Speaker 1 (00:05):
Welcome to Hospitals In Focus from the Federation of American Hospitals. Here’s your host, Chip Kahn.

Chip Kahn (00:14):
Now more than ever vulnerable populations need communication and outreach to quell misinformation, and provide pathways to better health and medical outcomes. Fortunately, community health workers, public health workers who are trusted members of the communities they serve, are on the front line providing this crucial link between patients and the resources they need to live healthier lives. It is a role that is vital to promote the voice of communities by addressing needs that when left unmet, drive poor healthcare outcomes and deepen the inequities in healthcare. Inequities that have been magnified by the current pandemic. Joining me today to discuss the growing importance of community health workers, is Dr. Chidinma Ibe. Dr. Ibe is the assistant professor of medicine and associate director for the Johns Hopkins Center for Health Equity.

Chidinma Ibe (01:10):
Thanks Chip. Glad to be here.

Chip Kahn (01:12):
So glad to have you. Chidinma, could you tell us a bit about yourself?

Chidinma Ibe (01:16):
Sure. So I’m a long time resident of Baltimore City. And essentially I’m a health equity researcher. I focus on community-based strategies to address chronic disease disparities. And I would actually say that my interest in community based research stems from being a first generation American. My parents are from Nigeria and it’s a very communal society. So that kind of instilled this desire to explore how members of communities come together to support one another. And then what the implications for that are for health. So early on in college, I was really influenced by research that highlighted all these racial and ethnic disparities in a host of health conditions. And then I started to become really fascinated by the prospect of community-based strategies to address these disparities. And to think about it more from a solutions and asset based orientation, instead of just, “This is what’s wrong in this community and what can we do?” And the hand wringing that kind of happens when we think about vulnerable or underserved communities.

When I graduated from college a mere 17 years ago, the first job I had involved working with community health workers. And that was really when I just became entranced by this idea that you could have [inaudible 00:02:40] people who were really good at navigating their own social circumstances. You could leverage those same people to help others in their communities do the same. And so really for the past several years I’ve had the privilege of working with, and then developing and researching and evaluating community health worker initiatives.

Chip Kahn (03:02):
So Chidinma, what is a community health worker?

Chidinma Ibe (03:05):
Well, I would say the way that you described it earlier really gets at the heart of what a community health worker or a CHW for short, actually is. I tend to favor the definition that comes from the

American Public Health Association. They have a CHW section and their definition was actually created by community health workers themselves. So they define a CHW as a frontline public health worker.
They tend to be trusted members of communities, and or have an unusually close understanding of the community that they serve.

And because of this understanding, they are able to establish a trusting relationship that then allows them to be a liaison between the communities that they’re working with, and then the health and social services that they may be employed by. And this all facilitates access to services, it improves the quality and cultural competence of service delivery. And then the other key thing about community health workers that’s a part of this broader definition, is that they help build individual and community capacity. And they do that through a range of functions in part by increasing health knowledge, by building individuals’ self-sufficiency, they do outreach community education and they’re advocates.

Chip Kahn (04:27):
Let’s do a deeper dive on that word trust which you mentioned. Trust is critically important in healthcare delivery. But unfortunately and maybe with some good reason, many in the community do not trust caregivers. How do the CHWs help to build that patient trust in healthcare providers? You mentioned some things, but sort of how do they really help the caregiver and the individual who needs that healthcare? How do they build a bond there?

Chidinma Ibe (05:01):
Yeah. I love that question because when I think about trust and I think about the role of community health workers in building trust, I actually think about what is the source of the distrust? You had mentioned earlier that there is reason for some members of communities, particularly of racial, ethnic minority communities to not trust the healthcare delivery system. So we have to really just situate that lack of trust in structural racism and classism and homophobia, for some populations [inaudible 00:05:36] fatphobia, and even the intersection of all of these different things, and how that can really disproportionally affect a large segment of the population in terms of how they want to engage with the healthcare system, and their actual engagement with the healthcare system. So there’s been some research done by Dr. Lisa Cooper who was at the Johns Hopkins School of Medicine and Public Health, and is actually the Director of the Center for Health Equity.

