Community Health Workers: Improving Linkage and Retention in HIV Care

Community health workers (CHWs)—trained lay people, often with lived experiences or cultural identities shared with the clients they work with—can serve as important members of care teams in a variety of settings. Through their life experience, knowledge of the community, and understanding of healthcare systems, CHWs address barriers to healthcare to ensure it is accessible to everyone. Ten organizations across the U.S. integrated CHWs into their multidisciplinary care teams, through Improving Access to Care: Using Community Health Workers to Improve Linkage and Retention in HIV Care, a Ryan White HIV/AIDS Program (RWHAP) initiative from 2016 to 2019. Clients who enrolled in this CHW intervention had statistically significant improvements in viral suppression, antiretroviral therapy (ART) prescription, and appointment attendance after six months in the program.

Birmingham, AL

Mobile, AL

Fort Myers, FL

Lake Charles, LA

New Orleans, LA

Baltimore, MD

Las Vegas, NV

Newark, NJ

Greenville, NC

Houston, TX

Evidence-Informed Intervention
Icon for Intervention Type
Support service delivery model
Icon for HIV Care Continuum
Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Pillar
Treat
Icon for Focus Population
People with HIV
Icon for Priority Funding
RWHAP Part A; RWHAP Part B; RWHAP Part C; RWHAP Part D; RWHAP SPNS
Icon for Setting
RWHAP-funded clinic or organization; Community health center, including Federally Qualified Health Centers (FQHCs); Hospital or hospital-based clinic; University-based clinic; Community-based organization/non-clinical setting
Need Addressed

Depending on what their clients need, CHWs make home visits, provide health education, offer treatment support, or make referrals to support services, as well as assist with transportation. The role CHWs play in improving access to care and health outcomes has been documented for a variety of chronic conditions. There is also increasing evidence suggesting that clinical programs integrating CHWs into their settings improve care across the HIV care continuum.1-4 Because of their unique role, often sharing a similar background or experience with clients, CHWs are able to help clients with linkage to and retention in HIV primary care. CHWs coach clients to navigate the care system, offering them skills to interact with their providers, which, in turn, contributes to improved treatment adherence rates. Serving as a bridge between the larger community and the medical and support staff who provide direct care, CHWs have contributed valuable insights into how to address racial and ethnic disparities, as well as social determinants of health such as housing, food, transportation, and employment, which impact many RWHAP clients.

“What I like about the community health workers is they meet your needs where you are individually. They can go outside the box a little bit with you, so to speak.”

Core Elements
Provide culturally-appropriate health education

CHWs deliver health education in a manner that is more accessible to clients, especially if they share similar socioeconomic, cultural, or linguistic identities. CHWS provide health education in the form of structured individual or group sessions, or integrate it more informally during face-to-face meetings or phone conversations with clients.

Care coordination & system navigation

CHWs support engagement and retention in care by coordinating referrals for services such as medical care, behavioral health services, transportation, and other social support services. CHWs should have a working knowledge of local resources and may have first-hand experience navigating benefits and services in the community.

Conducting outreach

As trusted members of the community, CHWs are in a unique position to identify people who are not in care and encourage them to reengage with services. In this capacity, CHWs connect clients, communities, and medical providers. CHWs are in a unique position to “meet clients where they are,” working outside of the clinic, in  homes, parks, or other community settings, to better meet clients’ needs.

Implement individual & community assessments

CHWs have an in-depth knowledge of their communities’ needs and the barriers to care community members may experience. They may play important roles in contributing to community needs assessments, and in assessing the needs of individual clients in their care.

Outcomes

The 10 sites enrolled 397 individuals in the CHW program: the majority of participants were male (69%) and Black/African American (76%). After six months in the CHW program, clients had statistically significant improvements in viral suppression, prescription of antiretroviral therapy, and appointment attendance, compared to baseline.

Category Information
Evaluation data Electronic health record data
Measures
  • Number of HIV primary care appointments attended
  • Prescription of ART 
  • Viral suppression
Results
  • Clients with at least one HIV medical care visit increased from 49.9% to 84.7%.*
  • Clients with an active ART prescription increased from 66.9% to 91.3%.*
  • Clients who were virally suppressed increased from 22.4% to 43.7%.*

* statistically significant 

Source: Drainoni ML, Baughman AL, Bachman SS, et al. Integrating community health workers into HIV care teams: Impact on HIV care outcomes. J HIV/AIDS Soc Serv. 2020; 19:204–19.

