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Transforming Care: Integrating Community Health Workers into Care Teams

Transforming Care: Reporting on Health System Improvement adbcba2a-4a4d-41a5-8c3f-980ecb13a6bf

In Focus: Integrating Community Health Workers into Care Teams

Community health workers who help patients navigate the health care system and work to address their social and economic needs have rarely been fully integrated into care teams. This issue reports on health care organizations that have integrated community health workers into multidisciplinary teams, which appears to be a factor in their success. 

Community health workers—the frontline lay workers who serve as a bridge between clinicians and their patients—have been around for several decades in the U.S., but they have rarely been fully integrated into care teams for a variety of practical and cultural reasons. This is in spite of a growing body of evidence that community health workers (CHWs) in the U.S. and overseas can help the sickest and neediest patients improve their health and avoid costly emergency department and hospital visits (see graphic).1

Many CHWs come from the communities they serve, and often speak the same language—literally or figuratively—as the patients living there. They call upon that shared experience to build relationships with patients, and in turn use their knowledge of patients’ neighborhoods and cultures to help providers fine-tune their approaches to the patients they serve. In this way, they differ from social workers, nurse case managers, or others tasked with helping people with complex needs.

The people CHWs help are often those who providers find are their most challenging and yet may have the most to gain from effective communication and encouragement. In some cases, the information they gather from frank conversations with patients has been life-saving, as happened for a 16-year-old on a kidney transplant list in New Mexico. Covered by Molina Healthcare, which operates Medicaid and Medicare managed care plans throughout the country, the teen was assigned a community health worker because her nephrologist and care manager were concerned her family was struggling with the pre-transplant care.

The concern escalated after her nephrologist discovered the girl wasn’t taking her medications. After trying for months to find out why, he gave up and recommended she be removed from the transplant list. Both the mother and daughter insisted to the CHW that the teen was taking the medications. Eventually, however, the teen admitted to her CHW that she had been lying to her mother—and had not been taking her medications because her cousins had been taunting her with texts about her “rotten kidney” and telling her it would be better for everyone if she let herself die. “She was passively letting herself die,” says Dodie Grovet, the program’s training manager.

The CHW was able to find the girl a counselor, get her a new cell phone number, and she eventually began taking her medications.

“Patients do not always tell their doctors the truth, or the whole story, and doctors are forced to make strategic decisions based on incomplete information,” says Sergio Matos, executive director of the Community Health Worker Network of New York City. “CHWs can get to the core issues and find information that clinicians don’t have access to.”

Impact of Community Health Workers 

A 2010 review found that many evaluations of CHW programs were weak, leading health system stakeholders to dismiss the evidence as anecdotal or, conversely, to set unrealistic expectations on what CHWs can do. But a recent New England Journal of Medicine Perspective noted that in the past five years many more rigorous studies of CHW programs have been published, leading to greater understanding of what works and pointing to specific ingredients for success.

The following round-up of evidence draws on selected studies on the impact of CHW programs. 

Community health worker programs have led to more appropriate use of preventive and primary care. For example, CHWs have been shown to:


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Community health worker programs have also been shown to help improve disease outcomes for patients with asthma, hypertension, diabetes, cancer, tuberculosis, HIV/AIDS, and depression, among other conditions.

Documented savings in CHW programs have been attributed to: 


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Sources: J. N. Brownstein, G. R. Hirsch, E. L. Rosenthal et al., “Community Health Workers ‘101’ for Primary Care Providers and Other Stakeholders in Health Care Systems,” Journal of Ambulatory Care Management, 2011 34(3):210–20,; “Community Health Workers: Getting the Job Done,” Network for Excellence in Health Innovation,; “Community Health Workers: A Review of the Program Evolution, Evidence on Effectiveness and Value, and Status of Workforce Development in New England,” Institute for Clinical and Economic Review, Draft Report, May 24, 2013,; and Community Health Worker Toolkit, Centers for Disease Control and Prevention,


Difficulty of Classifying CHWs

It’s difficult to determine how many CHWs are currently working in the U.S. They are a mobile workforce, employed by local departments of health or public health agencies as well as health insurers and provider organizations and moving between clinics and hospitals and community settings such as schools, public housing developments, job sites, or people’s homes. Most work in poor communities, both in cities and rural areas. One estimate put the figure at more than 120,000, but this included expected growth in the workforce that didn’t come to pass because of the recession.1

They also go by many names—patient navigators, outreach workers, peer health educators, community health representatives (in American Indian/Alaska Native tribal communities), and promotoras de salud (in Hispanic communities). In recent years advocates have sought to clarify their role by promoting standard definitions and certification/credentialing programs, though there is some disagreement whether this will constrain CHWs’ freedom.3

This issue of Transforming Care reports on health care organizations that have integrated community health workers into multidisciplinary care teams, which appears to be a factor in their success. We also look at barriers organizations face in doing this—among them concerns about funding, training, and cultural differences between CHWs and clinicians.

See the Q & A with Iora Health’s Rushika Fernandopulle, M.D., on how his clinics incorporate health coaches. To hear from a community health worker, see our profile of a CHW working with those newly released from prison in San Francisco. 

