A Primer on Managed Care: Multiple Chronic Conditions

More recently, in a series of systematic reviews (2015–2017), the Centers for Disease Control and Prevention (CDC) Community Pre- ventive Services Task Force (CPSTF) recom- mended “interventions that engage community health workers” for cost-effective prevention and management of diabetes and cardiovascular dis- ease (CDC/CPSTF, 2015, 2016, 2017). And beginning in 2017, the American Dia- betes Association (ADA), under the heading “Tailoring Treatment To Reduce Disparities,” recommended that “patients should be provided CHWs should teach diabetes educators and other healthcare team members about community needs. with self-management support from . . . commu- nity health workers when available. . . . There is growing evidence for the role of community health workers . . . in providing ongoing support” (ADA, 2017). CHWs’ contributions, challenges in managing chronic disease Even with the best available clinical care, suc- cessful chronic disease management depends upon patient engagement, adherence to treat- ment and self-care regimens, and recognition of the social determinants of health. CHWs have proven adept at addressing these areas through peer relationships based on shared life experi­ ence (Gustafson, Atkins, and Rusch, 2018). CHWs successfully assist individuals in setting goals and provide social support to help maintain their self-care plans (Kangovi et al., 2017). In chronic disease management, as in other domains, CHWs can contribute significantly to control- ling care costs, as was recently concluded in the Center for Medicare and Medicaid Innovation’s Health Care Innovation Awards program (Bir et al., 2018). Despite the appeal of CHWs, these work- ers are not widely accepted in the mainstream

of public health and healthcare due to uncer- tainties of state and federal policy and a lack of general understanding about the nature of this workforce. As of this writing, only ten states had formal standards and definitions of CHW practice and skill requirements, as codi- fied in programs of voluntary certification of CHWs (National Academy for State Health Pol- icy [NASHP], 2018). Most CHW employment is still financed through short-term grants and contracts, although some states have included CHWs in Medicaid transformation through mechanisms such as Medicaid Section 1115 waivers and Health Homes State Plan Amend- ments (Association of State and Territorial Health Officers, 2016; NASHP, 2018). Profiled below are three leading CHW initiatives related to chronic disease: the first is an ongoing effort in a regional healthcare provider system; the second is part of a statewide demonstra- tion of Accountable Health Communities; and the third is part of a culturally specific research project (each description is based on a summary of the cited reference). Spectrum Health, Grand Rapids, Michigan Spectrum Health (Larson, 2016), a nonprofit healthcare system, has employed CHWs for “many years,” including Healthy Start services under contract with the state health depart- ment, but over the past five years, Spectrum has ramped up efforts to document CHW impact on chronic disease. Spectrum’s CHWs cover a broad territory from their Grand Rapids, Michigan, base, following up on hospital discharges, moni- toring indicators such as blood glucose, or offer- ing self-management education. Spectrum’s Core Health program began in Grand Rapids hospitals and is now sustained with an annual operating fund, and is working to improve access and connect low-income and at- risk patients to community resources. Three Promising Innovations in CHW Integration

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