A Community Health Model Takes Hold in Texas

By Katherine Corley

Reporting Texas

In 2017, over 131,000 Texans died from chronic diseases – nearly equivalent to the population of the city of Waco. To lessen the toll such illnesses exact, the Texas Senate is considering a bill that would enable Medicaid health service providers to hire additional community health workers – a burgeoning profession in Texas that increasingly finds itself on the frontlines of treating chronic disease.

Introduced by Rep. Evelina Ortega, D-El Paso, the bill – HB 2091 – passed the Texas House on May 3, but is “in a tentative place on the Senate side,” Brooke Bennett Galindo, Ortega’s chief of staff said, in an email. Galindo declined to speak further about the bill, out of concern for “endanger[ing] its chances of passing.”  With the end of the 86th Legislative Session quickly approaching on May 27, the bill is still in committee and has yet to be considered by the full Senate, so its chances may be dwindling.

Whichever way it goes, Texas communities clearly need help. According to the CDC, chronic diseases, including heart disease, diabetes, and lower respiratory disease, made up eight of the top 10 causes of death in Texas in 2017, the most recent data available. A 2018 report by the Commonwealth Fund found that Texas ranks last in health-care access and affordability in the United States. Poverty and poor health outcomes run especially rampant along the 1,254 miles of border that Texas shares with Mexico.

“Chronic diseases don’t just show up one day — it’s something that happens over time,” said Jill Ramirez, CEO of Austin’s Latino Health Care Forum and a certified instructor providing community health worker training in Texas through the forum’s PromoSalud program.

Community health workers aren’t medical professionals, but play an important role in helping patients prevent and manage chronic diseases by encouraging patients to keep their medical appointments, take their medications and make healthy lifestyle decisions. Established in 2001, the Texas Community Health Worker Certification program is funded by the federal Maternal and Child Health Block Grant, Lara Anton, press officer for the Texas Department of State Health Services, said in an email. According to DSHS’s 2018 report, Texas has nearly 4,000 certified community health workers, an increase of 47% since 2013.

These workers are often members of the communities they serve and understand their culture and socioeconomic challenges. Many, though not all, are bilingual, allowing them to speak with a patient in her preferred language. They may do home visits or work alongside doctors, nurses and social workers in a clinic. They follow up with patients between visits and reach out to patients who rarely go to the doctor.

“If someone has asthma, and they’re in and out of the emergency room, that means their asthma is poorly managed,” said Dr. Paul Farmer, department chair of global health and social medicine at Harvard Medical School, and U.N. Special Adviser to the Secretary-General. “This problem … is a lack of connection between a hospital, a clinic and a home. Regardless of whether it’s Texas or Liberia, and regardless of whether it’s urban or rural, everybody needs accompaniment [when] facing these kind of problems,” Farmer told Reporting Texas.

Community health workers can also help address other factors that may be negatively impacting a patient’s health, including difficulties with housing, lack of transportation that prevents them from attending appointments and food insecurity.

“When you go to someone’s house and their lights are about to be turned off, they don’t care about managing their diabetes,” said Julie St. John, a member of the Texas Promotor(a) or Community Health Worker Training and Certification Advisory Committee. “[C]ommunity health workers help with that. … Let’s get your electricity taken care of. Let’s get food for your family,” said St. John, an assistant professor in the Department of Public Health at the Texas Tech University Health Sciences Center.

To become certified, community health workers in Texas must complete 160 hours of training in communication, advocacy, teaching and knowledge of a specific health issue, said Adriana Flores, program coordinator for the state’s certification program.

“A very common [specific knowledge base] is heart disease and diabetes,” Flores said.  “There are some areas that are focusing on cancer prevention. Others do tobacco cessation, and there’s some that are covering maternal child health topics.”

Much of the effectiveness of the community health worker model comes from the “trust component,” according to St. John. Patients are more likely to listen to and trust fellow community members than outsiders, even medical providers.

“It’s more like a partnership. Community health workers are like health coaches,” Ramirez said.

The University of Texas at Austin’s Dell Medical School has also joined the movement, exploring how community-based health workers can help improve patient outcomes in Austin. Dell’s Neighborhood Health Initiative, within the Department of Population Health, hired a community health worker for five months in 2018 for a pilot study that surveyed about 100 households in Northeast Austin, assessing different barriers to health.

Ricardo Garay, Dell’s manager for community engagement and health equity, said that they are still processing the data from the pilot study and actively investigating different models that could provide better health care.

“The dream really is to make sure to include the local leaders and the residents to really address the medical barriers,” Garay said. “The community health worker can help a lot … The idea is to be able to reach folks, based on that trust, that traditionally would not participate in health care as much.”

Barriers to health are by no means unique to Texas. Similar community-based delivery models, featuring the relational and preventative power of community health workers, have been surging around the globe.

As the co-founder of Partners in Health, Farmer has spent decades bringing health care to the poorest communities in countries such as Haiti, Peru, Rwanda and Malawi. To Farmer, a robust health care system includes three components: hospitals for critical care, accessible outpatient clinics, and community health workers who link patients to resources.

“[American challenges] are very different from the ones we see in rural Malawi — flood, famine, hunger,” Farmer said. In America, “we see addiction and housing instability. And yet they can still be helped … by community health workers.”

The growth in community health worker programs shows no signs of waning. In 2018, the World Health Organization published evidence-based guidelines to help governments implement effective programs.  At the May 2019 World Health Assembly, the WHO is considering a resolution recognizing that strong community health worker programs are integral to achieving universal health coverage.

Even as the local becomes global, community health care retains a strongly personal approach to health care.  Texas community health worker and instructor Tasha Whitaker, a program coordinator with Baylor Scott and White Health in Waco, emphasizes the importance of connecting with all dimensions of a patient’s life, as everything can impact health and wellness, she said.

“It’s not just about doing for the patient,” Whitaker said. “We always want to empower them – we want to teach them to fish, so that they can teach others how to fish.”