It can take an hour to get to an urgent care facility in parts of Kentucky. Some of the Commonwealth’s 120 counties are without a clinic or hospital and families need to drive narrow country roads to receive healthcare.
For most Kentuckians, there is just 1 primary care provider for every 1,000 people, well below the national average of 2.6 providers for every 1,000 people. But in some counties across the Commonwealth, that number drops to 1 for every 10,000 residents. That means that it can be months before a patient can see a provider and many must leave the county to see a specialist. Providers who work in overburdened systems often have just minutes to see each patient, reducing the quality of care the patient receives, and rarely making a strong connection with patients. Patients in these situations may find themselves with unaddressed health concerns, resulting in reduced compliance to medical advice, and lower quality of life. These challenges have led Kentucky residents to suffer needlessly from treatable chronic illnesses like diabetes, hypertension, depression, and heart disease.
Community health workers (CHW) are a rapidly growing population of “trusted messengers.” CHWs are most often not medical professionals, but instead are community members who function as the link between the people they serve and the web of social service and healthcare systems and services that are available but often overwhelming or logistically inaccessible. In Kentucky, CHWs have been active for years, and we have some of the strongest regional concentrations of CHWs in the country. Recent efforts through the Kentucky Association of Community Health Workers (KYACHW) is allowing our CHW workforce to develop the necessary infrastructure via the Office of Community Health Workers within the Kentucky Department for Public Health (DPH) to certify our CHWs. Established in 2016, the CHW program offers a certificate to Kentucky residents with 2,500 hours of practical experience over three years or educational requirements for those seeking work in the profession without previous experience. This is a critical and necessary step on the path to making CHW services Medicaid reimbursable. Additionally, the Kentucky Department of Health Chronic Disease Prevention Branch recently opened the Office of Community Health Workers.
To better address our state’s health challenges, Kentucky policymakers should adopt HB 525, in order to effectively equip our communities’ trusted messengers so they can more efficiently tackle the everyday obstacles Kentuckians’ face in accessing the care they need. Until the Senate adopts the state option to reimburse CHWs through Medicaid, more Kentuckians are at risk for poorer health outcomes that could otherwise be mitigated and even prevented.
CHWs Positively Impact Health
CHWs are critical in increasing health literacy in the communities where they live and work. CHWs can increase community capacity through outreach, offering community members informal counseling and trusted advice. In regions with few providers, clinical staff may not be able to take as much time with each patient as they would like, so patients may leave the clinic with more questions than answers after a new diagnosis or receiving confusing lab results. CHWs can bridge the gap, increasing health knowledge. In a guide on best practices for integrating CHWs into a clinical care team, the CDC asserts that CHWs improve patient knowledge about diagnosis and improve adherence to treatment and care.
As healthcare systems face staffing shortages nationwide, CHWs can help organizations address those shortages, improve patient outcomes, and address inequities of care. The COVID pandemic has led to greater numbers of providers using telehealth, but many in the US have been unable to access telehealth care due to limited access to broadband internet. As a result, the CDC found that during the summer of 2020, during a surge in cases of COVID infection, over 40% of those responding to the Household Pulse Survey had unmet healthcare needs. While the number dropped to about 15% during the summer of 2021, CHWs can offer a path to quality care. CHWs can offer guidance on when to go to an emergency department instead of a primary care provider, suggest ways to address chronic illness, or provide insight into which preventive care services must be addressed soon.
These protections are enforced in the No Surprises Act by creating a consumer right to a new patient-pIn the fight against COVID, the National Association of Community Health Workers (NACHW) has mobilized CHWs across the US to support local departments of public health and created community specific vaccine resources to address concerns some have about the safety and efficacy of the FDA approved COVID vaccines. NACHW has called on local CHWs to address the racial and social inequities of the pandemic, urging them to use their trusted status within their community to strengthen the local public health response to the COVID pandemic. In schools, studies show that CHWs support school nurses fighting the impact of COVID and have been shown to be effective at increasing understanding about the importance of vaccination on college campuses.
CHWs Can Slow the Spread of Misinformation
As of March 14, 2022, we have lost 14,380 lives to COVID-19 in Kentucky. And many of the more than 1,286,697 known cases will have long term health consequences we are just learning about. CHWs working within their own communities have counseled peers and neighbors about healthy behaviors that can reduce the spread of COVID. CHWs are also trusted messengers who can relay important health behavior information in a culturally appropriate way to their community, decreasing the impact of bad information that proliferates on social media. During the course of the COVID-19 pandemic, CHWs have become contact tracers and allies to their communities which may be struggling with the impacts of the virus. In communities with few trusted healthcare providers, CHWs are able to share evidence-based information about the safety and efficacy of the COVID vaccines, treatment, and prevention methods. For Kentuckians who must wait months to see specialists, CHWs can help patients who may be too ill to effectively manage their own care as they make the long journey back to health after weeks or months in the ICU. For Kentuckians who fall prey to healthcare myths or misinformation spreading through the community, CHWs offer judgment-free answers to questions about care, prevention, and more.
