The following highlighted best practices are based upon a literature of recent CHW cost-effectiveness research. The purpose is to draw out CHW program elements that have been found important to success and, where available, to cost-efficacy. It should be noted that the research, particularly in the United States, is only recently emerging. Most of what is available is focused on populations who face health disparities due to racial, ethnic, immigration, and language barriers; often within urban contexts, as opposed to the low-income, rural populations such as comprise a large sector of potential need in Maine.
The literature review drew upon multiple sources. Identification of research articles were conducted through searches of the PubMed database, maintained by the National Library of Medicine. Searches for abstracts used the following key terms:
1) CHWs and the chronic disease topics (limited to last 10 years, and NOT including developing countries).
2) CHWs in general and cost studies (also 10 years, NOT developing countries).
3) Health literacy and cost studies.
Abstracts were reviewed to identify those most closely related to the focus and aims of the four CHWI pilot sites. This includes research on CHWs with relation to asthma, breast cancer screening, and falls prevention and more generally CHWs and older adult chronic disease self-management. Note that there are many terms for CHWs, including Promotores (who typically work within Latino communities), that frequently appear in the literature. The list of sources that speak directly to one of the topics were narrowed down to identify those indicating positive health outcomes associated with CHW interventions. To identify further findings on cost-effectiveness, overview reports of the Centers for Disease Control, MA Department of Public Health, Annual Review of Public Health, and Agency for Healthcare Research and Quality were reviewed.
Relevant research on some of the desired topics was not found; yet it may be emerging. We describe what is currently available, and in some cases describe benefits from similar programs that did not include CHWs but may offer insight into what the benefits of a CHW program may offer (falls prevention, adult asthma). Most of the studies on these health topics that cite positive health outcomes with community health workers do not analyze cost-effectiveness. Some refer to "reasonable costs" without going into detail, or being "more cost-effective" than another referenced approach. Those specifically about cost-effectiveness were largely found to be diabetes and mammography interventions, and also cost-effectiveness of employing CHWs broadly across an entire city (Denver and NYC).
Fifty studies were compiled into a matrix which summarized conclusions and indicated whether each of the selected studies demonstrated health outcomes, cost outcomes, and/or focused on non-English speakers. The matrix was then used in order to pull out those studies that had the most relevant focus and these were reviewed in greater depth in order to compile the following summary findings to reflect upon key areas: a) linking to a primary care provider and b) referrals to services, c) patient self-management, d) appropriate Emergency Department (ED) use, e) patient satisfaction, f) successful CHW integration into care/service teams, g) replicating evidence-based models (EB) with fidelity, and h) elements vital to cost-effectiveness. Further findings specific to CHW services and older adults, asthma, and breast cancer screening are highlighted. Some areas of focus that were hoped to shed light upon were not observed, including details of impacts upon social determinants of health. Also focal areas on 1) patient self-management education specific to older adults and 2) medication reconciliation were not found; however these populations and activities are included within the general research on patient self-management and of medical management. Older adults or seniors were being served by 74% of the CHW programs across New England that were surveyed as part of the ICER review (Institute for Clinical & Economic Review, 2013).
Note that ICER did not find it possible to compare all studies in order to identify precisely which are the key characteristics of CHW interventions associated with positive results. Studies in their review, as in those we examined, simply did not include adequate descriptions of important aspects of CHW interventions. Those characteristics we have noted are simply a listing of what was gleaned from individual studies.
The review pulls key points and findings of interest from the full list of 50 articles reviewed. In some cases direct quotes from the research are used, and in others, key findings are summarized. Findings are bulleted in an attempt to make the review succinct and hone on key points.
