Funding the utilization of community health workers in Texas

Community health workers (CHWs) are volunteers or paid members of communities that perform outreach, patient assistance, health education, and assist in navigation of healthcare system amongst other duties. The utilization of CHWs in hospital and community setting provides health benefits to their communities while reducing cost to the overall healthcare system. ^ The general population of Texas lacks adequate access to primary care. An important indicator of such a crisis is excessive usage of emergency department services in Texas, especially by the large minority population within the state. Also, unmanaged chronic diseases have been shown to be correlated with the excessive usage of emergency services. According to a recent survey of 25 Houston metropolitan area hospitals, almost 54% of the ER visits could have been resolved in primary care settings. A Galveston based study also indicated that the ER usage was higher amongst African-Americans and Latinos. Meanwhile, 28.5% of the total ER visits were made by Latinos from the surrounding areas (Begley et al., 2007). There is substantial evidence present which indicates enormous cost-savings that CHWs have produced in Texas and nationwide through reduction in unnecessary ER visits along with better management of chronic diseases (Fedder et al, 2003). ^ This paper provides an analysis regarding the need and importance for sustainable and stable sources of funding for Community health workers (CHWs) in Texas utilizing Kingdon's model of Agenda Setting as framework. The policy analysis is also aimed at reporting on the policy process and actions taken by Children at Risk to address this critical issue. Children at Risk, a Houston based advocacy organization, has created a legislative proposal that calls on the Texas Health and Human Commission to apply for a Medicaid §§1115 waiver to provide sustainable sources of funding for CHWs, Rep. John Zerwas sponsored HB 2244 bill and it was filed on March 3, 2011. The bill would affect the use of CHWs in Texas in two ways: 1) through the establishment and operation of a program designed to train and educate CHWs 2) by creating a statewide training and certification advisory committee. The advisory committee is required in the bill to submit recommendations for providing sustainable funding and employment for CHWs. The HB 2244 failed to move out of the House Public Health committee. However, HB2244 was amended into HB 2610 introduced by Representative Guillen. The House Bill 2610 is geared towards establishing a community-based navigator program in order to assist individuals applying for public assistance through the Internet. The House Bill 2610 was signed by the Governor and will be effective September 1, 2011.^

Community referral for promoting physical activity among primary care patients

Introduction. There is a need for physical activity interventions based in primary care clinics that take advantage of community resources. The purpose of this randomized controlled trial was to compare the effects of two physical activity interventions: (1) physical activity prescription by a primary care provider plus referral to community physical activity resources and (2) physical activity prescription only. ^ Methods. Sedentary adult patients recruited from a general medicine clinic were randomized to receive a physical activity prescription, delivered by the primary care provider, plus referral to community physical activity resources (n=38) or physical activity prescription only (n=32). Outcomes were use of community resources (exercise facility and personal trainers), physical activity levels (self-report questionnaire and pedometer), and attitudes regarding physical activity assessed at 8 weeks. ^ Results. Three of 38 (7.9%) subjects referred to the community resources and none of the 32 subjects in the prescription only group used the community resources during the 8 week trial. Sixteen of 32 subjects in the prescription plus referral group and 19 of 38 in the prescription group completed the self-report follow-up forms at 8 weeks. For minutes of moderate- or vigorous-intensity physical activity per week, there were no between-group differences at baseline, follow-up, or change from baseline to follow-up. However, for moderate- and vigorous-intensity physical activity, there were significant improvements from baseline to follow-up within each group. For attitudes related to physical activity, there were no between-group differences at baseline, follow-up, or change from baseline to follow-up; neither were there any within-group changes. ^ Discussion. Physical activity prescription delivered by a healthcare provider in the context of a routine primary care visit can improve physical activity levels, with no additional improvement gained by referring to community resources. The intervention was feasible for primary care providers to deliver, but only 50% of subjects returned the self-report physical activity questionnaire at the 8 week assessment. ^

The movement toward patient safety: State action related to reporting and disclosure of healthcare-associated infections

