Consulting Associate Allgood and Noonan Submit Hillman Scholars Nursing Innovation Application

Kudos to Sally Allgood, consulting associate, and her mentor Devon Noonan, associate professor, and her entire team for the submission of her Hillman Scholars Program in Nursing Innovation application entitled "Developing Community Healthworker Innovation Toolkit." This proposal requests funding for a one-year period with a start date of July 1, 2020.

Chronic diseases (e.g., heart disease, diabetes, cancer) are the leading cause of morbidity and mortality in the U.S., accounting for about 75% of health care spending. Nearly half of U.S. adults (45%) carry a diagnosis of at least one chronic disease, with 25% having two or more. The prevalence and societal burden of chronic disease is expected to increase, thus increasing the demand for chronic disease prevention and control in primary care settings. While demand for primary care is increasing, there is also a shift in the way primary care is delivered. This shift is due, in part, to a move away from fee-for-service reimbursement models and towards value-based care as well as a recognition of primary care’s role in addressing non-medical causes of disease (i.e., social drivers of health like food and housing insecurity). While effective chronic disease prevention, screening, and management in a primary care setting is fundamental to controlling healthcare costs, improving quality of life, and reducing morbidity and mortality, this work cannot be done by providers alone.

Across the population, chronic disease burden is not uniformly distributed. Disparities in disease incidence, severity, and outcomes exist by race, ethnicity, socioeconomic status, and rurality, with Blacks, Latinx, low-SES, and rural populations experiencing greater disease burden than Whites, non-Latinx, high-SES, and urban populations. One way to address these disparities is the addition of community health workers (CHWs) in primary care setting. Evidence suggests that CHWs are effective at improving outcomes for a number of chronic diseases (e.g., cardiovascular disease, diabetes), particularly to these populations who have traditionally been underserved. CHWs are lay health workers who are “a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community” (APHA, 2009). CHWs provide a wide range of services including care coordination, health education, direct services, and cultural mediation. However, in practice, the effectiveness of CHWs is mixed due in part to CHWs not being effectively deployed in primary care settings. Reasons why the CHW workforce is not effectively employed include, (1) excitement for the potential of the CHW workforce has led to CHWs being deployed into settings that are inadequately prepared, (2) few resources exist to guide primary care clinics how to take advantage of the unique skills of CHWs, and (3) inexperience of other members of the primary care team in working with CHWs.

Across North Carolina (NC), there has been mounting interest in CHWs as valuable additions to the workforce. In response to this interest, the NC Department of Health and Human Services convened stakeholders in 2015, including the applicant Dr. Allgood, to devise a plan for recognizing the CHW workforce. In 2018, the NC Community Health Worker Initiative released recommendations for CHW training standards and certification requirements (NCDHHS, 2018). Currently, six community colleges, enrolling a total of 67 trainees, are piloting a standardized CHW training program in NC and we anticipate the training will be available across all NC Community College in Spring 2021. As the number of trained CHWs increases in NC, stakeholders recognize the need for effective deployment of CHWs, particularly as CHWs programs are implemented in primary care as a way to reduce health disparities and improve quality of care.

Therefore, I will take advantage of the increased interest and supply of the CHW workforce across the state and partner with Tish Singletary, the state CHW Program Coordinator in the NC Office of Rural Health, to develop a CHW integration tool kit to improve CHW deployment into primary care settings, particularly in low resource practices serving a high percentage of underserved patients (e.g., minorities, low-SES). To accomplish this, we will fill gaps in the existing evidence by conducting in-depth interviews and surveys understand how CHWs were integrated into primary care settings across the state.

Aim 1. Explore how CHWs are integrated into primary care settings serving adults across NC. This will be accomplished through interviews and surveys with members of primary care settings (3-6 members in up to 10 practices) where CHWs have been integrated into the workflow. 

Aim 2. Develop a tool kit for integrating CHWs into primary care settings. This will be accomplished by using existing evidence along with findings from Aim 1 to develop a draft. The draft will be presented in several community listening sessions for feedback and further refinement before being disseminated.

Long-term outcomes from the proposed study include CHWs being successfully deployed in primary care settings, therefore improving outcomes for populations traditionally underserved by health care. This study will also lay the groundwork for a program of research to reduce chronic disease morbidity and mortality through deployment of CHWs in primary care settings.