She and other researchers throughout the country over the past several years have really built, a large body of evidence that highlights that there is a link between implicit bias on the part of providers, and then their communication with patients. And they have found that the nature of their communication is less participatory and partnership oriented, with African-American and other ethnic minority patients. Then we’ve seen similar trends in terms of how some physicians communicate with overweight or obese patients. And then I have been thinking a lot about how this operates in tandem with some recent work. This really great study that just came out earlier this month, the month of September. Published by doctors, Greenwood, Hardman, [inaudible 00:00:06:54], and Sojourner. And what they found was that newborn physician racial concordance, was associated with reduced infant mortality for black infants. And they did this analysis looking at 1.8 million births, essentially nearly 2 million births occurring in Florida between 1992 and 2015.

So when I think about all of these things and then I think about the role of community health workers, I think about how some of these issues of distrust are warranted. And where community health workers step in and where their power lies is that, when they become members of patients’ care teams, they’re kind of serving as a bridge between those on the healthcare side and the patients that they’re serving. So they advocate for their patients by helping healthcare team members understand, the social and cultural context under which a patient is experiencing their life or navigating their life. And then they help patients by coaching them to communicate their needs to providers. So some of the work that I’ve done has looked at the role of community health workers and equipping patients with the tools to have more constructive communications with their providers. And what I did was that I looked at patients who had high blood pressure and had some difficulty managing their hypertension, but had a community health worker that provided lifestyle management support and communication coaching.

And what I found was that patients who spent more time with the community health worker, actually had better communication with their providers. And so it’s really this bridging of the two worlds that CHWs do that helps to foster stronger trust and health healthcare settings for patients. But I think you also made a really interesting point, when you kind of asked about the role of community health workers in helping providers and their trust as well with patients.

So if you talk to any community health worker, they’ll tell you that when they are communicating with members of a healthcare team, they’re usually trying to provide some context for why a patient might exhibit certain behaviors. So let’s say there’s a patient that frequently uses the emergency room. What a community health worker can do in that situation is talk to the care team, and alert them to certain situations that might be happening in that person’s life. Whether it’s family related issues, social economic circumstances, or just challenges that they’ve encountered if they’re in a precarious situation. But the main thing is that because community health workers, they really do tend to treat patients with dignity and genuine concern, it helps patients feel like they have a true ally on their side. And that helps foster that sense of trust that I think is really important and can sometimes be missing for patients from certain populations and communities, when they’re encountering the healthcare system.

Chip Kahn (10:01):
The care team you describe, and the work of the care team with patients is so critical to health. But also so much of health is really outside the doctor visit or the interaction. There’s food insecurity, loneliness and racism. These are just a few things among all the factors that affect health. What kinds of social resources do CHWs provide their communities to mitigate these kinds of factors, those that are in the community, really outside the purview of the care team itself?

Chidinma Ibe (10:34):
You raise a really important point that so much of what affects a patient’s health is not amenable to intervention in a lot of ways within a healthcare setting. All of the things that you mentioned, in and of themselves they can affect a person’s health. But when they’re all coming at you at the same time it can be overwhelming. And so when I think of what community health workers do, I would say the best way I can answer your question is through a story. So a few years ago, I was really fortunate to accompany this really dynamic community health worker on home visits she was doing that day. So we must have done about four or five home visits, just one right after the other, each patient with their own set of circumstances that vary depending on who they were, but all of them really in need of that additional support from a community health worker. Some of the patients had issues with transportation.

Some of them had issues with housing. So we would go into the patient’s house and the conditions under which the patient was living in and their family was living, they weren’t conducive to being healthy or maintaining health. But one of the visits that really stood out to me was, we went to the home of a patient who kind of admitted to the community health worker that they were having a hard time going to their appointments because, the bus schedule was at odds with the clinic hours. And so in order for them to get to the clinic, they would have to wait 45 minutes for the bus. Sometimes the bus wouldn’t even come when it was supposed to come. When it did come, sometimes the bus was crowded and this was a patient that had some difficulty with mobility. And actually also disclosed that they had some mental health struggles.

