Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study

Respondents were asked to describe a CHW’s roles and responsibilities. There was diversity in how CHWs were employed in the provision of services within the health system. This could be observed in the broad range of CHW job titles, service populations, service delivery models, and roles and responsibilities (Table 2). Different formal job titles were used for CHWs both within and across sub-units. Some programs also assigned “informal” job titles that were distinct from the formal human resource title. Due to specific hiring limitations within the organization of study, none of the respondents reported a formal job title of “Community Health Worker”, but identified informally as such. The CHW’s target population or focus area was also different across subunits—some CHWs focused on a specific disease, location, or prevention activity. Some CHWs delivered services primarily in the community while others were based in a clinical setting. Roles and responsibilities described by respondents were also broad. Some CHWs assisted patients in accessing clinical services, others supported patients' psycho-social needs, or served as a “cultural translator” between the patient and the health system. Some CHW roles required specific certifications such as HIV testing/counseling. CHWs acknowledged the breadth of their roles and responsibilities. One CHW stated, “We all do more than what we should do. We do a lot more than what we should be doing [CHW].” While another described a CHW’s role by saying, “They wear a lot of hats [CHW].” Respondents commonly reported that a CHW’s roles were not well understood. One administrator noted that when “trying to plug [in] community health workers, you’ll run into [this] kind of thing where nobody’s quite sure where they’re supposed to fit [administrator].” Also, respondents described a lack of clarity regarding what CHWs were responsible for and how responsibilities were divided within the team.

Respondents were asked why CHWs were employed as part of the team (the CHW’s purpose) and how the CHW contributed to helping patients or the team (their value). CHWs were perceived to play a critical role as “connectors” by serving as the linkage or middleman between the patient and the health system. Other respondents valued CHWs for their ability to build trusting relationships with patients. For some respondents, building trust required that CHWs invest time working closely with patients and the communities where they reside. But some discrepancy existed in how a CHW’s value was perceived among members of the team. Generally, CHWs emphasized their ability to reach or impact individual patients, framing their value from the perspective of the patient’s experiences or needs. While administrators and clinicians more commonly perceived a CHWs value in their ability to contribution to health service goals. For example, a CHW was valued by health providers or administrators for helping patients access care, improving physician efficiency, or reducing healthcare provider burnout. While all interviewed respondents valued CHWs and understood their purpose, respondents indicated that not all care team members shared this understanding (Table 3).

Respondents were asked how CHWs were evaluated and how they assessed whether CHWs were effective. While some common elements of evaluation emerged, there remained considerable diversity in evaluation metrics both across sub-units and between CHWs and administrators. Some CHWs were assessed on activities completed (number of calls or home visits completed), patient engagement (patient no-show rates), or biological metrics (hemoglobin A1C levels). Common evaluation tools included patient health assessments, patient satisfaction surveys, CHW activity reports, health action plans, or treatment plans. Some sub-units also tracked costs associated with CHW services to assess cost effectiveness or return on investment (ROI), others used healthcare utilization metrics (such as hospital readmission rates) to estimate a CHW’s impact. But perspectives on health and cost metrics were mixed. While these metrics were perceived to be valuable in sustaining funding and leadership support for CHW models, they were also perceived to be limited in their ability to properly capture a CHW’s value. Common was the perception that it takes time for CHWs to change individual health outcomes. One administrator noted, “It becomes very difficult for anyone to find money because then what they get used to doing is looking at what’s the direct return on investment immediately for this work. And, you know … it isn’t immediate …. and so the benefits might be a couple years down the road or even further [Administrator].” Consequently, a CHW’s positive impact may be missed by short-term evaluation cycles.

Additionally, CHW respondents reported that the full scope of their work was not properly captured by quantitative assessments of activities completed. CHWs described taking hours, weeks, or even months to build trust with patients to work toward health improvement goals. One CHW noted, “So, I do all these other little things that I don’t necessarily put on the chart. So yes, I do spend two hours or three hours with a client or however long it takes with the client because I need to make sure that the client is well taken care of and not just, you know, not just another number [CHW].” Assessments that relied heavily on numerical counts of CHW activities did not always capture the nuanced work essential for patients with complex health and psychosocial needs.

In addition to these formal metrics, CHWs commonly assessed their effectiveness based on qualitative experiences with patients. CHWs described visual assessments of patients either via observations in the home or during patient interactions. For example, one CHW observed patients for signs of recent drug use (fresh IDU tracks) while another observed child tooth brushing to determine the regularity of practice. CHWs also received direct feedback from patients via success stories, and they identified this direct feedback as critical in assessing effectiveness.

Thus, respondents reported inconsistent perceptions related to CHW roles and purpose. CHW roles were not always understood, and the CHW’s purpose and value were sometimes framed differently by different members of the care team. Moreover, evaluation metrics did not always effectively capture a CHW’s impact on the health care system. But in some cases, care teams were more aligned around a shared understanding of the CHW’s role and purpose within the care team (Fig. 2)—with some sub-units reporting little alignment and others reporting close alignment in perceptions.