Increasing attention has been given to the problem of medical errors over the past decade. Included within that focused attention has been a strong interest in reducing the occurrence of healthcare-associated infections (HAIs). Acting concurrently with federal initiatives, the majority of U.S. states have statutorily required reporting and public disclosure of HAI data. Although the occurrence of these state statutory enactments and other state initiatives represent a recognition of the strong concern pertaining to HAIs, vast differences in each state’s HAI reporting and public disclosure requirements creates a varied and unequal response to what has become a national problem.^ The purpose of this research was to explore the variations in state HAI legal requirements and other state mandates. State actions, including statutory enactments, regulations, and other initiatives related to state reporting and public disclosure mechanisms were compared, discussed, and analyzed in an effort to illustrate the impact of the lack of uniformity as a public health concern.^ The HAI statutes, administrative requirements, and other mandates of each state and two U.S. territories were reviewed to answer the following seven research questions: How far has the state progressed in its HAI initiative? If the state has a HAI reporting requirement, is it mandatory or voluntary? What healthcare entities are subject to the reporting requirements? What data collection system is utilized? What measures are required to be reported? What is the public disclosure mechanism? How is the underlying reported information protected from public disclosure or other legal release?^ Secondary publicly available data, including state statutes, administrative rules, and other initiatives, were utilized to examine the current HAI-related legislative and administrative activity of the study subjects. The information was reviewed and analyzed to determine variations in HAI reporting and public disclosure laws. Particular attention was given to the seven key research questions.^ The research revealed that considerable progress has been achieved in state HAI initiatives since 2004. Despite this progress, however, when reviewing the state laws and HAI programs comparatively, considerable variations were found to exist with regards to the type of reporting requirements, healthcare facilities subject to the reporting laws, data collection systems utilized, reportable measures, public disclosure requirements, and confidentiality and privilege provisions. The wide variations in state statutes, administrative rules, and other agency directives create a fragmented and inconsistent approach to addressing the nationwide occurrence of HAIs in the U.S. healthcare system. ^

The relationship between surgical residents' perception of leadership and patient safety culture

Introduction. Patient safety culture is the integration of interrelated practices that once developed is supported by both the culture and leadership of the organization (Sagan, 1993). The purpose of this study is to describe and examine the relationship between surgical residents’ perception of their leadership and the resulting organizational safety culture within their clinical setting. This assessment is important to understanding the extent that leadership style affects the perception of the safety culture.^ Methods. A secondary dataset was used which included data from 68 surgical residents from two survey instruments, Organizational Description Questionnaire (ODQ) and Patient Safety Climate In Healthcare Organizations (PSCHO) Survey. Multiple regressions followed by hierarchical regressions with the introduction of the Post Graduate Year (PGY) variable examined the association between the leadership styles, Transactional and Transformational and the organizational safety culture variables, Overall Emphasis on Safety, Senior management engagement, Organizational resources for safety. Independent t-tests were conducted to assess whether males and females differ among the organizational safety culture variables and either leadership style.^ Results. The surgical residents perceived their organizational leadership to have greater emphasis placed on transformational leadership culture style relative to transactional leadership culture style. The only significant association found was between Transformational leadership and Organizational resources for safety. PGY had no significant effect on the leadership or the safety culture perceived. No significant difference was found between females and males in regards to the safety culture or the leadership style.^ Discussion. These results have implications as they support the premise for the study which is surgical residents perceive their existing leadership and organizational culture to be more transformational in nature than transactional. Significance was found between the leadership perceived and one of the safety culture variables, Organizational resources for safety. The foundation for this association lies in the fact that surgical residents are the personnel which are a part of the organizational resources. Although PGY differentiation did not seem to play a difference in the leadership perceived this could be attributed to the small sample size. No gender difference were found which supports the assumption that within such a highly specialized group such as surgical residents there is no gender differences since the highly specialized field draws a certain type of person with distinct characteristics. In future research these survey tools can be used to gauge the survey audiences’ perception and safety interventions can be developed based on the results. ^