So even the prospect of being on a bus was, they didn’t want to be on a bus and felt nervous about it. So what I thought was really interesting was that the community health worker did a couple of things. First, they asked that patient if they had a family member that could help them. And they kind of talked through some different strategies on who to contact. But the second thing that they did was to link that patient up with mobility services. And I think that’s kind of an example… The micro issue is getting to the appointment itself. The larger issue is this situation of the transportation system, and then converging with the clinics hours, and then the patient’s own barriers in terms of how they felt about being on the bus and their physical limitations.

So when I think of how community health workers address all of these social determinants of health, and even these intrapersonal determinants of health, that example really stands out to me, of just the ways that the community health worker even in that instance, they built that individual’s capacity by helping them think through some problem solving strategies.

But then when they identified that there was a gap… So for this particular patient they didn’t have a family member that could drop them off. What they did was they helped to fill that gap by connecting them to what could be available. And for those of us who have had the opportunity to work with community health workers and to learn from them, we see this a lot in terms of other services they provide. That if a patient is struggling with food insecurity, they link them up to local food pantries or to other forms of more material support.

And then you mentioned loneliness and that stood out to me because, it’s something I’ve been really interested in for a long time. Is looking at the relationships that patients and community health workers build together. And how for a lot of the patients that receive community health worker delivered services, sometimes according to community health workers that we’ve talked to, patients will disclose things to them that they don’t feel comfortable sharing with anyone else. And so I’m not suggesting that community health workers are magicians, but they do a lot of things that provide material and then emotional support for people who are in particularly vulnerable circumstances.

Chip Kahn (14:53):
So really for this broad and unique role, how does CHWs get funded?

Chidinma Ibe (14:59):
Yeah. That’s actually one of the challenges because… So there’s some variability in terms of funding. By and large they tend to be funded through grants, but we all know that soft money funding mechanisms aren’t really a longterm sustainable mechanism. Especially when you think about the broad range of services that community health workers provide, and just the importance of what they do. So increasingly some health systems, hospitals and health plans are actually employing community health workers themselves, and paying for their work through their own operating budgets. And that’s great. That’s a testament to the recognition of their importance in addressing patients’ social determinants of health and, the roles that community health workers can play and coordinating care, and delivering other essential services that really helps speak to patients’ overall health and wellbeing. And they do this in concert with the care that they’re receiving from other members of a care team.

But interestingly, there’s been a lot of momentum over the last few years in particular towards Medicaid reimbursement, as a strategy for providing more sustainable funding for CHWs. There’s this really great report from Families USA that highlights all the various strategies to do so. And it could be done through state plan amendments for reimbursing preventive services, through managed care contracts, and then through state legislation and state plan amendments. But the thing that really stands out to me that I think is important to take note of is that, because community health workers do so many different types of things, it actually has been challenging to even use Medicaid reimbursement as a strategy for funding their work. So some states and Ohio is an example of one of them, there’s like a narrow conception of what constitutes a reimbursable service. And so what it means is that, some of the services that are more patient center … Well, direct patient care and individual health, may get reimbursed.

But if you remember the role that community health workers play, and that a lot of what they do isn’t just on an individual level, but really on a community centered foundation, some of the other activities that they embark on like community outreach or health education, or just general community based health promotion activities, some of those they might not be covered by Medicaid currently. And so it’s really important that when we think about funding community health workers that, we’re really taking into account not only what they do on the individual level, but also community capacity building services and how those are essential for health as well. And that we really need to think about the full spectrum of activities that CHWs adopt, so that they are reimbursed and that we’re not artificially constraining their impact by only supporting some of the work they do.

