PERSPECTIVE COMMUNITY HEALTH WORKERS Models for Organizing Community Health Workers(CHWs)in the United States. Extensions of hospital or clinic systems, with health care system New york (WIN) for Asthma Program, New York: CHWs serve as the single gement or care teams and are focused on clinical point of contact for families; in clinics, the hospital, and the community, services they provide asthma education, support, and referrals for social services. Community-based nonprofit organizations, rooted in commu ess. Oran CA: CHWs educate their ganizations often provide a of ost of other services for the community, both health-related tal health, domestic violence, parenting, and access to and non-health-related “ entities, organizations dedicated to CHWs that are City Health Works, New York: A close-to client network of CHWs whe t support financial sustainability, population and environmental in community settings, and primary care coordination for chronic goals, and local workforce dev conditions ganizing U.S. CHWs: employment when delivered by more exten- often fragmented CHWs who can of CHWs as extensions of hospi- sively trained health care workers integrate knowledge of the local tal systems, management of CHWs and that are difficult to coordi- social service milieu with knowl- through community-based non- nate in community settings. edge of patients'individual cir profit organizations, and man- The Affordable Care Act(ACA) cumstances can create a vital link agement of CHWs by entities that includes levers to shift our health for vulnerable populations. In con operate at the interface between care systems focus toward com- cert with social workers, CHWs health systems and the commu- prehensive, high-quality care for can mobilize social support, cre- nity(see table). The first two ap- populations. Through structures ate avenues for family members proaches reflect CHWs' historical such as accountable care organi- to engage in the care process, roles-as a means for broaden- zations and incentives such as and strengthen long-term commu ing the health care system's reach readmissions penalties, hospitals nity relationships that help pa- and as community activists and are increasingly responsible for tients sustain healthful behaviors health educators. The third ap- the care of patients both in and There's also an economic ra proach aims to synthesize these outside the hospital. For example, tonale for considering CHW pro- roles while borrowing principles hospital systems have invested in grams. Employment of CHWs from global experiences with care coordinators, aiming to re- creates meaningful job growth scalability and opportunities for duce readmission rates by strati- for people with lower educational financial sustainability. For exam- fying patients according to risk attainment (passage of the Gen ple, the Prevention and Access to level and tailoring their discharge eral Educational Development are and Treatment(PACT) proj- interventions. As these systems [GED] or higher tests)-often ct drew from the nonprofit or- look further beyond their own in low-income communities that ganization Partners in Health in walls, they may see opportunities have been hardest hit by the eco- integrating CHWs into a care- for lower-cost, CHW-based pro- nomic downturn-and particu- management program for patients grams to demonstrate superior larly for women. From the per- in boston who have Hiv-alds. value. 3 spective of a health system, CHW The PACT model was subsequent yond reducing read be a bargain, with mean an- ly expanded to cover patients with CHW programs may help to ad- nual pay of about $37,000 in diabetes or other chronic condi- dress the root causes of prevent- 2012. Further research is needed tions. More generally, organiza- able chronic disease. Social ex to assess the cost-effectiveness of tions dedicated to CHWs could clusion, poverty, marginalization, interventions by CHWs, but pilot support health systems by re- and the built environment con- programs have shown both re cruiting, training, and supervising tribute to the high burden of ductions in spending for Medi- CHWs. Longitudinally developed chronic disease, particularly in care and Medicaid populations expertise in CHW management low-income communities. But so- and clinical improvements in allows such organizations to pro- cial services addressing these so- areas such as medication adhe vide interventions that are costly cial determinants of health are too ence and glycemic control N ENGL J MED 369: 10 NEJM.ORGn engl j med 369;10 nejm.org september 5, 2013 PERSPECTIVE 895 community health workers ganizing U.S. CHWs: employment of CHWs as extensions of hospi￾tal systems, management of CHWs through community-based non￾profit organizations, and man￾agement of CHWs by entities that operate at the interface between health systems and the commu￾nity (see table). The first two ap￾proaches reflect CHWs’ historical roles — as a means for broaden￾ing the health care system’s reach and as community activists and health educators. The third ap￾proach aims to synthesize these roles while borrowing principles from global experiences with scalability and opportunities for financial sustainability. For exam￾ple, the Prevention and Access to Care and Treatment (PACT) proj￾ect drew from the nonprofit or￾ganization Partners in Health in integrating CHWs into a care￾management program for patients in Boston who have HIV–AIDS. The PACT model was subsequent￾ly expanded to cover patients with diabetes or other chronic condi￾tions. More generally, organiza￾tions dedicated to CHWs could support health systems by re￾cruiting, training, and supervising CHWs. Longitudinally developed expertise in CHW management allows such organizations to pro￾vide interventions that are costly when delivered by more exten￾sively trained health care workers and that are difficult to coordi￾nate in community settings. The Affordable Care Act (ACA) includes levers to shift our health care system’s focus toward com￾prehensive, high-quality care for populations. Through structures such as accountable care organi￾zations and incentives such as readmissions penalties, hospitals are increasingly responsible for the care of patients both in and outside the hospital. For example, hospital systems have invested in care coordinators, aiming to re￾duce readmission rates by strati￾fying patients according to risk level and tailoring their discharge interventions. As these systems look further beyond their own walls, they may see opportunities for lower-cost, CHW-based pro￾grams to demonstrate superior value.3 Beyond reducing readmissions, CHW programs may help to ad￾dress the root causes of prevent￾able chronic disease. Social ex￾clusion, poverty, marginalization, and the built environment con￾tribute to the high burden of chronic disease, particularly in low-income communities. But so￾cial services addressing these so￾cial determinants of health are too often fragmented. CHWs who can integrate knowledge of the local social service milieu with knowl￾edge of patients’ individual cir￾cumstances can create a vital link for vulnerable populations. In con￾cert with social workers, CHWs can mobilize social support, cre￾ate avenues for family members to engage in the care process, and strengthen long-term commu￾nity relationships that help pa￾tients sustain healthful behaviors. There’s also an economic ra￾tionale for considering CHW pro￾grams. Employment of CHWs creates meaningful job growth for people with lower educational attainment (passage of the Gen￾eral Educational Development [GED] or higher tests) — often in low-income communities that have been hardest hit by the eco￾nomic downturn — and particu￾larly for women. From the per￾spective of a health system, CHWs may be a bargain, with mean an￾nual pay of about $37,000 in 2012. Further research is needed to assess the cost-effectiveness of interventions by CHWs, but pilot programs have shown both re￾ductions in spending for Medi￾care and Medicaid populations and clinical improvements in areas such as medication adher￾ence and glycemic control. Models for Organizing Community Health Workers (CHWs) in the United States. Model Example Extensions of hospital or clinic systems, with health care system as base of operations; CHWs are integrated with disease￾management or care teams and are focused on clinical services. New York–Presbyterian Hospital Washington Heights/Inwood Network (WIN) for Asthma Program, New York: CHWs serve as the single point of contact for families; in clinics, the hospital, and the community, they provide asthma education, support, and referrals for social services. Community-based nonprofit organizations, rooted in community mobilization, activism, or faith; organizations often provide a host of other services for the community, both health-related and non–health-related. Latino Health Access, Orange County, CA: CHWs educate their neighbors about a broad range of social and health issues, including nutrition, diabetes, mental health, domestic violence, parenting, and access to health care. Management entities, organizations dedicated to CHWs that are integrated with clinical and community organizations; oriented around financial sustainability, population and environmental health goals, and local workforce development. City Health Works, New York: A close-to-client network of CHWs who perform protocol-driven early risk detection, self-management support in community settings, and primary care coordination for chronic conditions