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Community Health Workers and Family Medicine Resident Education: Addressing the Social Determinants of Health
Abstract
Background and objectives:
Neither the health care system nor the training of medical residents focus sufficiently on social determinants of health. Community health workers (CHWs) are a growing presence in health care settings. Culturally and linguistically competent, typically they are from underserved communities and spend more time addressing social determinants of health than others on the health care team. However, CHWs are an infrequent presence in resident clinical training environments. The University of New Mexico Family Medicine Residency placed family medicine residents at a community clinic in Albuquerque managed by CHWs, recognizing that CHWs' collaboration with residents would enhance resident competency in multiple domains. Residents gained skills from CHWs in inter-professional teamwork, cultural proficiency in patient care, effective communication, provision of cost-conscious care, and advocating for both individual and community health. Our model recognizes the value of CHW skills and knowledge and creates a powerful rationale for greater recognition of CHW expertise and integration of CHWs as members of the care team.
... Internationally, there has long been a call for a change in perspective of health-care services to focus on maintaining and promoting community health rather than treating medical needs (Cuff, 2015). A district model of care, with a focus on Primary Health Care (PHC) interventions, is seen as the way to achieve this (McCalmont et al., 2016). Within this, many countries rely on the efficacy and insight of a community-based team or community health workers (CHWs) to connect individuals with needs to health professionals at health-care facilities (Franklin, Bernhardt, Lopez, Long-Middleton, & Davis, 2015;Losby et al., 2015). ...
... CHWs are educated in the essentials of health-care monitoring, many on the basis of a Grade 10 school education, which is the attainment of Level 2 or lower secondary education according to the International Standard Classification of Education (Balcazar, Rosenthal, Brownstein, Rush, & Hernandez, 2011;McCalmont et al., 2016;Nxumalo et al., 2016). The CHWs' role is to spend up to 90% of their time engaging with the community compiling a database of community members. ...
... Although South Africa's resources are limited and human resources are expensive, centralizing the majority of health professions in this way limits their capacity to contribute to the priorities of health promotion and disease prevention and situates them in a curative environment with little knowledge of the challenges and realities of PHC. Interventions aimed to address shortfalls in the current PHC model need to speak not only to medical and disease models, but also to the social determinants of health by targeting the available resources, specifically to the poorest and most vulnerable individuals (McCalmont et al., 2016;Pálsdóttir et al., 2016). In order to achieve this, Chopra et al. (2009) recommended amongst other, investing in the training and employment of mid-level workers and expanding and strengthening CHW programmes. ...
Many countries rely on community health workers (CHWs) at a primary health care (PHC) level to connect individuals with needs to health professionals at health-care facilities, especially in resource-limited environments. The majority of health professionals are centrally based in facilities with little to no interaction with communities or CHWs. Stellenbosch University (South Africa), included interprofessional home visits in collaboration with CHWs as part of students’ contextual PHC exposure in a rural community to identify factors impacting on the health of patients and their families. The aim of this study was to determine the impact of this interprofessional student service-learning initiative on identifying and addressing health-care challenges of households known to CHWs. Active physical, social and attitudinal factors were identified and recorded using a standardized paper case report form. Data were anonymized, captured and categorized for analysis. The frequency and proportion of each type of active problem and referral were calculated. The collaborative team identified many unaddressed health and social issues during their visits. Their exposure to communities at a PHC level offered benefits of experiential learning and provided insight into community needs, as well as offering services to enhance the current health-care system.
... Screening for, and addressing, these needs can have positive effects on parental employment, connection with social resources, reducing homelessness [26] and improved food security [27]. CHWs may be uniquely placed to address SDOH, and prior studies have demonstrated their efficacy in improving, education, income, housing, neighborhood safety, food security, and social inclusion leading to improvements in overall pediatric and adult patient health [28][29][30]. ...