Connecting to Sources of Support

One of CHWs’ key roles is to connect people to social services, legal services, housing support, or public insurance programs for which they may be eligible—doing everything from helping people fill out applications to reaching out to homeless people in shelters to making connections with service providers.

At Christus Spohn Health System, a Corpus Christi, Texas–based system, CHWs help uninsured patients navigate the health care system. They meet with patients, assess their needs, and work to build bridges between patients, primary care providers, and nonprofits that can help them.

One Christus CHW visited a woman in her early 30s who had been discharged from the hospital after experiencing complications from her asthma, diabetes, and hypertension. “We noticed she had not filled her medication or gone to see her doctor and were trying to figure out why,” says Liza Esparza, Christus’ director of transitional care. The CHW learned the woman’s water had been turned off and she was struggling to care for a disabled child—issues that meant her own health wasn’t a priority. The CHW was able to find local organizations to help her with water and electricity bills and later helped her find stable housing.

Encouraging Behavior Changes

CHWs are often trained to use motivational interviewing and other coaching techniques to encourage people to make changes to improve their health. At the Mayo Clinic in Rochester, Minnesota, they follow a strength-based approach to motivate patients with multiple chronic conditions who are not actively participating in their care. “Sometimes we ask what a good day looks like. They will say I don’t have good days,” says Diane Holland, clinical nurse researcher at Mayo. “It takes a lot of sophisticated problem-solving to recognize that they have strengths and build on them.” One CHW helped an elderly, socially isolated man with poorly controlled chronic conditions sign up for VA services so he could receive home health care and other support. He then found a way to help him get back to woodcarving—a cherished hobby he had given up because of his limited mobility—by creating a small, accessible workspace.

Catherine Vanderboom, clinical nurse researcher, says this approach is part of a strategy to broaden the definition of well being and identify nonmedical impediments to health. “We have found repeatedly—it’s pretty remarkable—when we bring a patient into the program, we hear about problems like finances, housing, and social isolation. It is really stepping back from that medical management to look at basic needs,” she says.

Offering Empathy and Building Trust

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Another role of community health workers is to help people surmount linguistic or cultural barriers that prevent them from speaking honestly with their providers—some because of a deep-seated distrust of the medical establishment, for others because they are embarrassed to admit their failings or don’t want to disappoint their providers. With a still predominantly white and Asian medical workforce treating an increasingly diverse population, CHWs can serve as a trusted peer for patients.

Latecia Turner, a CHW working for Grand Rapids, Michigan–based Spectrum Health, draws on her own experience in caring for her diabetic mother when she talks to patients about their chronic conditions. “I let them know that I have struggles, too,” she says. “I let them know that they are not alone. I let them talk about their fears. And I offer them encouragement by saying where you see yourself now is not where you will always be.”

Partnering with Care Teams

CHWs are most effective, their advocates say, when they are fully integrated with multidisciplinary care teams—when they have access to patients’ health records, take part in case review meetings and rounds, and have a say in developing care plans.

Spectrum Health accomplishes this by using CHWs to complement the skills of nurses, as part of the Core Health program, run by a charitable arm of the health system that aims to improve population health. Recently, a Spectrum CHW and nurse took care of a 50-year-old morbidly obese man with asthma, diabetes, and hypertension who was hospitalized with an A1c level over 11. “While the nurse worked with his primary care doctor to review his prescriptions, the community health worker was able to call local pharmacies to find ones that could deliver and had the lowest copays,” says Bethany Swartz, supervisor of the program. The CHW also helped enroll the man in health insurance and taught him how to ride the bus so he could make it to his doctor’s office. After three months, his A1c level had dropped to 6.3 and he had lost 15 pounds.


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Albert Slezinger, M.D., and Maria Murphy, a community health worker with Bronx-Lebanon, visiting a former patient at home.

The Bronx-Lebanon Hospital Center in New York has used CHWs since 2007, beginning with a grant-funded pilot in one of its South Bronx medical homes that produced a return of $2 per $1 invested (based on reductions in admissions/emergency department visits and increased revenue from outpatient visits for patients who were considered high utilizers). The results led administrators to dedicate operational funds.4

Today, the system uses some 35 CHWs to help hospital patients prepare for discharge, track down those who don’t show up for appointments or need certain screenings, and make home visits to identify patients’ challenges and help them take steps to improve their health. In addition to training CHWs for this work, Bronx-Lebanon trains clinical staff in how to partner most effectively with CHWs. CHWs present their cases at team meetings, and medical residents go with them on home visits. “Residents say now I understand why my patient is unable to control his A1c: he’s living in a one-bedroom apartment with six other people,” says Jose Tiburcio, M.D., associate chair of the Department of Family Medicine and an attending physician.

Fostering relationships between residents and CHWs had its challenges at the outset, says Matos of the Community Health Worker Network of New York City, who worked with Bronx-Lebanon to evaluate the program. “When the CHWs first arrived the residents were uncomfortable with high school graduates being on the team. It led to a lot of tension, but by the end of the first year residents loved them and would go crazy if the CHWs didn’t come in,” he says.

