Urban Healthy Start Program Offers Support at Each Stage of Childbearing Cycle, Leading to Fewer Low- and Very Low–Birthweight Babies | AHRQ Innovations Exchange

Urban Healthy Start Program Offers Support at Each Stage of Childbearing Cycle, Leading to Fewer Low- and Very Low–Birthweight Babies | AHRQ Innovations Exchange

Service Delivery Innovation Profile

Urban Healthy Start Program Offers Support at Each Stage of Childbearing Cycle, Leading to Fewer Low- and Very Low–Birthweight Babies

A Community Health Worker Program Takes a Holistic Approach to Care for At-Risk Women By Mark Redding, MD, FAAP, Director of Development, Community Health Access Project Baltimore City Healthy Start (BCHS) is a national nonprofit leader, employing and training neighborhood health advocates to reach out mainly to African American women and connect them to health and social service interventions. The innovative program began using community health workers (CHWs) in 1991, nearly a decade before CHWs gained national recognition. BCHS targets an inner-city population characterized by a complex set of risk factors that affect birth outcomes. These factors include poverty, homelessness, low high school graduation rates, illiteracy, crime, as well as health and behavioral health care issues. This population also has a high risk of infant mortality, with a prevalence rate of 18.5 per thousand, which is 5 times the rate for whites.1  For at-risk women, dealing with problems such as insufficient food, clothing, and housing often takes priority over obtaining preventive health care. Even if a woman has access to a respected medical facility in her community, she may never use it because she just received an eviction notice, has inadequate food for her children, lacks transportation, faces domestic violence, or has other urgent problems in her life. All of these stressors add up to a major barrier to getting prenatal or other preventive health care. Although at-risk women may be eligible to receive Medicaid, they may not have assembled the necessary documentation to receive insurance. Other barriers to medical care include a limited number of providers willing to accept Medicaid patients or to treat complex and time-consuming patients. A high percentage of complex patients are no-shows and require more time than the typical 10-minute visit allotted by providers dealing with a high volume of patients. In addition, some social service agencies may avoid women with multiple problems and conditions. To navigate the complex health care and social service systems, at-risk women and families need a trusting relationship with someone who connects with them culturally. CHWs are usually from the same communities as their clients. A CHW takes a holistic approach to assessing and identifying a client’s needs and helps her overcome barriers and receive recommended interventions. CHWs must provide health, behavioral health, and social services that are consistent with their clients’ priorities. If a CHW is serving a 17-year-old pregnant mother who has an 18-month-old child and has just been evicted, the mother’s first priority may not be preventive medical care. The CHW has a dual focus of helping the client secure housing, food, and other survival resources that ensure a stable environment for her family while starting prenatal care and other preventive medical services. Research shows that reducing the stress level of at-risk women decreases certain biological responses that can have a devastating impact on birth outcomes, including premature births.2 Improving health is primarily a matter of addressing social, environmental, and behavioral factors; in fact, lack of access to medical care accounts for less than 20 percent of preventable mortality.3 Challenges The research on home visitation programs has shown that they can have a positive impact on children’s cognitive outcomes; however, more rigorous research is needed to determine their impact on birth outcomes.4,5 Case-matched control studies evaluating CHW interventions are challenging to conduct. There are both logistical and ethical barriers to finding at-risk women and placing them in control groups without providing interventions. Emerging strategies include examining State health department and Medicaid data to develop case-matched controls for individuals who receive CHW services. The goal is to compare the outcomes between the control and intervention cases. We are currently conducting this type of case-control research for pregnant clients served by CHWs in Ohio though a partnership with the State Health Department. However, more research and funding are needed to support similar evaluation strategies. Alignment of financial incentives is needed to compensate the additional time and expense required of doctors and social service agencies who work with at-risk populations. The Pathways Community Hub Model in Ohio, Michigan, New Mexico, and Oregon is developing risk-scoring strategies that incorporate geographic risk and individual risk factors such as behavioral health, social service issues, and the number and severity of comorbid health conditions. The goal is to reduce risk factors that influence health outcomes, which can be tracked over time. Risk scoring can then be incorporated into contracting and funding arrangements with specific incentives to serve at-risk populations. National quality standards for community-based care coordination are also needed. While a few States such as Texas, Alaska, and Ohio have developed statewide certification for CHWs, not all CHW programs within those States require certification. BCHS requires CHWs to complete a rigorous 80-hour course at a community-based college. BCHS also requires supervision for its CHWs. Other CHW programs provide less training and supervision. Certification standards for CHWs are necessary to ensure quality of care and improvements in outcomes, as with any effective health or social service profession. Sustainability  The Health Resources and Services Administration has provided significant funding support for BCHS and other Healthy Start programs nationwide.6 Financial support for CHW programs has also come from other Federal agencies, including the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention, and National Institutes of Health, as well as from Medicaid, managed care, private businesses, and foundations. Connecting at-risk individuals with basic health and social services offers a cost-effective approach to improving health outcomes. A national network of programs that facilitate these connections can help to reduce infant mortality, health care costs, and health disparities. As a leader in this network, BCHS should be sustained and should also grow and develop. About Mark Redding, MD, FAAP Dr. Redding is a pediatrician with broad primary care experience in rural and urban settings. A special interest is transitions of care (care coordination) for at-risk populations. Dr. Redding and his wife, Dr. Sarah Redding, have worked in communities in Alaska, Baltimore, and Ohio to train and support community-based navigators (community health workers) to address social barriers and achieve prevention and early treatment. Since the late 1980s, the Reddings have focused on initiatives to reduce health disparities. This work has involved developing specific tools and measures focused on care coordination. Work on the Community Pathways Model was facilitated by the AHRQ-sponsored Community Care Coordination Learning Network and published on the AHRQ Innovations Exchange Community Care Coordination page. Disclosure Statement: Dr. Mark Redding reported that BCHS contacted him about the Pathways Model and that he conducted a free webinar for the organization in March 2014. Dr. Mark Redding and Dr. Sarah Redding provide expertise and financial support to a private for-profit organization (Care Coordination Systems) that is developing inexpensive software and learning support tools for community health workers. References 1 Maryland Vital Statistics Administration. Maryland Vital Statistics Annual Report. 2009. Available at:http://dhmh.maryland.gov/vsa/Documents/09annual.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .). 2 Latendresse G. The interaction between chronic stress and pregnancy: preterm birth from a biobehavioralperspective. J Midwifery Womens Health. 2009;54(1):8-17. [PubMed] 3 McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21(2):78-93. [PubMed] 4 Filene JH, Kaminski JW, Valle LA, et al. Components associated with home visiting program outcomes: a meta-analysis. Pediatrics. 2013;132 Suppl2:S100-9. [PubMed] 5 Avellar SA, Supplee LH. Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics. 2013;132 Suppl2:S90-9. [PubMed] 6 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health. Healthy start [Web site]. Available at: http://mchb.hrsa.gov/programs/healthystart/. Additional Resources American Public Health Association. Community health workers [Web site]. Available at:http://www.apha.org/membergroups/sections/aphasections/chw/ U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. Connecting those at risk to care: the quick start guide to developing community care coordination pathways. Developed by the Community Care Coordination Learning Network. Available at: http://www.innovations.ahrq.gov/guide/QuickstartGuideTOC.aspx. Rockville Institute. Center for Pathways Community Care Coordination [Web site]. Available at:https://www.rockvilleinstitute.org/CPCCC/index.asp.