... However, the goals identified by these families are within the scope of a community-based health advocate, such as a CHW. CHWs routinely advocate for program eligibility and assist families with navigating healthcare and social safety net programs and offer help with completing application and enrollment forms [28,39], facilitate connections with behavioral health professionals and social work teams qualified to improve family dynamics, and connect families with peer support resources [40] and networks [41]. However, SDOH screening needs to be implemented to routine diabetes care in order to identify and address the significant challenges faced by these families. ...
Introduction
Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased healthcare utilization. This study aimed to describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals and to determine the correlation between SDOH, glycemic control, and healthcare utilization.
Methods
Caregivers of children aged 4 to 18 years with a diagnosis of T1D >1 year, poor glycemic control (hemoglobin A1c (A1C) ≥ 9.5%) or high healthcare utilization (≥2 diabetes-related hospitalizations, emergency department attendances, or missed outpatient appointments in the prior year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (MSED), and SDOH were assessed. Goals were identified following assessment by a community health worker.
Results
Fifty-three families were included; and most (n=48, 91%) had government insurance. Children had a median (IQR) age of 13.4 (12, 15.3) and median (IQR) A1C of 11.1 (10, 13) %. Almost half of the families (n=24, 45%) reported ≥1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [38.5, 70.7] vs. 77.8 [60.8, 92.4], p=0.004), but not associated with A1C (p=0.3), ED visits (p=0.9), or MSED (p=0.5).
Discussion
Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high healthcare utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population
... Past research also reported that SDH screening adoption may be fostered through champion-driven activities such as trainings, interprofessional interaction, formal and informal conversations about the value of SDH screenings, and communicating leadership support for SDH screening. 27,28 This aligns with findings from a systematic review of the role of champions in supporting practice change, in which typical champion responsibilities include advocating for the initiative, developing materials for the intervention, serving as a stakeholder contact, and troubleshooting problems. 29 As an SDH proponent can generate enthusiasm and motivation for conducting SDH IMPLEMENTING SDH DATA COLLECTION 5 screenings, CHCs could consider supporting such advocates. ...
... This research identified several facilitators previously reported to support adoption of systematic, EHR-based SDH screening in CHCs 28,31 ; these facilitators align with the implementation science literature on factors that can support clinics' adoption of new practices. This study also offers 3 unique contributions that build on this knowledge base. ...
Successfully incorporating social determinants of health (SDH) screening into clinic workflows can help care teams provide targeted care, appropriate referrals, and other interventions to address patients' social risk factors. However, integrating SDH screening into clinical routines is known to be challenging. To achieve widespread adoption of SDH screening, we need to better understand the factors that can facilitate or hinder implementation of effective, sustainable SDH processes. The authors interviewed 43 health care staff and professionals at 8 safety net community health center (CHC) organizations in 5 states across the United States; these CHCs had adopted electronic health record (EHR)-based SDH screening without any external implementation support. Interviewees included staff in administrative, quality improvement, informatics, front desk, and clinical roles (providers, nurses, behavioral health staff), and community health workers. Interviews focused on how each organization integrated EHR-based SDH screening into clinic workflows, and factors that affected adoption of this practice change. Factors that facilitated effective integration of EHR-based SDH screening were: (1) external incentives and motivators that prompted introduction of this screening (eg, grant requirements, encouragement from professional associations); (2) presence of an SDH screening advocate; and (3) maintaining flexibility with regard to workflow approaches to optimally align them with clinic needs, interests, and resources. Results suggest that it is possible to purposefully create an environment conducive to successfully implementing EHR-based SDH screening. Approaching the task of implementing SDH screening into clinic workflows as understanding the interplay of context-dependent factors, rather than following a step-by-step process, may be critical to success in primary care settings.