Gathering Health Information and Facilitating Education

While many CHWs focus on the socioeconomic determinants of health, some organizations are pushing the boundaries of what they have traditionally done to support patient care. A new team of CHWs hired by the Los Angeles County Department of Health, for instance, connects patients to services, but the CHWs—25 now with 25 more to be hired next year—also accompany patients on visits, provide health coaching, follow protocols to support them after hospital discharge, and gather information about what medications they are and are not taking as recommended.

They also deliver 50-item biopsychosocial assessments, using the results to work with providers and patients to prioritize goals and create care plans, and draw on some 70 scripts to facilitate conversations about things like managing medications and chronic diseases, navigating the health care system, healthy eating on a budget, and spirituality and health. “We want to take CHWs’ unique knowledge and shared experience and weave it into the way we deliver care,” says Clemens Hong, M.D., medical director of the project and cofounder of Anansi Health, a nonprofit whose mission is to help organizations launch CHW programs. New York City’s Department of Health and Mental Hygiene is following a similar tactic, hiring CHWs to help public housing residents manage their health conditions.5

Reducing Barriers to Integrating CHWs

If CHWs are able to help complex—and expensive—patients in ways that other health care professionals sometimes can’t, why are they not more commonly included in health care teams? Not surprisingly, one major reason is funding. Many CHW programs are grant-funded and tend to end when grants do. Several states are now using State Innovation Model grants from the Center for Medicare and Medicaid Innovation to support CHWs’ work. Such efforts are likely to provide an important evidence base on their impact—but it’s uncertain whether they will lead to longer-term commitments.

There are a few avenues to secure public funding for CHWs. Some states, including New York, Oregon, Minnesota, and Massachusetts, have used Medicaid waivers to reimburse CHWs. And the Centers for Medicare and Medicaid Services recently announced that states can be reimbursed for using CHWs to deliver preventive care services—although there has been limited take-up of this rule, in part because of the need for states to file detailed plan amendments.

Need for Standards on Training and Scope of Practice

Another set of concerns relates to uncertainty about how to train CHWs and how to define their scope of work. Some states require CHWs to gain formal certification, but there is wide variety among the curricula and standards. For instance in Ohio, Matos notes, CHW certification is governed by the board of nursing—leading to requirements that CHWs take courses on topics such as anatomy and physiology that are more appropriate for nurses. “This type of training is not relevant to their practice,” he says.

Nell Brownstein, who spent 25 years working on CHW programs at the Centers for Disease Control and Prevention and is now an adjunct associate professor at Emory University’s Rollins School of Public Health, is taking part in a national effort to develop recommendations on CHWs’ scope of practice and core competencies to inform training curricula and practice guidelines. “Because the most troubling thing to me is people reinventing the wheel and each group coming up with its own curriculum,” she says.

Training programs should include information on HIPAA, motivational interviewing, how to work with clinicians, and public speaking as well as some information on lifestyle risk factors, behavioral health problems, and disease-specific information, among other topics, Brownstein says. Having national standards on what CHWs can do and what they need to know to do it should promote greater understanding of their work and how it aligns with health system goals.

In defining CHWs’ scope of practice, it’s important to preserve their unique identity, advocates also say. “They are not low-paid replacements for office workers or clinical staff,” Brownstein says. It’s also important to train clinical staff on what CHWs do and how to take advantage of their work. Otherwise, it’s easy for them to become marginalized in clinical settings.

Some CHW competencies go beyond training, and must be identified in recruitment, says Matos, noting that employers tend to look for “the stuff your momma gave you: honesty, integrity, commitment, and compassion.” And while it’s not crucial CHWs come from the same neighborhood or share the same language as the patients they serve, “life experiences, beliefs, norms, and shared socioeconomic backgrounds” drive their relationships, he says, describing a Latina CHW who was able to form a bond with a Pakistani family as a result of their shared experiences as immigrants.

Looking Ahead

Finding a place for CHWs on care teams will require more leaders to understand the value CHWs bring, says Hong, something that may be aided by the experience and lessons learned through large-scale efforts such as those ongoing in Los Angeles and New York. A lot of what has happened to date has been driven by the grassroots CHW movement, he says, noting that a “tipping point” will come when health system leaders say, “this is what we need.”

This also will require ensuring there are financial incentives to promote their use. ACOs may help if they demonstrate that CHWs offer a sustainable strategy for containing costs. And with an influx of newly insured patients and a shortage of primary care clinicians, leaders may recognize that CHWs can extend providers’ capacity to meet their patients’ needs, particularly for support in accessing social services and managing chronic conditions.

“New care structures such as ACOs and medical homes are going to be under considerable pressure to improve the quality of communication between providers and patients—the continuity and honesty of it,” says Carl Rush, principal of Community Resources, which provides policy and training assistance to CHW programs. “This is a key way in which CHWs can add value.”