Analysis of community health worker utilization in El Paso County, Texas

Community health workers (CHWs) are an accepted, viable component of health systems worldwide. Most often they are utilized in developing regions where health care access is limited and/or health care practitioners are scarce. In this way community health workers have been used to extend the reach of primary care delivery to whole nations, and can be used to reduce health disparities in disadvantaged populations or minority groups as well. In the United States, utilization of CHWs is fragmented, and an amalgam of programs exist which are usually only community-specific. These programs are often burdened by financial un-sustainability. The Community Health Worker National Workforce Study (2007) was markedly the first effort to compile a profile of the CHW workforce in all 50 states. El Paso County, as a uniquely bi-national setting, provided a prime locale to assess CHW utilization on a localized scale, and in a distinctively Latino population and medically underserved area. ^ Results gleaned from this study of 45 CHWs and 5 administrators demonstrate commonalities between El Paso County CHWs and the national CHW workforce; differences were found in average education level, wages for experienced CHWs, as well as primary target populace and target health issues. Future research should focus on cost-effectiveness of CHW utilization.^

Camp For All Connection: a community health information outreach project

Purpose: The purpose of the Camp For All Connection project is to facilitate access to electronic health information resources at the Camp For All facility. Setting/Participants/Resources: Camp For All is a barrier-free camp working in partnership with organizations to enrich the lives of children and adults with chronic illnesses and disabilities and their families by providing camping and retreat experiences. The camp facility is located on 206 acres in Burton, Texas. The project partners are Texas Woman's University, Houston Academy of Medicine-Texas Medical Center Library, and Camp For All. Brief Description: The Camp For All Connection project placed Internet-connected workstations at the camp's health center in the main lodge and provided training in the use of electronic health information resources. A train-the-trainer approach was used to provide training to Camp For All staff. Results/Outcome: Project workstations are being used by health care providers and camp staff for communication purposes and to make better informed health care decisions for Camp For All campers. Evaluation Method: A post-training evaluation was administered at the end of the train-the-trainer session. In addition, a series of site visits and interviews was conducted with camp staff members involved in the project. The site visits and interviews allowed for ongoing dialog between project staff and project participants.

Health education intervention to reduce risk of infectious disease transmission among community health workers and their clients

Indigent and congregate-living populations have high susceptibilities for disease and pose a higher risk for disease transmission to family, friends and to persons providing services to these populations. The adoption of basic infection control, personal hygiene, safe food handling and simple engineering practices will reduce the risk of infectious disease transmission to, from and among indigent and congregate-living populations. ^ The provision of social services, health promotion activities and other support services to indigent and congregate-living populations is an important aspect of many public health-related governmental, community-based and other medical care provider agencies. ^ In the interest of protecting the health of indigent and congregate-living populations, of personnel from organizations providing services to these populations and of the general community, an educational intervention is warranted to prevent the spread of blood-borne, air-borne, food-borne and close contact-borne infectious diseases. ^ An educational presentation was provided to staff from a community-based organization specializing in providing housing, health education, foodstuffs and meals and support services to disabled, low-income, homeless and HIV-infected individuals. The educational presentation delivered general best practices and standard guidelines. A pre and post test were administered to determine and measure knowledge pertinent to controlling the spread of infectious diseases between and among homeless shelter-living clients and between clients and the organization's staff. ^ Comparing pre-test and post-test results revealed areas of knowledge currently held by staff and other areas that staff would benefit from additional educational seminars and training. ^

Community health workers: The critical link to sustainable, healthy societies in low-resource settings---A model for the Baylor Shoulder to Shoulder Foundation

Community health workers (CHWs) can serve as a bridge between healthcare providers and communities to positively impact social determinants of health and, thus, the overall health of the population. The potential to effect lasting change is particularly significant within resource-poor settings with limited access to formally trained health care providers such as the small, rural village of Santa Ana Intibucá, Honduras and surrounding areas—located on the geographically and politically isolated border of Honduras and El Salvador. The Baylor Shoulder to Shoulder Foundation (BSTS) works in conjunction with Santa Ana's volunteer health committee to bring a health brigade that has provided health care and public health projects to the area at least twice a year since 2001. They have also hired a full-time Honduran physician, a Honduran in-country administrative director, and built a clinic; yet, no community health worker program exists. This CHW program model is the response to a clear need for a CHW program within the area served by BSTS and presents a CHW program model specific to Santa Ana Intibucá and surrounding areas to be implemented by BSTS. Methods used to develop this model include reviewing the literature for recommendations from leading authorities as well as successfully implemented CHW programs in comparable regions. This information was incorporated into existing knowledge and materials currently being used in the area. Using the CHW model proposed here, each brigade, in conjunction with the communities served, can help develop new modules to respond to the specific health priorities of the region at that time, incorporating consistent modes of contact with the local physician and the CHWs to provide refresher courses, training in new topics of interest, and to be reminded of the importance of community health workers' role as the critical link to healthy societies. With cooperation, effort, and support, the brigade can continue to help integrate a sustainable CHW system in which communities may be able to maximize the care they receive while also learning to care for their own health and the future of their communities.^

