Opportunities to Enhance Health Equity by Integrating Community Health Workers into Payment and Care Delivery Reforms

Executive Summary

Growing interest in advancing health equity among health systems, payers, government agencies, and community based organizations, and initiatives such as the Centers for Medicare & Medicaid Services’ (CMS) Framework for Health Equity has created a window of opportunity to translate evidence gathered during the COVID-19 pandemic into broader, equity-focused health care transformation efforts. The COVID-19 pandemic has underscored the importance of developing and sustaining a robust health workforce at the community level. Community health workers (CHWs), also known as promotoras or promotores de salud, lay health advisers, or health navigators have served in critical roles to improve equitable access to COVID-19 testing, vaccination, and therapeutics. Community-based care delivery models can bridge systemic and cultural gaps in coverage, service delivery, and affordability, demonstrating potential to make meaningful improvements in health outcomes and reduce
health disparities.

Evidence from a review of the initial publications generated by the Rapid Acceleration of Diagnostics – Underserved Populations (RADx-UP) initiative demonstrates that community-based care delivery models that prioritize CHWs in a health care workforce can not only respond during acute public health crises, but also be incorporated sustainably into existing infrastructure to support the design and implementation of equitable health policy and practice. In 2020, the National Institutes of Health (NIH) invested more than $500 million in community-based COVID-19 testing and associated services through the RADx-UP initiative. Many of the 137 RADx-UP projects embedded CHWs as key partners in their programmatic infrastructure to reduce inequities in COVID-19 testing. In this policy brief, we have synthesized experiences from RADx-UP projects during the COVID-19 pandemic and identified policy changes that prioritize community health in payment and care delivery
reforms.

CHWs that collaborated with RADx-UP projects served in multiple roles on a continuum ranging from advisory to outreach to shared project leadership. In the majority of studies we reviewed, where the CHW role was defined, CHW roles included disseminating culturally and linguistically appropriate information about the COVID-19 pandemic, providing direct services such as administering COVID-19 tests, and coordinating care and health system navigation. Additional CHW roles reported by RADx-UP projects included patient outreach, research and evaluation, community assessment, and community advocacy. As demonstrated through the RADx-UP initiative, the trust building and relationship development necessary for successful community-engaged interventions require time, organizational capacity, and financial resources dedicated to these activities. CHWs are essential links in community based care delivery models and assume a variety of critical roles both within and outside of clinical settings. Therefore, policy efforts to sustain these models can focus on aligning lessons learned from the COVID-19 pandemic to broader health care transformation initiatives. Policy efforts to sustain CHW models include revising quality metrics to support CHW engagement in care delivery, expanding alternative payment models (APMs) to prioritize CHWs in transformation efforts, using existing competency frameworks to outline reimbursable CHW roles, and creating multi-year funding opportunities that support robust measurement and evaluation.