1 Community health workers are much more common in low-income countries, where they are used to make up for shortages of medical professionals by performing public health and some clinical functions, such as vaccinations.
2 Community Health Workers National Workforce Study, United States Department of Health and Human Services, Health Resources and Services Administration, March 2007. By contrast, there were an estimated 560,800 medical assistants working in the U.S. in 2012, with 29 percent growth expected in the profession over 2012–22. See
3 The American Public Health Association’s 2009 policy statement defines CHWs as follows: “Community Health Workers (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.”
4 S. Findley, S. Matos, A. Hicks et al., “Community Health Worker Integration into the Health Care Team Accomplishes the Triple Aim in a Patient-Centered Medical Home: A Bronx Tale,” Journal of Ambulatory Care Management, Jan.–March 2014 37(1):82–91,
5 See Implementation of the program has been slow and troubled because of the recent firing of a nonprofit hired to do the work. See

Publication Details


Putting Health Coaches Front and Center: Q&A with Rushika Fernandopulle of Iora Health


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Primary care physician Rushika Fernandopulle, M.D., M.P.P., founded Boston, Massachusetts–based Iora Health in 2010 with the goal of rebuilding primary care from the ground up—using health care teams that include an abundance of health coaches (Iora’s term for community health workers) to provide practical and emotional support to patients. Iora customizes its care model to the needs of particular patient populations, including freelancers, casino workers, carpenter union members, health system employees, and Medicare beneficiaries. To enable this approach, Iora works with self-insured purchasers and health plans and accepts global payments. It now has a network of 29 practices and is set to open about 20 more in the coming year.

Q: Iora Health’s primary care teams are configured very differently than those in other practices—with far more health coaches than nurses. What’s the rationale for that?

A: The health coaches are what make our business model work. We have structured Iora Health completely as a value-based provider. We do no fee-for-service billing. As we see it, our job is not to see one patient at a time and do the best we can and bill for that. Instead we need to figure out how to improve the health of a population of patients and keep them out of trouble.

You really need health coaches to do that. They are the ones who help patients with all the blocking and tackling to execute the treatment plan. They help patients understand it. They will hold your hand when that is the right thing to do, and kick you in your behind when that is the right thing to do, help you navigate the system when that is the right thing to do.

Q: You’re ramping up your hiring of health coaches as you expand your practices across 11 states. How do you go about finding the right people for the job?

A: We want people who have minimal social distance from the people they serve—ideally they live in the community. We also look for empathy, that they are willing to learn, and that they work well in teams. We don’t care what they did before. Some of them do come from health care. That doesn’t disqualify you but it doesn’t qualify you, either. Some of our health coaches worked at Dunkin Donuts, and Target and Sears or Teach for America. They’ve worked on the buffet line at a casino. We’ve found the way not to pick them is to look at their resume, which is what everyone else does. You have to meet them. We do a form of speed dating. We bring in lots of people. They meet a lot of our folks and we look for those who are able to connect with different sorts of people.

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Q: You’ve said before that health coaches are not low-cost substitutes for other providers, but how much do they make?

A: The salary varies dramatically depending on the geography and what other jobs people are coming from, but in general it’s close to the starting salary for a teacher. We say we’re not trying to make you poor or make you rich. We try to pay fairly and we give full benefits. We also have a career ladder: health coach, senior health coach, and after that health coach trainer. We pay for people to get further education if that is what they want. The whole idea is to turn it into a real career as opposed to a dead-end job.

All that said, health coaches are much cheaper for us than hiring nurses or doctors, and much easier to find. There are many, many more potential candidates. But that's not why we hire them. It’s because they can actually do the job better than a doctor or a nurse.

Q: Can you give us a sense of what they do day by day—what makes them different than the other members of the team?

A: Health coaches are very involved in office visits. When patients come in they first meet with the health coach who tees up the issues, finds out how things are going, what agenda the patient has, then they get the doctor. The health coaches will stay in the room while the doctor is there and their role is first to be the patient’s advocate and second to be a scribe. So they actually write up the notes while I can make eye contact with the patient. When I leave, the health coach stays and closes the loop using the teach back approach and talks about challenges the patient is going to face. They say things like, “O.K. you are going to exercise. When are you going to exercise? How are we going to make sure you do that? What are the barriers? What can we do to avoid them?” and so on.

The doctor’s involvement during visits could vary from 10 seconds if the patient is doing great—I walk in and say, “Hey, I hear you are doing great. Keep up the good work. I’ll see you next time.”—to an hour of doctor time if it is a really complicated case or a new patient.

Q: We have also heard that at the outset of the visit, the health coach meets with patients when they are fully dressed, sitting in a comfortable setting outside of the exam room. Why is that important?

A: Health care services have been turned into transactions: you document for billing and everyone’s job is to make the transaction as efficient as possible. So we have patients disrobe before the doctor arrives to save time. That is hokum: transactions have never healed anyone. The thing that heals is relationships. We focus on how to build a relationship with patients. That means putting them on equal footing and making them feel comfortable.

Q: So what are the health coaches doing outside of the office visit?

A: About half of a health coach’s time is spent outside of traditional visits. A lot of times it is emailing, texting, or video chatting with patients. They meet patients at least once in person but after that a lot of the checking in can be done virtually. It’s 2015. Why not, for God’s sake? They also go to people’s homes. They can evaluate how the patient is doing, whether their home is safe, if they have food. A lot of times the health coach goes to the grocery store with the patient. They encourage the patient to shop for everything they usually would, and then they’ll look in the cart and help the patient figure out why some of it is a bad idea and what possible substitutes are. Taking patients for walks is something else they do. It’s a really good way to talk about and model exercise behavior.