Restoring mortality as a measure of community health

In the last several decades traditional community health indicators have become ambiguous and lost some of their relevance. During this same period national and international health agencies adopted new expanded definitions of Health that include underlying social determinants. These two influences are responsible for a proliferation of new health indicators and many are constructed from a combination of older mortality measures and available information on morbidity. Problems inherent in attempting to combine these sources of information have produced a situation where some indicators are difficult to calculate at the national level and may not function at all for small communities. What is needed is a relevant measure of the burden of ill health appropriate for smaller populations that is accessible to local health planners. ^ Death records are still the best available population health information. In Europe the burden of health problems is often portrayed using 'premature' death. Health agencies in the United States have moved to adopt Years of Potential Life Lost. Both these regions are also developing systems of 'avoidable' or 'preventable' death as health indicators. This research proposes a method combining these methodologies to produce a relevant indicator portraying the burden of ill health in communities. ^

Using service-learning to encourage community health advocacy among high school students

The project outlined throughout this program management plan aims to develop a health-focused student advocacy group in the San Antonio Independent School District (SAISD). At its core, this project will be an opportunity for SAISD students to engage in service-learning, through which they will learn and develop by designing, organizing and participating in meaningful public health service experiences. ^ This program management plan addresses the genuine need for public health community education by using the service-learning model as a framework to engage students to effect change. The plan delineates the process by which the student advocacy group is to be assembled, selection of service-learning project, project objectives, technical objectives, and communication requirements. Ideally, the plan should help to facilitate project coordination, communication, and planning, and to support the direction of resources. The appendices that follow also provide useful tools with which to follow through with project implementation. ^ The plan is about more than providing a tool to educate students about the health issues in their community. It is about providing a way to teach health advocacy and self-interest and encourage civic engagement via public health. Students have the potential to positively effect lasting change among their peers, in their schools and in the community.^

Better together: Addressing maternal and child health outcomes through community health worker continuing education curricula

Background. The incidence of birth defects is a significant public health issue in the United States, adversely affecting the quality of life for parents as well as children born with these defects. Minority populations face a greater burden of birth defects and associated health problems. Prenatal practices can have a large impact on infant health outcomes. Several behaviors during pregnancy, including the intake of folic acid, can greatly influence the likelihood of a child being born with a birth defect. Community Health Workers have been shown to be effective agents at improving prenatal practices, especially when they facilitate support groups that feature pregnant women. ^ Methods. A continuing education curriculum has been created for Community Health Workers that provides content in the area of Maternal and Child Health. Content was selected after conducting a review of relevant literature and theory. Materials for conducting a training for Community Health Workers have been created in addition to materials that were designed for the population with whom the CHWs work. ^ Results. A description of each "key point" of the curriculum and a justification how it relates to the literature of the prevention of birth defects is given here. Additionally, the process of creating the curriculum using the platform delineated in the methods is described. ^ Discussion. Insights for future curriculum development are discussed along with next steps in the process of certifying the curriculum at the state level. A framework for future evaluation of the curriculum is given.^

WORKLOAD AND PERFORMANCE FACTORS ASSOCIATED WITH MULTIMEDIA JOB AIDS FOR COMMUNITY HEALTH WORKERS

This dissertation focuses on factors of multimedia job aids that modify workload, protocol adherence and clinical errors in community health workers. Literature shows that community health workers performance is not acceptable even with support of paper job aids. There are cognitive theories that try to explain reasons why the performance of community health workers is poor regardless of the access to paper based-job aid. Based on cognitive science and multimedia design theories an intervention was designed to compare alternative representations for the information contained on paper job aids and the capability of this new designed job aids to enhance community health workers performance. The dissertation is divided in 5 main parts: 1. identification and description of the problem, 2. a methodological approach to create and evaluate an intervention, 3. Presentation of results of the intervention evaluation, 4. Discussion of findings and 5. Conclusions