“Within HIV care, CHWs are a bridge between HIV clinics and support service agencies and health care organizations.”

Planning & Implementation

Integrating CHWs into a RWHAP clinic requires careful planning and consideration of roles, recruitment, training, and intended outcomes. For this RWHAP-funded SPNS initiative, Boston University provided training, technical assistance, and support to the intervention sites. 

CHW role within organizational context. Consider how CHWs will fit into the broader care team and existing service delivery model at the organization. CHW services should be expansive and complement existing services while focusing on meeting client needs. For example, when medical case managers connect clients to services, CHWs could provide coaching, social support, and encouragement that help clients achieve their goals. Development of CHW roles and responsibilities should be a collaborative effort, incorporating suggestions and feedback from key staff. Clinical champions may help secure buy-in from senior leadership by explaining the approach and vision of the CHW program. Organizations can use the CHW Core Consensus Project’s CHW roles to inform how to define the CHW role in their setting.  

Infrastructure to support CHWs. CHWs are fully integrated staff members who should have a clearly defined job description, designated office space, and resources needed to complete their work. Resources may include a cell phone or access to an agency vehicle for conducting home visits or other community-based work. CHWs should have a clear position on the organizational chart, with a direct supervisor to whom they report, and can bring concerns to, as well as support their professional development.

CHW recruitment strategy. Prior to recruiting and hiring CHWs, decide whether the position should be full- or part-time, based on the organization’s needs. The job description and salary should align with others at the organization, and candidates should have clear opportunities for professional development and career advancement.

Onboarding and training. CHWs should receive the same onboarding, orientation, and training as similar positions in the organization. Foundational training on HIV and CHW core competencies should be an important part of the onboarding process. Immediate inclusion into regularly scheduled meetings and other activities will help the new CHW integrate into the clinic team. Opportunities to shadow other staff members should be provided, regular supervision check-ins scheduled, and opportunities provided for ongoing training and skills building at conferences.

CHW Certification. Although CHW certification is not required, it should be considered if available, as there is an increasing expectation from providers and payers that the scope and training of CHWs be standardized. Certification availability and requirements vary from state to state.

“State health departments are promoting CHW workforce development and supporting CHW employment to address a range of public health issues.”

Sustainability
  • The integration of CHWs is considered a cost-effective strategy to improve health outcomes and address health disparities in a variety of settings. CHWs are recognized as primary care professionals under federal law, and there are now over 40 local, state, and regional CHW networks and associations across the U.S. The National Association of Community Health Workers offers resources to promote professional development and training for CHWs. 
  • Many state Medicaid programs reimburse for CHW services, and services may be eligible for RWHAP funding under the service categories of health education/risk reduction, non-medical case management services, outreach services, or psychosocial support services. 
  • The ongoing success of a CHW program depends on continuous quality improvement (QI) and evaluation. CHWs themselves should play a major role in these QI and evaluation efforts, helping the program to run more effectively and efficiently. These efforts will also equip the organization with CHW program data, including process and outcomes measures, to help garner ongoing financial support for the program.
Lessons Learned
  • Retention strategies, including career and educational opportunities, will strengthen the CHW program. Recruiting and hiring ideal CHW candidates is only the first step in establishing a successful CHW program. A program’s ongoing success will depend on providing professional support and opportunities for growth in order to retain key staff. Consider connecting staff to professional CHW organizations for additional support and mentorship opportunities. 
  • Consider all aspects of hiring CHWs who are clients. CHWs should have shared lived experience and share cultural, linguistic, or other identities with the people they serve. CHW candidates can be recruited from within the clinic or program they receive services from. This type of recruitment can be highly effective because candidates are likely to already have a working knowledge of the programs and services available. In these cases, organizations should consider the potential impacts of employment on CHWs who are receiving RWHAP or other public benefits such as Medicaid, social security insurance/social security disability insurance, or housing benefits. Hiring managers should present information about the CHW salary range and its potential impact on benefits eligibility clearly. They should also explain the implications of various benefits, so CHW candidates understand them, along with related payment options. If candidates are clients at the clinic, hiring managers should also review all policies regarding privacy and confidentiality with them. Boundaries should be established about balancing CHWs’ needs as clients with their potential professional employee roles.
Contact
Boston University
Allyson Baughman, MPH, PhD
Project Director

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