Q: As health coaches take on these roles, do you have any concern about patient safety or the accuracy of information they provide?

A: We invest in training quite a bit and the role they play varies by how experienced they are. So at the beginning a doctor will do a good part of closing the loop and the health coach will listen. And then when they are ready the health coach will do it and the doctor will stay and make sure it is right, then eventually the doctor can just walk out the door because you know they can do it because they’ve done it so many times. We have 30 or 40 different competencies they need to demonstrate. But what makes me feel better is they are doing it in front of our faces. This is why the integrated model is so much better—there are a lot of CHW models that are good, but the CHWs are free-floating out there in the community and not working as closely with the doctors. I overhear the health coaches when they are calling patients. They are in the huddle room sitting next to me.

Q: Can you give us a flavor of some of the competencies they must demonstrate?

A: They vary from the mundane such as how to take a blood pressure to something such as sitting with someone when they get bad news, which is much more touchy.

Q: You also use group visits, or clubs, for diabetes, for instance. What role do the health coaches play in running them?

A: Each coach will run at least one club, based on their particular interest. It really varies completely by the population we are serving. One of the things we’ve learned is that yoga is really helpful for stretching and meditation and mindfulness, and so with the Freelancers Union in New York, health coaches ran a yoga club. For our carpenters, if we run a yoga class, they don’t come. So one of the health coaches said we are not going to call it yoga we are going to have hammer time. They are doing yoga and holding tools in their hands. We have health coaches who teach tai chi, do walking groups, Zumba—all sorts of things.

Q: Can you give us an example of how the health coaches have made a difference in terms of health outcomes?

A: Sure. We had a Medicare patient in Seattle. She had moved from California after her husband died to live with her daughter. The problem was the daughter lived in the suburbs and the mom couldn’t get around and was getting isolated. Her diabetes and hypertension were getting worse. The health coach realized that the problem wasn’t that she needed more medicine; she needed to stop being isolated. So the health coach essentially taught her to use the bus, first by riding to the clinic together. The patient figured out how to do transfers and ride the bus back. Now this has nothing to do with health care and yet it has everything to do with health care. Now she can come to us, she can visit friends. And by the way her diabetes and blood pressure are in great control. We didn’t touch her medicine.

Q: It sounds like coaches are allowed some creativity in coming up with approaches.

A. Yes. People often ask us, “What are your protocols?” I always go back to the quote from Tolstoy that happy families are all alike and each unhappy family is unhappy in its own way. Patients are unique when it comes to their problems and they require very different approaches. Frankly, we as health care professionals are not smart enough to create protocols that work with this level of variation. Our view is to hire smart, creative people who are empathetic and let them figure out what patients need in order to fix the problem. Then let them do it. Don’t tell them what to do. It is a very heretical and different sort of culture.

Q: Do they have some discretionary spending if they see a need?

A: Absolutely. They have a small budget, which they can spend on patients if they think it would make a difference. We had a patient in Hanover, New Hampshire, who was not very engaged in her care. Her diabetes was out of control. The health coach noticed her toes were painted and remarked on it. The patient said, “I can’t afford to go to the spa anymore and I can’t reach and do it myself.” The health coach offered to paint her nails. She also pointed out that if she didn’t take care of her diabetes, she might lose her feet, which got her attention. The patient started asking what she could do to prevent it. So while she was painting her nails, the health coach taught her how to monitor and maintain her blood sugar. All of a sudden, she is engaged. It took a $2.99 bottle of nail polish and her diabetes is under control. The budget for these things is about $1,000 per practice per year.


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Iora Primary Care health coach Brendalys Rosario takes senior Marina Haley on a tour of the new Iora practice in Hyde Park, Mass.

Q: We’re interested in some of the challenges you’ve encountered in integrating health coaches into care teams. You are bringing in people in who may have no background in health care and who are working with people who have advanced degrees. Do the typical hierarchies come into play and how do you manage that?

A: It could be an issue, and that’s exactly why we are starting from scratch. When we hire people, like doctors, we say this is how we work and if you don’t like it, you can go elsewhere. We’re also willing to fire people over this issue. And we have lots of cultural things that flatten the hierarchy such as the daily huddle. We all take turns running it. So the doctor gets to run it one out of 12 days. So does the health coach, so does the operations assistant. So does the social worker. Our concept is that the health coaches work for the patient and they are the closest to them. The doctor works for the health coaches—not the other way around. They drive the culture.

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Q: How do patients react to the altered hierarchy? Don’t they prefer to interact with the doctor?

A: Often patients are a little skeptical. Who is this person? Why is he or she there? It’s key to have the patient meet the health coach the first time with the doctor’s arm around them. So you take this doctor magic that patients imbue in us and you transfer it to the health coach. I tell the patients the health coaches work closely with me and I say, when you tell her, you tell me. I also point out she is nicer than me and she is easier to get a hold of. And so that works. I think we are very quickly able to convince almost every patient that the health coach adds value.

