Barriers to the Integration of Community Health Workers in Coordinated Care Models: A Qualitative Analysis in the United States

A Research Brief By: Neha Kumar


Community Health Workers (CHWs) are an important component of integrated service delivery and community health, with 51,900 employed in almost 50 states in the United States. More than just public health workers, CHWs are unique because they are often members of the community they are serving and can therefore establish trust and rapport within it. CHWs improve health outcomes, using their connection to the community, through preventive services and targeting social determinants of health. They have been shown to increase access to and quality of health care, while also reducing the overall cost of care., More specifically, they have been successful in targeting chronic conditions like asthma, COPD, diabetes and hypertension.

Often employed in communities that lack access to quality care, CHWs work towards community sustainability by helping members to identify individual needs and determine their own solutions. Although their roles and involvement vary across states, they generally provide services including community outreach, health literacy and education, informal counseling, and serving as a liaison between health and social services and the community. Training for CHWs also differs across states, with nine states currently having an official training and certification program, and several states having state statutes or laws that create advisory boards in order to establish training program curricula. Additionally, CHWs can be paid employees or volunteers, and CHW programs are funded by a variety of public and private agencies.

In order for CHWs to be successful in their roles, they must fully integrate into health systems and care teams; however, there are significant barriers in doing so. Clear role definition and understanding is important in the efficacy of a healthcare team, and the lack of standardization in both the roles and training for CHWs can hinder potential benefits of integration into the team. Many degreed health providers and healthcare systems do not adequately understand how to properly integrate or utilize CHWs to their fullest potential., Additionally, CHWs often face cultural barriers to acceptance in the clinical and healthcare community. Non-standardized training and role definitions lead to a lack of legitimacy, and there are concerns about the standard of care and degree of professionalism in these individuals. There are also significant financial barriers to successfully integrating CHWs, because of funding instability.

CHWs have been used in the United States for decades, but it is only recently that legislation has emphasized their utility in healthcare. The Patient Protection and Affordable Care Act (ACA), passed in 2010, emphasizes community health and integrated care teams: Section 3024 outlines funding for interdisciplinary outreach programs for at-risk populations, and in Section 3021, the Center for Medicaid and Medicare Innovation (CMMI) pushes for testing state-level health service models, called the State Innovation Model (SIM). The purpose of the SIM is to transform healthcare, while improving access, quality and reducing the cost of healthcare. Each participating state's model is different, and some have begun to utilize CHWs as a way to achieve those goals.