"Putting the 'Care' in our Health Care System"

 By Ashley Thompson

When most people think of health care reform and legislature in the United States, the most common words that come to mind might be “medical,” “doctor,” or “nurse.” News concerning the work of these medical professionals can be frequently seen in headlines across the country when discussing this increasingly heated topic. However, it's much rarer to see the words, “Community Health Worker” on the front page of any newspaper or even above a smaller side column. Nonetheless, recent strides made by these men and women have taken them from discussing medical information with members of their neighborhoods to joining the conversation on health care reform.
 

The role of a Community Health Worker (CHW) is not to be confused with the role of other medical professionals such as doctors or nurses.

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“Over the years, we've developed the definition and it's based on a lot of qualitative and quantitative research we've done to actually describe the scope or the role of CHWs and what sets them apart from other professionals,” says Gail Hirsche, the Director of the Office of Community Health Workers in Boston. “What sets them apart is because they are hired primarily for their unique understanding or experience with the populations that they serve.” Hirsche first became affiliated with the CHW profession when it emerged in the 1990s as a response to the then recent infant mortality disparities and the continuing HIV/AIDS epidemic in the United States. “Basically, people in multiple venues came to me and said 'We are undervalued, undertrained, and under supported.'” Hirsche went on to become a founding member of the Massachusetts Association of Community Health Workers (MACHW), a statewide network of CHWs from all disciplines carrying the mission of strengthening their professional identity and fostering leadership among one another.
 

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Another primary goal of MACHW is to promote the integration of CHWs into the health care and public health workforce and in September 2010, the MACHW fulfilled part of that mission. It was then that Massachusetts Governor Deval Parick signed into law, "An Act to Establish a Board of Certification of Community Health Workers" (Chapter 322 of the Acts of 2010). This law, which went into effect in January of last year, created a new board of certification for CHWs to function under the protection of the state’s Department of Public Health's Division of Health Professions Licensure. Although the signing and initiation of this law was a great milestone for MACHW, there are some who don't believe that the law has created a lot of significant change for CHWs in Massachusetts.

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“At this point, it hasn't had an impact on the CHWs living and working in Massachusetts,” replied Lorenza Holt, a board member of MACHW and executive director of the Boston Association for Childbirth Education & Nursing Mothers' Council (BACE-NMC). Holt, who now works to promote comprehensive childbirth education at BACE-NMC, was a part of MACHW while the 2010 law was being considered and described the battle in making sure that the legislation included certification for all CHWs in Massachusetts no matter the extent of their educational backgrounds.

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“We wanted certification to be in the spirit of including as broad a group of CHWs as possible. We wanted to embrace people of different cultural and linguistic backgrounds, and a variety of educational backgrounds. You don't need a master's degree or to be highly educated in English to be a good CHW.”
 

The importance of certification for CHWs was brought up in the 2010 law and has more recently been discussed in the Massachusetts State House's Nurses Hall. Every year, MACHW organizes a day for CHWs to gather in the Hall and call on the state to recognize their value to the state's medical infrastructure. The speakers of this annual day highlight the cost effectiveness of integrating CHWs into routine medical care and the important role that CHWs could play in eliminating barriers to that care.

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Although certification for CHWs hasn't dramatically changed the landscape of health care in Massachusetts during the past year, some, including Hirsche, have credited it with laying down the foundation for a greater identity of CHWs by bringing a wide array of partners to the table.

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“We're convening people that we have never reached before and the fact that we now have certification on the books helps to further our mission of integrating CHWs within health care reform. Certification has highlighted the work of CHWs and we're hoping that CHWs will be a part of the changing models of payment for health care.”
 

A significant stride for national health care reform also took place in 2010 with the introduction of the Affordable Care Act (ACA) which aims to reduce the social and financial costs of chronic diseases and eliminate racial and ethnic disparities. While this act has been discussed in relation to the 2006 Massachusetts health reform law, it has failed to bring to light the role that CHWs have to play in Massachusetts health reform.

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“We are always the cultural gap between the community and the health care system,” says Niem Nay-Kret, a board member of MACHW. “In my work, I meet a lot of patients from the community who are looking for help and seeking social and health services. A lot of them have a hard time understanding the health insurance plans or are trying to become eligible for one. But, you have to know what you're looking for and if you're not English-speaking then it is very difficult.” Nay-Kret currently works at Lowell Community Health Center and is used to assisting members of the Hispanic community where English is not always a person's first language. “A lot of the time, you are in the community and have the conceptual knowledge of the culture of your community and this allows for your community to come to you.”
 

Holt, a fellow board member of MACHW, also described what she feels is the importance of CHWs to the communities that they service.

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“I think of CHWs as a bridge between an individual and the health care system, between the home and the hospital, between one language and another, between a cultural belief and the culture of health care.” Holt went on to discuss how a CHW can help anybody engaging in our sometimes complicated health care system whether they are a newborn in the Intensive Care Unit or a person with diabetes. Although CHWs do not provide health care, Holt says that they can help communicate with the individual and the medical team that is supposed to be taking care of them in a city brimming with cultural diversity.  “Health care really has its own culture which can come across as domineering. For that individual looking at the health care system, it can be an intimidating and daunting process.” She also described a more dismal situation involving her highly educated and English-speaking neighbor who was recently diagnosed with cancer. “It's daunting for her. Imagine being an immigrant from another country and you don't speak the language. By understanding what the patient needs, a CHW can be the difference between good communication and no communication at all.”
 

Although MACHW has made strides in recent times, including the signing of the law by Gov. Deval Patrick in 2010, Hirsche believes that they still have a ways to go when it comes to their involvement in health care reform. “We're not done. This is just the beginning. We need everyone who's involved in health care to understand that this is a unique profession and how we can help to address the needs of populations that usually just fall through the cracks.”