Q: Despite their potential benefit, health coaches or community health workers have not been widely used within health care organizations. What might it take to spread the approach? Why isn’t it catching on?

A: The obvious elephant in the room is the payment model. No one pays for health coach visits let alone health coach phone calls or huddles. We also have these things we call cuddles where the health coach and the doctor will talk about their common patients together, and wuddles, which are weekly meetings where we try to identify common problems and new approaches to addressing them. The only way we can afford to do this is because we’re getting paid on a population basis.


Publication Details


Profile: Joseph Calderon, Community Health Worker for Transitions Clinic Network

Joseph Calderon is a community health worker for the Transitions Clinic Network, a national network of 16 clinics across the U.S. that helps those newly released from prison who have chronic conditions establish relationships with primary care providers. Transitions Clinic programs are embedded in other practices; the goal is to help parolees make the difficult transition from prison—where they were passive players in health care—to the health care system “outside the wall.” Many parolees have multiple chronic conditions and behavioral health problems and distrust providers. Calderon, who spent 17 years in prison, serves as a bridge between parolees and clinicians.

I’m working with individuals who have no concept of taking care of themselves or their chronic conditions. Some have substance abuse problems. Others are homeless. For some of the homeless ones, thinking of a warm place to sleep and shower trumps medical care. Most of the people I work with have had a lot of bad experiences with the providers in the prison system—just as I did. Watching what happened there brought a lot of heartache and madness. I have never seen so many people die from things that could have been prevented.


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Joseph Calderon (right), a community health worker for San Francisco’s Southeast Health Clinic, part of Transitions Clinic Network, with a client.

In my own case, I had a history of high blood pressure, a grandfather who died of a stroke, a father who died of a massive heart attack, and an uncle who died of stroke, so it was a real concern of mine. One night when I was in solitary confinement, I woke out of sleep with terrible chest pains. When I reported it in the morning, nothing was done for two to three weeks. And when I finally saw a doctor and described my history, he told me I was having muscle spasms and sent me back to the cell. I heard about Transitions at a mandatory parole meeting when one of their community health workers said the clinic could get me blood pressure medicine right away. That was my first experience with Transitions.

I’ve found a lot of recent parolees are unaware there’s help. Now that they are out, they don’t know how to get the care they need—or even that they need it. I understand that based on my own background. I grew up in the Mission District in San Francisco. A lot of my family didn’t really go to the doctor regularly. They went when they were sick and usually in a bad situation. Friends of mine went when they were beat up, shot, or stabbed. Based on that, and with my prison experiences with care, I didn’t really have the greatest view of what health care was going to look like on the outside or how I was going to take care of myself.

This is what I always tell guys I’m working with: In the communities we came from, we took better care of our cars than we did ourselves. Our cars got oil changes, tires rotated, you know, nice rims, music, but we didn’t go to the doctor for checkups or care.

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My work with them is a lot of relationship-building, trust, and bonding. We are talking about men who have dealt with institutional discrimination. Many had no access to medical care prior to Obamacare. They are also dealing with cultural and social issues—the gangs, the madness, who to trust, the race issues. I’m able to listen to them and then when I tell them that I too was incarcerated—they know I understand the obstacles on both sides of the “fence.”

It’s my job to teach them how to make appointments, how to get medication. I advocate for them. Being able to call me relieves some of the stress of trying to navigate the system. I use those situations to empower that individual—not only doing it for them once or twice, but more importantly by showing them how it’s done.

Still there are some who doubt me. They ask why are you helping me? What are you getting out of it? I tell them I’m not getting paid $10 a head for helping them. I’m passionate about this job. I want a better world.

There’s one guy who comes to mind. He had trust issues and he didn’t do well in shelters. I worked with him to get him an SRO [single room occupancy housing], getting him off the street so he could try to address his other issues with substance abuse. Now he is sober. He understands the medical system, he’s working, and has housing. We want to see people integrated back into the community.

Showing them that they have some choices helps a lot. They have been in places where everything was done for them. They’re obligated to speak to parole officers and assigned doctors while in prison. Now they need to understand that they can choose their own doctor, their own therapist, and they’re there to help them and their interactions are completely confidential. That makes a big difference.

I really wish I could change society’s view of parolees and their potential. When it comes to hiring for these positions, I agree that books are great, degrees are great, resumes are great. I’m planning on getting a bachelor’s degree and maybe a master’s in psychology or social work. But there’s experience that can’t be taught. I came out of prison with that experience and passion. Yet in many situations we’re still not looked upon as being worthy enough to be part of the system. On the contrary, I think we have a lot to give back to society.