... 1,9,13 Many health systems are already taking steps to collect these SDH through a combination of strategies such as collecting data directly from patients, using publicly available data, or using geographic information systems to assign census-based variables. [14][15][16][17][18][19][20][21] Early views on this transformation reveal that common concerns include the privacy and ethical considerations 22 linked to possessing social risk data with limited health system infrastructure and psychosocial skills [22][23][24] to address them. An unintended consequence of such a setup could be the erosion of the patient-physician relationship. ...
... Others have reported strategies to mitigate logistical barriers associated with collecting SDH. These include: utilizing computer-based self-completed questionnaires, which are cost and resource effective 14,23 ; the use of community health workers to screen patients, because they have established relationships and trust with patients 17,18 ; providing physicians with SDH tool kits 20,33 ; and changing the EHR format and diagnoses codes to diminish provider burden. 28,34 Health systems can empower providers with resources to address SDH by making sure that there are established referrals and resource information that physicians can give. ...
Social determinants of health (SDH) impact health outcomes. Medical centers have begun to collect SDH data, urged by government and scientific entities. Provider perspectives on collecting SDH are unknown. The aim is to understand differences in views and preferences according to provider characteristics. A cross-sectional survey of University of Miami clinical faculty was conducted in late 2016. The survey contained 11 questions: 8 demographic and departmental responsibilities questions and 3 Likert scale questions to capture collection and use of SDH perspectives. The main outcome was whether providers thought the benefit of collecting SDH outweighs the burden and risks. In all, 240 faculty members were included. The majority were men (64%), with a mean age of 51 years. Among participants, 53.5% were non-Hispanic white, 32% were Hispanic, 5% were Black/African American, and 5% were Asian. The majority agreed that SDH are important predictors of health outcomes and quality of care (83%). When comparing minority to nonminority faculty, 25% believed that SDH should only be available to PCPs, compared to 8% of nonminorities (P < 0.01). In a multivariate model, belonging to a racial ethnic minority was the only characteristic associated with believing that benefits of collecting SDH outweigh the risks (odds ratio 1.87, 95% confidence interval 1.02- 3.5) after adjusting for age, sex, minority status, health care provider type, type of responsibilities, and department. This study reveals that although most providers of a health system believe social risks impact health outcomes and quality metrics, the buy-in to collect SDH varies according to the racial/ethnic composition of the faculty.
... For example, community health workers have been shown to be effective trainers of social determinants to family medicine residents. 30 Health extension agents have made a major contribution in linking community health needs with university resources in education, service and research. 14 Social scientists have played a central role in training physicians to be accountable to their communities and to ensuring that residency programs are outward facing and responsive to community needs. ...
Because graduate medical education (GME) is largely publicly funded, it should be judged on how well it addresses the public’s health needs. However, the current system distributes GME resources inequitably by specialty and geography, and neglects to focus on training physicians adequately in the care of populations while reducing health disparities. Instead, GME continues to concentrate training in hospital-based academic centers and in subspecialties, which often exacerbates disparities in health outcomes and access to care. GME can be more socially accountable by shifting incentive structures to support primary care, creating more equitable distribution of residency slots and funding, and promoting training programs that focus on social and structural determinants of health.
... Improving people's access to primary health care and prevention services, in the long term, can reduce the burden of diseases and reduce the need for hospitalization [12,13]. Improving people's access to services via the implementation of FPP is a findings that have been cited by many researchers [14][15][16]. The launch of this project in Iran has helped to increase people's access to primary health care, especially in rural areas [17]. ...
Background:
Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.
Methods:
This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.
Results:
FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.
Conclusions:
FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people's access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.
... Improving people's access to primary health care and prevention services, in the long term, can reduce the burden of diseases and reduce the need for hospitalization (12,13). Improving people's access to services via the implementation of FPP is a findings that have been cited by many researchers (14)(15)(16). The launch of this project in Iran has helped to increase people's access to primary health care, especially in rural areas (17). ...
Background: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services. Methods: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms. Results: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods. Conclusions: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.
