Moving the Advance Care Planning Needle With Community Health Workers

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This issue of Medical Care presents a study by Litzelman et al,1 “Impact of community health workers on elderly patients’ advance care planning and health care utilization: moving the dial,” that reports the results of an innovative model at the Indiana University Center for Aging Research’s Aging Brain Care (ABC) Program in which community health workers (CHWs) are trained to initiate and conduct advance care planning (ACP) conversations with elderly patients and their caregivers during home health visits. Investigators found that they were able to increase ACP documentation from <5% to almost 50% and that ACP documentation was associated with a significantly lower risk for hospitalization and emergency department visits. These impressive results should provide hope to health care systems nationwide who are actively working to engage their patient populations in the important act of discussing and documenting ACPs.
These findings are reminiscent of the initial success of the well-publicized experience in LaCrosse, Wisconsin, where now an estimated 96% of those who die have an advance directive established. But this was not always the case. When Hammes and his colleagues started their community-wide project, only 2% of the population had a documented advance directive. Through the well-coordinated efforts of nonphysician facilitators, they were able to increase ACP documentation from 2% to 45% within 2 years, and the rest, as they say, is history.2 Health systems across the nation have been clamoring to replicate these results ever since, but have struggled with pervasive challenges such as lack of manpower (including questions of who will initiate ACP conversations) and locally diverse patient populations. How to engage communities of color with ACP is no small issue,3 which is one of the reasons why the CHW model presented by Litzelman and colleagues is so intriguing. Not only can CHWs create “community clinical linkages,” an essential step toward addressing health outcomes and health inequities, but CHWs can bridge cultural gaps that impair health care delivery.4
But let’s take a step back and define “who are CHWs?” The short answer is that CHWs are community members with focused health care training.5 The more complete answer is found in the definition from the CHW Section of the American Public Health Association:
CHWs are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.6
CHWs have been utilized in the United States for decades as outreach workers, promatores de salud, patient navigators, and community advocates.5 As members of the communities they serve, CHWs spend significant portions of their time working in community-based settings and often in clients’ homes. This community-based work allows CHWs to reach deep into their communities and connect people who are isolated and hard-to-reach with needed health and human services.7
Health care systems are actively exploring the best strategies for integrating CHWs into health care delivery. In the United States, various models have been explored to engage CHWs into patient care, including the following: (1) hiring CHWs as employees of the institution to work as part of a multidisciplinary team; (2) interfacing with CHWs who are employed at community-based nonprofit organizations that provide both health-related and non–health-related services; and, in fewer exploratory cases (3) contracting with dedicated CHW management entities that serve to integrate with clinical and community organizations.
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