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Publications of Note

Insurance Expansion May Lead to Better Management of Chronic Conditions

To gain insight into the health effects of insurance expansion under the Affordable Care Act (ACA), researchers evaluated the relationships between health insurance and the diagnosis and management of diabetes, hypercholesterolemia, and hypertension. They found people with insurance had significantly higher probabilities of diagnosis than uninsured people, by 14 percentage points for diabetes and hypercholesterolemia and 9 percentage points for hypertension. Among those with existing diagnoses, insurance was associated with significantly lower hemoglobin A1c (−0.58 percent), total cholesterol (−8.0 mg/dL), and systolic blood pressure (−2.9 mmHg). If the number of nonelderly Americans without health insurance were reduced by half, the researchers estimate that there would be 1.5 million more people with a diagnosis of one or more of these chronic conditions and 659,000 fewer people with uncontrolled cases. Their findings suggest that the ACA could have significant effects on chronic disease identification and management, but policymakers need to consider the possible implications of those effects for the demand for health care services and spending for chronic disease. D. R. Hogan, G. Danaei, M. Ezzati et al., “Estimating the Potential Impact of Insurance Expansion on Undiagnosed and Uncontrolled Chronic Conditions,” Health Affairs, Sept. 2015 34(9):1554–62.

Incentive Programs Must Also Reflect Patient Values and Goals

The authors of this commentary say value-based purchasing programs that tie incentive payments to quality metrics should include measures that are relevant to people living with frailty or advanced illness. These patients are weighing health care decisions with other critical factors such as being comfortable, controlling finances, having food and shelter, being connected to others, honoring their family and social role, and spiritual commitments—which current metrics do not assess. The authors also recommend that every older patient have a comprehensive assessment and care plan that includes such goals and an assessment of the financial costs of treatment to patients and their families and caregivers. J. Lynn, A. McKethan, and A. K. Jha, “Value-Based Payments Require Valuing What Matters to Patients,” Journal of the American Medical Association, Oct. 13, 2015 314(14):1445–46.

Medicare’s Chronic Care Management Program a Potential Boon to Primary Care Practices

A study designed to estimate the financial impact of new payments for chronic care management (CCM) of Medicare patients found that practices that rely on nonphysician team members to provide these services outside of office visits will likely experience substantial revenue gains but must enroll a sufficient number of eligible patients to recoup the costs. Practices could expect approximately $332 per enrolled patient per year if CCM services were delivered by registered nurses, approximately $372 if services were delivered by licensed practical nurses, and approximately $385 if services were delivered by medical assistants. S. Basu, R. S. Phillips, A. Bitton et al., “Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study,” Annals of Internal Medicine, Oct. 20, 2015 163(8):580–88.

Financial Burden for Patients with Dementia Higher Than with Other Diseases

Researchers examining the financial risks faced by Medicare beneficiaries in the five years before death found that, on average, the total cost for those with dementia ($287,038) was significantly greater than for those who died of heart disease ($175,136), cancer ($173,383), or other causes ($197,286). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia was 81 percent higher than that for patients without dementia ($61,522 versus $34,068). A similar pattern held for informal care. Out-of-pocket spending for the dementia group represented 32 percent of wealth measured five years before death compared with 11 percent for the nondementia group. This proportion was greater for black patients (84%), patients with less than a high school education (48%), and unmarried or widowed women (58%). A. S. Kelley, K. McGarry, R. Gorges et al., “The Burden of Health Care Costs for Patients with Dementia in the Last 5 Years of Life,” Annals of Internal Medicine, Nov. 17, 2015 163(10):729–36.

High-Cost Patients More Likely to Switch from Medicare Advantage to Fee-for-Service Medicare Than the Other Way Around

Researchers found high-cost Medicare Advantage members—defined as those who are hospitalized, and/or use home health care services or nursing homes—leave those plans for fee-for-service (FFS) Medicare plans more than the reverse. For those who are hospitalized, the switching rates are 2 percentage points higher (5.3% vs. 3.4%). For those using home care services rates are about 3 percentage points higher (7.5% vs. 3.4%) and for those with long-term nursing home stays the rates were six times higher (17% vs. 3%). The findings are consistent with previous research and raise questions about whether Medicare Advantage payment formulas work for these patients. Another possibility is that Medicare Advantage plans do not have sufficient incentives to pay for better services for these patients, the researchers say. M. Rahman, L. Keohane, A. N. Trivedi et al., “High-Cost Patients Had Substantial Rates of Leaving Medicare Advantage and Joining Traditional Medicare,” Health Affairs, Oct. 2015 34(10):1675–81.

Medical Homes Appear to Improve Access to Mental Health Services

Adults with mental health disorders who are aligned with patient-centered medical homes (PCMHs) were significantly more likely than those with no usual provider to have experienced a primary care mental health visit and to have received psychiatric medication than similar patients without a usual primary care provider or practice. Participants with a PCMH were additionally more likely than those with no usual provider to visit a mental health specialist and receive mental health counseling. A. L. Jones, S. D. Cochran, A. Leibowitz et al., “Usual Primary Care Provider Characteristics of a Patient-Centered Medical Home and Mental Health Service Use,” Journal of General Internal Medicine, Dec. 1, 2015 30(12):1828–36.

Functional Status Predictive of Readmissions in Medically Complex Patients

Researchers found readmission models based on functional status consistently outperformed models based on medical comorbidities. This approach, based on gender and functional status, was developed to predict the odds of three-, seven-, and 30-day readmission from inpatient rehabilitation facilities to acute-care hospitals. The researchers compared this approach to six other predictive models—three of which combined comorbidity and functional status measures and three that excluded functional status and relied on gender and a comorbidity measure. S. L. Shih, P. Gerrard, R. Goldstein et al., “Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients,” Journal of General Internal Medicine, Nov. 2015 30(11):1688–95.