... Improving people's access to primary health care and prevention services, in the long term, can reduce the burden of diseases and reduce the need for hospitalization (12,13). Improving people's access to services via the implementation of FPP is a ndings that have been cited by many researchers (14)(15)(16). The launch of this project in Iran has helped to increase people's access to primary health care, especially in rural areas (17). ...
Background: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.
Methods: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.
Results: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in the short term, but in an increase in costs in the long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.
Conclusions: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policy makers must adopt an agenda to revise and re-design the plan.
... Improving people's access to primary health care and prevention services, in the long term, can reduce the burden of diseases and reduce the need for hospitalization (12,13). Improving people's access to services via the implementation of FPP is a findings that have been cited by many researchers (14)(15)(16). The launch of this project in Iran has helped to increase people's access to primary health care, especially in rural areas (17). ...
Background: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.
Methods: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.
Results: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.
Conclusions: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.
... Appointing CHWs to focus on enhancing social support could help address SDoH-related barriers to T2DM self-management. This notion is supported by J. Freeman (2016) and McCalmont et al. (2016) who advocate for CHWs to work as part of the clinical team to address SDoH-related issues. ...
Type 2 diabetes (T2DM) is increasing in global prevalence. It is more common among people with poor social determinants of health (SDoH). Social determinants of health are typically considered at a population and community level; however, identifying and addressing the barriers related to SDoH at an individual and clinical level, could improve the self-management of T2DM. This literature review aimed to explore the methods and strategies used in clinical settings to identify and address the SDoH in individuals with T2DM. A systematic search of peer-reviewed literature using the electronic databases MEDLINE, CINAHL, Scopus and Informit was conducted between April and May 2017. Literature published between 2002 and 2017 was considered. Search results (n = 1,119) were screened by title and abstract against the inclusion and exclusion criteria and n = 56 were retained for full text screening. Nine studies met the inclusion criteria. Review and synthesis of the literature revealed written and phone surveys were the most commonly used strategy to identify social determinant-related barriers to self-management. Commonly known SDoH such as; income, employment, education, housing and social support were incorporated into the SDoH assessments. Limited strategies to address the identified social needs were revealed, however community health workers within the clinical team were the primary providers of social support. The review highlights the importance of identifying current and individually relevant social determinant-related issues, and whether they are perceived as barriers to T2DM self-management. Identifying self-management barriers related to SDoH, and addressing these issues in clinical settings, could enable a more targeted intervention based on individually identified social need. Future research should investigate more specific ways to incorporate SDoH into the clinical management of T2DM.
... A recent effort in New Mexico required managed care organizations serving Medicaid enrollees to integrate CHWs into the primary care setting to address the needs of high utilizers. 23,24 In this initiative, patients completed an initial screening designed by CHWs that assessed 11 common social determinants of health. In the initial screening of more than 3000 patients, the majority reported at least 1 adverse social determinant of health, and many reported more than 1. ...
Limited access to care can negatively affect population health, which is particularly concerning for individuals of lower socioeconomic status. Shortages of US health care providers in areas that predominantly serve Medicaid enrollees contribute to a lack of access. The Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative was designed as a workforce development initiative to train and deploy community health workers (CHWs). The authors conducted 55 key informant interviews with preceptors, CHWs, and administrators across 5 sites with the specific aim of improving understanding of common barriers to and benefits of CHW program implementation across different CHW programs in Ohio. CHW programs reportedly act as a bridge between the patient and providers, and program benefits were reported for participants, organizations, and patients. This study found that CHW programs enabled training of health professionals that can empower participants while allowing them to also give back to their communities. Organizations employing CHWs reported being able to extend clinic services, increase utilization of community resources, and improve patient compliance through the efforts of CHWs; program impacts also led to increased patient support, patient education, and overall better care. To better integrate CHWs into health care organizations, organizations should focus on clearly defining the CHW role and ensuring adequate infrastructure to support CHW efforts.
