A Primer on Managed Care: Multiple Chronic Conditions

employers and programs (per in-person inter- view with Celeste Sánchez Lloyd, June 22, 2018). The Washington State experience illustrates the potential for CHW inclusion and sustainabil- ity in chronic disease prevention and manage- ment resulting from the interest of managed care organizations and new structures that empha- size care coordination, and from addressing the social determinants of health. It also reflects, however, the need for due deliberation and ade- quate time for inclusive design processes, partic- ularly efforts to include leadership from a broad spectrum of CHW backgrounds and practice settings. Especially when considering CHW cre- dentialing (certification), the process requires a full airing of aspirations, fears, and preconcep- tions about the nature of certification and its impact, especially among stakeholders who may have limited understanding of the true nature of CHW practice. Healthy Fit represents a large number of grant-funded pilots and demonstrations involv- ing CHWs in management of chronic disease. It clearly illustrates the importance of CHW engagement in designing culturally responsive approaches to prevention and self-management support. Dozens, if not hundreds, of such proj- ects have shown promising results, but either

have not been included in meta-analyses or sys- tematic reviews (sometimes due to study limita- tions, but often because such research projects do not use metrics that are comparable to those in other studies). Further efforts are needed to arrive at common metrics that can facilitate pooling or comparison of research data. Managed care organizations are scrutiniz- ing CHW initiatives such as these with a view to increasing the robustness of community-level prevention, improving continuity and coordi- nation of care, and emphasizing chronic con- ditions, which absorb increasing amounts of healthcare resources. Despite a growing body of evidence nationally, stakeholders at the state and local levels often insist upon seeing localized results from CHW interventions to be assured that these interventions will work in their spe- cific communities. Similarly, workforce develop- ment for CHWs depends on public policies that are adapted to local realities and created with CHWs’ active participation. Carl H. Rush, M.R.P., is principal consultant at Community Resources, LLC, in San Antonio, Texas, and is a research affiliate of the Project on CHW Policy and Practice at the University of Texas-Houston Institute for Health Policy.

References American Association of Diabetes Educators. 2003. “Position State- ment: Diabetes Community Health Workers.” The Diabetes Educator 29(5): 818−24. American Diabetes Association. 2017. “Standards of Medical Care in Diabetes 2017.” Diabetes Care 40(Suppl 1): S1–2. American Public Health Associa- tion. 2018. “Community Health Workers.” Retrieved November 5, 2018.

Association of State and Territorial Health Officers. 2016. “Community Health Worker Certification and Financing.” Issue Brief. tinyurl. com/ydhtjsxh. Retrieved October 13, 2018. Bir, A., et al. 2018. Health Care Innovation Awards (HCIA) Meta- Analysis and Evaluators Collab- orative . Annual Report Year 3. Research Triangle Park, NC: RTI International.

Bodenheimer, T., Chen, E., and Bennett, H. D. 2009. “Confront- ing the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do the Job?” Health Affairs 28(1): 64–74. Brown, L. D., et al. 2018. “Evalua- tion of Healthy Fit: A Community Health Worker Model to Address Hispanic Health Disparities.” Preventing Chronic Disease 15(E49): 1–11.

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