like those experienced by Lisa Coppedge, who works for Molina in Cuba, a small rural community in Sandoval County, or Jorge Monroy Sosa and Margarita Perez Pulido, who work in an immigrant-heavy area of Albuquerque.
To do the job, Ms. Coppedge said, “You have to have empathy, to be a good listener.” In one case, she said, she visited a woman who is a victim of domestic abuse. “She lives in a run-down trailer in poor condition and she doesn’t want to move. There’s no heat, no air conditioning, no running water. No internet service. No SNAP benefits.”
“She was completely unaware of community resources — that there was a local community food distribution group that gives out wonderful food boxes. I was able to get Home Depot to donate a window air-conditioning unit for her. Local churches picked up the unit and got it installed.”
Dr. Kaufman and several colleagues followed 448 Molina patients over a six-month period, measuring their use of emergency rooms before and after working with community health workers. Molina paid $650,875 for emergency room visits before the change and $225,324 afterward.
“Her health issues mostly involved mental and behavioral health. Depression. I needed to advocate for her to see a counselor. She had no car or transportation.” Ms. Coppedge helped the client deal with these obstacles, and the woman, who used to appear in the emergency room with mental breakdowns on a regular basis, now does so less often.
Now, when first meeting a patient, community health workers like Ms. Pulido and Mr. Sosa, who work at the First Choice clinic in Albuquerque, fill out a “WellRx,” asking questions about a patient’s access to utilities, transportation, child care, shelter, and food. The WellRx emerged from Dr. Kaufman’s offices; he said it is more useful than some other required tests.
One patient Ms. Pulido helped was an 85-year-old had been missing her doctor’s appointments; the home care nurse had stopped coming after, on several visits, no-one opened the door for her. Family members had chosen to keep her isolated. When Ms. Pulido got in to talk to the patient and her granddaughter, she got the granddaughter’s assurance that the patient would now go to the doctor.
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Patients’ fear of authorities — some poor immigrants see the medical system as part and parcel of threatening government agencies — is perhaps the most pervasive obstacle community health workers must overcome.
The obstacle that advocates like Dr. Kaufman had to overcome was the financial structure of the health care industry, which long created incentives for maximum payouts for procedures, and minimal payout for community and preventive healthcare. “The reason it didn’t happen in the past is because the incentives were not aligned with community health,” he said.
“The incentives for drug companies, for doctors, for hospitals, all of that was geared to fee-for-service. Not only fee-for-service but specialized care and procedural specialists’ care. Who determines that? Specialists who did procedures. You had these strange incentives that worked absolutely against community health.”
But, in a sign of the attitudinal change now underway, Dr. Kaufman said, “We just got a $4.5 million grant, five-year grant” from the federal Center for Medicare and Medicaid Services “to screen all Medicaid and Medicare patients for social determinants and for the higher risk ones to intervene and see if you could increase quality and reduce costs.” They hope to screen 75,000 patients a year in Bernalillo County, around Albuquerque. With some of the grant, he hopes to get community health workers smartphones loaded with contacts for social service agencies, local food banks, clinics, and other things they might need.
Ideally, he said, “We will be able to track where patients are sent, whether they arrived, whether there’s duplication. Everyone knows if this person has gotten food at a food bank. We don’t have to get food elsewhere. This would diminish the chance of waste.”
Increasingly, this blend of a social work and health care, long familiar to rural New Mexico, is a basic part of New Mexico’s health care delivery. Community health workers, Secretary Gallagher said, “can actually have meaningful discussions” to change attitudes — and cut health-care costs.