... Residents learned practical skills for engaging patients in discussions that would not normally surface during clinic visits. 8 Primary care physicians were initially skeptical about the value of the pilot to patient care, but residents who took part in the pilot became its strongest advocates, teaching attending physicians who were not participating in the pilot about the importance of screening for social needs. At 1 site, 7 providers who were not involved in the WellRx pilot were so impressed by what the residents had been teaching them that they decided to start using WellRx as their diabetes control quality improvement project, and they began referring appropriate patients in this select population to CHWs for action on social needs. ...
Although it is known that the social determinants of health have a larger influence on health outcomes than health care, there currently is no structured way for primary care providers to identify and address nonmedical social needs experienced by patients seen in a clinic setting. We developed and piloted WellRx, an 11-question instrument used to screen 3048 patients for social determinants in 3 family medicine clinics over a 90-day period. Results showed that 46% of patients screened positive for at least 1 area of social need, and 63% of those had multiple needs. Most of these needs were previously unknown to the clinicians. Medical assistants and community health workers then offered to connect patients with appropriate services and resources to address the identified needs. The WellRx pilot demonstrated that it is feasible for a clinic to implement such an assessment system, that the assessment can reveal important information, and that having information about patients social needs improves provider ease of practice. Demonstrated feasibility and favorable outcomes led to institutionalization of the WellRx process at a university teaching hospital and influenced the state department of health to require managed care organizations to have community health workers available to care for Medicaid patients. ( J Am Board Fam Med 2016;29: 414 - 418.).
... In New Mexico, family medicine residents work in community clinics staffed by local community health workers. 8 There, residents' education is enhanced by inter-professional teamwork, cultural proficiency, effective communication, provision of costconscious care, and advocating both for individual and community. ...
Of all ethnic groups in New Mexico, Native Americans have some of the best screening and treatment for diabetes, yet have by far the worst outcomes from that disease—kidney failure, amputations, blindness. High-quality care cannot adequately compensate for decades of low income, low educational achievement, poor nutrition, poor housing, and social marginalization—all social determinants of health (SDH). With appropriate transformation, primary care practices are well-suited to address SDH.
Objective
Advocacy has been identified as a core element within the practice of medicine and thus a key component to medical education. However, there are challenges regarding teaching and evaluation of advocacy within medical education. Community-based service learning (CBSL) has emerged as a valuable educational tool to foster knowledge and skills related to advocacy. CBSL is particularly relevant to psychiatry, given the extent of engagement with underserved communities and opportunities to advance learning in these environments. A scoping review was conducted to identify current educational strategies and outcomes related to advocacy training among medical learners in the context of CBSL.Methods
Between July and October 2019, the authors searched PsycINFO, MEDLINE, Embase, ERIC, Web of Science, Scopus, and ProQuest for English language literature with no date limits and retrieved 2,813 articles and abstracts; 68 were included in this review. Two reviewers independently screened articles and extracted data. Data were then charted, analyzed, and discussed with the research team.ResultsSeven key themes related to approaches to advocacy education were identified: (1) type of community partner; (2) populations served; (3) program participants; (4) program structure; (5) evaluation of learner outcomes; (6) sustainability; and (7) challenges and limitations.Conclusions
This scoping review provides insights into the variety of CBSL-based advocacy program formats and evaluation methods, which is of particular importance to psychiatry. There is heterogeneity in the methodology by which CBSL is implemented and how outcomes are measured. A list of recommendations for future areas of inquiry is provided.
Background: Family physician program (FPP) and health transformation plan (HTP) are two major reforms that have been implemented in Iran's health system in recent. The present study was aimed at evaluating the impact of these two reforms on the level of service utilization and cost of health care services.
Methods: This longitudinal study was conducted on people insured by social security organization in Fars province during 2009-2016. The data on the utilization of services and costs of general practitioner visits, specialist visits, medications, imaging, laboratory tests, and hospitalization were collected. Interrupted time series analysis was used to analyze the effect of the two mentioned reforms.
