I recently attended a symposium entitled “Community Health Workers: Getting the Job Done in Health Care Delivery.” (My concluding remarks begin at the 6:00:40 mark in the video.) Speakers examined the evolving role of Community Health Workers (CHWs) in the current era of delivery system reform. Health Affairs has published work documenting the importance of this part of the workforce, and our November issue is dedicated to the topic of “Collaborating for Community Health.”

I was asked to summarize some key points from the day-long conversation. In this post I highlight some of the themes covered.

Over the course of the day I heard the elements of two very different paths forward for community health workers. Each path was coherent and compelling, but they lead in very different directions.

A Professional, Specialized Workforce

The first model is one that leads to a professionalized workforce with formalized training, qualifications, and certification. Community health workers become integrated into care teams along with doctors, nurses, and other professionals. CHWs develop the “business case” for their services and are paid by the health care system, either plans or providers. Ultimately, community health workers become part of the professional culture of medicine and grow and develop along with the health care system.

A Workforce Serving the Community

The second model views CHWs as part of the communities in which they work. The roles of community health workers are defined by the community and CHWs through a process of community engagement. CHWs are valued for their contribution to community health, not for the savings they generate for health plans or providers. CHWs are embedded in the community, not in a clinician’s office or hospital. Advocacy is required to effect a transfer of resources out of clinical care into the community. This model is one more closely aligned with public health than with personal health services.

Both are viable models for the future of community heath workers, but they raise a few questions:

  • Can these two models coexist in a single community, state, or even nation?
  • If not, who chooses which model will exist?
  • Is it possible to combine the best features of the two models?

I posit that it is unlikely that both models will be able to coexist. With its substantial resources, the health care system is likely to make the choice, and the first of the two models is a better fit for how health care is organized. Strong and sustained advocacy by those who believe in the second model is the only way to achieve it.

But I believe there are ways to combine the two models. The starting point must be an explicit commitment of money to community health — with the most likely source of those funds being an assessment or set aside from health care services. I see the beginnings of this approach in efforts such as Vermont’s Blueprint for Health, which includes community health teams, with positions selected by local leadership based on what is needed in the community. Similarly, the structure of Colorado’s Regional Care Organizations allows them to tailor their structure, staffing and financing to local circumstances. Massachusetts recently established a trust fund that is providing grants to community-based prevention and wellness programs.

These examples go beyond the typical accountable care organization (ACO) model, which provides incentives for providers to support population health but leaves resource control in the hands of the health care system and does not support a community-based infrastructure.

The United States stands out in the world for treating community health workers as part of the health care system, rather than as part of the community. We should honor the wisdom and experience of CHWs as they define their future rather than assuming that they will be absorbed into a health care system that is only beginning to learn how to support people in their communities.