Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Building on the June 2009 AHRQ Evidence Report entitled “Outcomes of Community Health Worker Interventions,” we propose the following new research to generate evidence on:

(1) What is the effectiveness of the use of Community Health Workers in a range of distinct settings --FQHC/migrant health centers; other primary care settings; specialty care; social service agencies and other community settings; and emergency departments.

(2) Are there CHW models that show greater levels of evidence for improving health outcomes for particular diseases and particular populations? And when compared with other health professional care manager models? (3) What is the cost effectiveness of using CHWs to enhance the productivity of primary care health professionals, to reduce the longer term health care costs of the patient, and to improve their ultimate health outcomes?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Clinically-based CHW in FQHC/migrant clinic vs. community-based CHW vs. CHW in mainstream primary care health clinic vs. CHW in emergency departments
• CHW vs. no CHW
• CHW vs. nurse care manager

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Low income, un/underinsured men, women and children

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Patients with chronic diseases or need for frequent contact with the health system, women with high-risk pregnancies.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Improved health outcomes for patients
• Reduced overall costs to the delivery system
• Cost savings with more appropriate use of primary care health professionals.
• Cost savings from improved health outcomes.
• Better patient adherence to treatment recommendations.
• Improved patient self-management and understanding of the disease process and the medical system

Describe any health-related risks, side effects, or harms that you are concerned about.

• Declining health outcomes
• Increasing health disparities for vulnerable populations
• Rising costs of primary care
• Growing Medicaid eligible-but-not-enrolled, uninsured children and families.
• Missing standards for CHW evaluation and evidence base

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Cardiovascular disease, including stroke and hypertension
• Depression and other mental health disorders
• Diabetes mellitus
• Obesity
• Pregnancy, including preterm birth

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)
• Other

Importance

Describe why this topic is important.

Used more commonly outside of the United States, community health workers are joining mainstream health care delivery across the United States. Health care and non-healthcare organizations are implementing various forms of case management, care management, patient navigators, community health workers, and “promotores” (health promoter) models in hopes to better coordinate fragmented care delivery and to better serve un/underinsured patients. These new approaches also aim to address limitations of the current health care system by improving cultural competency, developing a more diverse workforce, and expanding available health care providers. The June 2009 AHRQ EPC Evidence Report “Outcomes of Community Health Worker Interventions” identifies many areas where new research is needed to fill identified evidence gaps. CHW models vary widely and many are disease-specific or population-specific.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Many stakeholders (payers, community clinics, Medicaid programs, Medicaid managed care organizations, hospitals, foundations etc.) are interested in evaluating the various CHW models to better understand their effectiveness and the cost benefit as they look for longer-term solutions to health care delivery and financing reform challenges.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Appropriate health care access continues to be limited for vulnerable populations.

Provider shortages and insurance coverage limitations remains a reality so physician extender models are important to evaluate.

Health disparities of vulnerable populations continues to be a reality and addressing models to improve health outcomes and translate policy into practice is critical.

Communities and states continue to feel the strain of Medicaid populations (those who qualify or don’t), the growing number of uninsured and these vulnerable populations’ strain on the local health care and community systems.

Emphasis on disease management and prevention can reduce costs and improve outcomes, but these are often difficult to address in an uninsured/underinsured population.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

This research could offer solutions to a range of organizations struggling to provide quality care to vulnerable populations, to fund effective models for delivery system reform, to save costs by using CHWs, and to improve the health outcomes of many patients.

The systematic review of CHW in the range of types of clinical and community settings would offer a significant piece of information to the health care reform debate at the national, state and community level at this particular point of time.

Describe the timeframe in which an answer to your question is needed.

Next year or two.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Those for whom their primary language or lack of formal education make it difficult to navigate the US health system Those for whom lack of resources (financial, transportation) make it difficult to follow the recommendations of their health care provider Immigrants who do not understand the US health system

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

This research could offer solutions to a range of organizations struggling to provide quality care to vulnerable populations, to fund effective models for delivery system reform, to save costs by using CHWs, and to improve the health outcomes of many patients.

The systematic review of CHW in the range of types of clinical and community settings would offer a significant piece of information to the health care reform debate at the national, state and community level at this particular point of time.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

Evelyn Whitlock and Pam Curtis; Susan Stearns as liaision