Kentucky CHWs Save Money
In Kentucky, CHWs have addressed inequitable distribution of primary care providers between urban and rural areas. In underserved areas, limited access to preventive care can lead to poorer health outcomes; missing treatment for chronic health conditions and difficulties adhering to medication regimens leads to a worsening of symptoms. This often leads to seeking care in emergency departments, where the cost of care is high. With CHWs, Kentuckians can seek lower cost care at health clinics or primary care offices.
One model that has been shown to be effective is the Kentucky Homeplace. Since 1994, Kentucky Homeplace has offered residents of rural Kentucky access to CHWs to help address the high levels of chronic disease, increase health literacy, and assistance with navigating the complex system of healthcare and health insurance. CHW services are free for consumers in 30 Appalachian counties. Between 2001 and 2019 over 166,000 Kentuckians received services and the return on investment was huge: for every $1 invested, $11.34 was saved. In 2020, Kentucky Homeplace reduced emergency room visits by 10%, non-emergency ER visits by 13%, inpatient admissions by 23%, and the number of days in the hospital by 27%. One of the ways that Kentucky Homeplace keeps costs low is by assisting Kentuckians pay for needed medication. During the COVID pandemic, CHWs at the Kentucky Homeplace helped Kentuckians impacted by floods and quarantine access needed supplies, medication, and resources. CHWs have also been instrumental in helping Kentuckians stay healthy as they became the primary contact for many who wanted to know more about the COVID vaccine.
The Affordable Care Act Allows Medicaid to Reimburse for CHWs
Since 2014, the Centers for Medicare and Medicaid Services (CMS) has allowed states to reimburse for preventive services by professionals that are outside of physicians or other licensed practitioners, which includes CHWs. Before the ACA allowed for the reimbursement of CHWs, providers needed to pay for programs out of their operating budgets. Medicaid reimbursement is a more sustainable way to integrate CHWs into patient care. In order to bill Medicaid, CHWs are required to be supervised by clinically licensed care providers and states must define the scope of services allowed, focusing on what is best for their residents.
Kentucky Legislative Actions
The Cabinet for Health and Family Services (CHFS) has laid the foundation for CHWs in the state. CHFS and the Kentucky Department of Public Health (KDPH) have the framework for occupational regulations and Kentucky legislators can ensure there are strong policies enacted to ensure that Kentuckians can access needed health care providers like CHWs.
During the Kentucky General Assembly 2022, Representatives Kimberly Moser, Kimberly Banta, Samara Heavrin, Kim King, Ruth Palumbo, Cherlynn Stevenson, Buddy Wheatley, and Lisa Willner introduced bipartisan legislation to make certain services of Certified Community Health Workers reimbursable by Medicaid. This legislation, HB 525, would help to integrate CCHWs more fully into patient care across the Commonwealth. The bill is now awaiting a final vote on the consent calendar in the Senate.
The Association of State and Territorial Health Officials (ASTHO), a nonpartisan organization of leaders in public health representing the US, recently recommended that CHWs be reimbursed through federal funds allocated by the American Rescue Plan Act (ARPA). ASTHO argues that state Medicaid agencies submit plans to Medicaid for reimbursement or apply for a federal waiver to integrate CHWs into statewide health system reforms.
House Bill 525 (HB 525) does just that. Introduced to the House Health and Services Committee in February, HB 525 would enable healthcare systems, substance treatment facilities, community mental health centers, and other federally qualified health centers to bill Medicaid for services provided by CHWs. It paves the way for the kind of community centered care CHWs do well, offering direct service to meet the needs of Kentuckians. This comprehensive reimbursement plan for CHWs, like the one put forth by Republican House Leadership at the end of the 2020 session, shows the commitment legislators have in improving health outcomes for Kentuckians. Research shows that CHWs expand access to care and increase quality of care in other states; there is evidence that these programs work in Kentucky, too. The cost reductions shown in the CHW program at the Kentucky Homeplace, offering a nearly 12 to 1 return on investment, ensures that any changes made are sustainable.
Kentucky can be at the forefront of a movement towards healthcare that reaches all Kentuckians, whether they live in an urban area like Lexington or a holler in Pike County.
To learn more about the author, visit: https://kyvoicesforhealth.org/our-team/.