Chip Kahn (18:09):
Obviously CHWs don’t have MD or RN behind their name, yet they operate with the care team. How do they fit into the clinical setting, particularly when we’re talking about patients that are in hospitals or in some kind of procedure diagnostic or procedural situation? How do we get better health outcomes in those situations?

Chidinma Ibe (18:35):
In the projects that I’ve worked on and in the things that I’ve observed in terms of how they work with members of interdisciplinary care teams, part of the function of a community health worker in terms of what they do for patients, is really important when we think about their integration into a healthcare setting. And that’s actually been a challenge, is how to incorporate community health workers into the workflow of a healthcare organization or even into a care team. And I’ve noticed from some of the work that I’ve been a part of is that, the extent to which community health workers do get integrated into care teams, basically that the extent of this integration could have some bearing on their capacity to influence patients’ health. The most successful models I’ve seen are when there’s open communication between all of the care team members. So a care team could comprise a primary care physician, a nurse care manager, a social worker, a pharmacist, perhaps a specialist, and then a community health worker.

And in those types of situations, it’s essential that all of the care team members have a firm understanding of what a community health worker does, what their unique contributions to patient care are, and what their tasks are. And part of that can happen through rounding. Part of it can also happen by granting community health workers access to patients’ medical records, so that they’re able to upload their notes, and really provide some context for a patient’s familial circumstances. So all of these different strategies of building teams within health care settings, and then adding community health workers as a part of those teams, has ramifications for building or cultivating effective treatment plans for patients. And that of course would affect their health care outcomes.

And then in contrast, if community health workers are there and they’re not being well utilized by a member of a care team, patients could potentially miss out on needed services which could affect their health. And so some of the work that I will be doing in the future, is going to be looking at all of these different factors that shape how community health workers become a part of a clinical setting, and what that actually means for patients’ outcomes.

Chip Kahn (21:01):
So you’ve had some experience with this, but what do you think the challenges are to actually scaling the model? Because whatever success you’ve had in Baltimore, this is something frankly we should have every place in every community.

Chidinma Ibe (21:16):
I think the challenges that I’ve had, or the challenges that I’ve seen a lot of really innovative community health worker programs across the country have. The interesting thing about the community health worker model is that, in as much as there’s concern about standardization of the delivery of treatment or of strategies, the tasks that community health workers assume are pretty similar across the board. And it also means that the challenges that we’re seeing in terms of scalability are also pretty common across the board. So I mentioned difficulties integrating community health workers into healthcare settings and clinic workflows, funding is a really big issue. And I also think that we have a number of studies that have demonstrated the effectiveness of community health workers across a range of conditions and contexts. And I think that work is really critical.

I think we need to keep building that evidence-base, and we need to build programs that are based on that evidence that highlights their effectiveness. But I also think at the same time when we start to think about issues of scalability, we need to start broadening the lines of inquiry, and we need to really be asking some slightly different questions. So not just whether or not they work, but under what context are responsible for optimizing their effectiveness. What are some of the characteristics of settings that have successfully used community health workers to reduce or to improve I should say, patients’ outcomes and reduce disparities. What is actually needed to incorporate CHWs into care teams, and what are the barriers and facilitators of that? What are some of the funding streams that are going to make this possible, and how could that impact patients’ outcomes? So alongside colleagues at the Johns Hopkins Evidence-Based Practice Center, I led an ARC-funded report that looked at community health worker certification.

And one of the interesting aspects of certification is something that you alluded to earlier. That community health workers may not have a formal title after their name. They may not have a master’s or an MD. They may not be formally credentialed in institutions of higher learning, but they bring their own lived experiences and that forms the basis of their expertise. When we think about the move toward certification, what we essentially found in our report is that, we don’t really know what role certification plays on patients’ outcomes. And this all plays a role in the ways that we think about scalability. So I think we need more funding. We need more research on some of the factors that underlie the implementation and the infrastructure of community health worker programs. We need to be thinking about what types of supervision structures are needed to support CHWs. And we need to be doing this with community health workers at the forefront of advancing that agenda.