Black Nursing Facility Patients Disproportionately Likely to Be Rehospitalized

Researchers found that when compared with white residents of skilled nursing facilities (SNFs), black SNF residents are more likely to be rehospitalized even after adjusting for patient risk factors. Black–white disparities, especially in potentially preventable rehospitalizations, are largely the result of black residents tending to be admitted to the small number of SNFs with very high rehospitalization rates. The 30-day all-cause and potentially avoidable rehospitalization rates were 21.9 percent and 8.8 percent, respectively, for black residents, and 17.7 percent and 7.9 percent for white residents. Black residents and white residents admitted to SNFs with high proportions of black admissions (>25%) were 31 percent and 19 percent, respectively, more likely to be rehospitalized than white residents admitted to SNFs caring for only a small percentage of black postacute residents (<3%). Y. Li, X. Cai, and L. G. Glance, “Disparities in 30-Day Rehospitalization Rates Among Medicare Skilled Nursing Facility Residents by Race and Site of Care,” Medical Care, Dec. 2015 53(12):1058–65.

Progress with Maryland’s Global Hospital Budget Program

The authors of this commentary describe Maryland’s Global Hospital Budget program, through which hospitals receive a fixed annual amount for inpatient and outpatient services. Six months into the program, which was launched in January 2014, hospitals had agreed to move more than 90 percent of the state’s aggregate hospital revenue into global budgets. The initial cost results have been promising, the authors note: per capita hospital costs decreased by 1.08 percent in Maryland in 2014, compared with an increase of 1.07 percent nationally. Quality of care also improved in many areas. Maryland’s rate of hospital admissions and per capita spending for Medicare patients are still among the highest in the country, however. A. Patel, R. Rajkumar, J. M. Colmers et al., “Maryland’s Global Hospital Budgets—Preliminary Results from an All-Payer Model,” New England Journal of Medicine, Nov. 12, 2015 373(20):1899–1901.

Paying for the Value of Physician Services in Medicare

This commentary explores the potential benefits and challenges of the Merit-Based Incentive Payment System (MIPS), which will be phased in over five years beginning in 2018. The payment methodology moves Medicare toward value-based purchasing by tying physician payment to individual or group-level measures of cost and quality. Performance will be judged by quality of care, resource use, meaningful use of electronic medical records, and participation in clinical practice improvement activities. The poorest performers will face fee cuts of 4 percent in 2019, 5 percent in 2020, 7 percent in 2021, and 9 percent in 2022. A key challenge, the author notes, will be measuring quality at the level of the individual physician. M. B. Rosenthal, “Physician Payment After the SGR—The New Meritocracy,” New England Journal of Medicine, Sept. 24, 2015 373(13):1187–89.

The Pitfalls of Hospital Consolidation

In this commentary the authors consider the implications of hospital consolidation, which has increased substantially in the past five years. They say many of the potential benefits, including improved quality and outcomes, can be achieved through collaborations among hospitals, interoperable electronic medical records, and better transparency. After citing research on the negative impact of mergers on utilization, price, and access to services, they suggest that as consolidation continues, there be greater emphasis on quality reporting and transparency. T. Xu, A. W. Wu, and M. A. Makary, “The Potential Hazards of Hospital Consolidation: Implications for Quality, Access, and Price,” Journal of the American Medical Association, Oct. 6, 2015 314(13):1337–38.

PCPs Needed to Meet Medicaid Demand

If all states were to expand Medicaid, researchers say the U.S. would need 2,114 additional primary care providers, an estimate somewhat lower than recent forecasts. The estimate assumes that adults with Medicaid coverage at any point in the year have an average of 1.32 visits per year to primary care providers, 0.45 more than low-income adults without Medicaid. Because some counties have fewer primary care providers per capita, the authors suggest that efforts to expand capacity focus on where providers practice rather than simply training more providers. E. T. Roberts and D. J. Gaskin, “Projecting Primary Care Use in the Medicaid Expansion Population: Evidence for Providers and Policy Makers,” Medical Care Research and Review, Oct. 2015 72(5):515–61.

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Editorial Advisory Board

Special thanks to Editorial Advisory Board member Eric Coleman for his help with this issue.


Eric Coleman, M.D., M.P.H., associate professor of medicine, University of Colorado 

Don Goldmann, M.D., senior vice president, Institute for Healthcare Improvement 

Thomas Hartman, vice president, quality improvement, IPRO 

Rosalie Kane, Ph.D., professor of public health, University of Minnesota 

Gordon Mosser, M.D., senior fellow, School of Public Health, University of Minnesota 

James F. Pelegano, M.D., M.S., Program Director, Masters of HealthCare Quality and Safety, Thomas Jefferson University

Christopher J. Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Michael Rothman, director, quality and operations support, Permanente Medical Group of Northern California

Paul Schyve, M.D., senior advisor, healthcare improvement, Joint Commission 

Editorial Team 

Sarah Klein, B.A., editor

Martha Hostetter, M.F.A., contributing editor, [email protected]

Douglas McCarthy, M.B.A., contributing editor

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