Results: FPP resulted in a significant reduction in the number of specialist visits, imaging, and laboratory tests in the short term, and in the number of radiology services, laboratory tests, and hospitalization in the long term. In contrast, HTP significantly increased the utilization of radiology services and laboratory tests both in the short term and long term. Concerning the costs, FPP resulted in a reduction in costs in short and long term except general practitioners' and specialist visit, and medication in long term. However, HTP resulted in an increase in health care costs in both of the studied time periods.
Conclusions: FPP has been successful in rationalizing the utilization of services. On the other hand, HTP has improved people’s access to services by increasing the utilization; but it has increased health care costs. Therefore, policymakers must adopt an agenda to revise and re-design the plan.
Executive summary:
A growing literature regarding the health consequences of social risks, such as substandard housing and food insecurity, combined with increased adoption of risk-based payment models have contributed to a wave of healthcare sector initiatives focused on the social determinants of health. Yet decisions about how and when to address adverse social conditions are frequently guided by limited information about potential interventions and a lack of data on their effectiveness. We describe four complementary strategies that healthcare leaders can pursue to intervene on social adversity, split between patient care and community-level approaches. Patient care strategies rely on data about patients' social risks to adapt medical care or improve patients' social circumstances directly. Community-level strategies focus on improving the broader health and well-being of the local population through a mix of direct investments in communities and collaboration through multisector partnerships. Each approach presents unique incentives and challenges, and healthcare systems wanting to address social adversity may adopt one or more. Understanding the range of potential choices may help healthcare leaders make more informed choices in response to patient needs and changing payment and policy initiatives.
Inspired by the Affordable Care Act and health care payment models that reward value over volume, health care delivery systems are redefining the work of the health professionals they employ. Existing workers are taking on new roles, new types of health professionals are emerging, and the health workforce is shifting from practicing in higher-cost acute settings to lower-cost community settings, including patients' homes. The authors believe that although the pace of health system transformation has accelerated, a shortage of workers trained to function in the new models of care is hampering progress. In this Perspective, they argue that urgent attention must be paid to retraining the 18 million workers already employed in the system who will actually implement system change.Their view is shaped by work they have conducted in helping practices transform care, by extensive consultations with stakeholders attempting to understand the workforce implications of health system redesign, and by a thorough review of the peer-reviewed and gray literature. Through this work, the authors have become increasingly convinced that academic health centers (AHCs)-organizations at the forefront of innovations in health care delivery and health workforce training-are uniquely situated to proactively lead efforts to retrain the existing workforce. They recommend a set of specific actions (i.e., discovering and disseminating best practices; developing new partnerships; focusing on systems engineering approaches; planning for sustainability; and revising credentialing, accreditation, and continuing education) that AHC leaders can undertake to develop a more coherent workforce development strategy that supports practice transformation.
INTRODUCTION
The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice.
AIM
We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs?
PROGRAM DESCRIPTION
The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, ‘medical home builder’ tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs).
RESULTS
The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs.
DISCUSSION
The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
The gross inequalities in health that we see within and between countries present a challenge to the world. That there should be a spread of life expectancy of 48 years among countries and 20 years or more within countries is not inevitable. A burgeoning volume of research identifies social factors at the root of much of these inequalities in health. Social determinants are relevant to communicable and non-communicable disease alike. Health status, therefore, should be of concern to policy makers in every sector, not solely those involved in health policy. As a response to this global challenge, WHO is launching a Commission on Social Determinants of Health, which will review the evidence, raise societal debate, and recommend policies with the goal of improving health of the world's most vulnerable people. A major thrust of the Commission is turning public-health knowledge into political action.
In the 117th Shattuck Lecture, Dr. Steven Schroeder asks why the American system fails to deliver a standard of health similar to that observed in many other countries. In his arguments, he focuses on the public health risks of smoking and obesity and how they have been managed.