Chip Kahn (24:29):
COVID has exposed so many inequities and amplified so many problems that are already in communities. And it’s also causing us to reevaluate many of the ways we provide care and deal with patients. What have you learned from the COVID experience regarding the role that CHWs can play, in helping patients particularly in this very critical time, when we have this overhang of this pandemic that’s so affecting communities?

Chidinma Ibe (25:06):
Yeah. When I think of the things that I’ve learned about community health workers during this pandemic period in particular. So I think kind of taking a step back, one of the things about COVID-19 is that it’s really forcing us to see what isn’t working in this country and for whom. And we know that there have been rampant disparities in COVID transmission and outcomes among ethnic minority communities, in fact even irrespective of socioeconomic status. So when I think about what I’ve learned for the impact of community health workers during this period, one of the things [inaudible 00:25:50] I personally find exciting is something that’s happening right here in Baltimore City, which is that the city health department and other city leaders are collaborating with stakeholders to hire, train, and then deploy 300 community members to serve as CHWs, and one important function of their role is to actually be a contact tracer.

I think the thing I’m learning about community health workers during this pandemic is that, we actually need to be seeing more of this type of thing happening. Where working with communities to figure out what appropriate strategies are for addressing the disparities that have emerged during this pandemic, all the inequities that have come to light that many of us in the health equity health disparities world have been long aware of. I think of the things community health workers do and how they’re uniquely qualified for such a time as this, given that they tend to address social determinants of health, the very social determinants of health that have been amplified over the past several months.

There was this excellent op-ed that came out a couple of months ago, written by Dr. Shreya Kangovi who leads the Penn Center For Community Health Workers, and Dr. Uché Blackstock. They published this in the Washington Post, and they did a really nice job of situating community health workers within this context of the COVID-19 pandemic. And they essentially argued a lot of what I’m saying right now, which is that, this is really the time to marshal our resources to uplift and amplify this workforce. Because so much of what they do is essential for addressing the kinds of things that we are seeing during this pandemic.

Chip Kahn (27:41):
To move this along and get some progress here and to sort of conclude our discussion, what would you recommend to policy makers particularly at the national level, regarding CHWs. At the community level they can see the role, but at the national level it’s not necessarily always as clear. So what would your recommendations be?

Chidinma Ibe (28:01):
There are two key recommendations. First, that there needs to really be an awareness of community health workers or a framing of community health workers as essential to the solution, whatever the problem is that they are essential to the solution to addressing that problem, especially during this pandemic. The other thing that I think is really critical is we absolutely need to determine funding mechanisms that are sustainable, and that will actually allow the community health worker workforce to grow. We really just need more CHWs. And we need strategies to support them that are sustainable, that are not going to go away when a project ends, or aren’t at the whims of what a funding agency may be able to provide at that particular time. I was really excited to see that in Joe Biden’s caregiving proposal, that he mentioned community health workers and actually advocated for expanding the numbers of CHWs in this country. I think we need more things like that.

Chip Kahn (29:10):
[inaudible 00:29:10] thank you. This was just a wonderful conversation for me. I learned so much. And so appreciate Chidinma all the work that you’re doing. It’s really about changing health and healthcare outcomes, at a level that is so important to people who’ve been left out in the past, and just deeply appreciate admire your work. Thanks so much.

Chidinma Ibe (29:32):
Thank you so much. It was a pleasure being a part of this. So thank you.

Speaker 1 (29:42):
Thanks for listening to Hospitals In Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media at FAHhospitals, and follow Chip at Chip Kahn. Please rate, review, and subscribe to Hospitals In Focus. Join us next time for more in-depth conversations with healthcare leaders.

Dr. Chidinma A. Ibe, Assistant Professor of General Internal Medicine and Health, Behavior and Society at Johns Hopkins University School of Medicine

Dr. Chidinma Ibe is an assistant professor of medicine at the Johns Hopkins University School of Medicine.

She received her B.A. from the University of Pennsylvania and her Ph.D. from the Johns Hopkins Bloomberg School of Public Health.