RN, DNP, CNS, APN, AOCNS®
System Cancer Services,
Memorial Hermann Hospital System
With the current economic strife we are facing in healthcare today, finding ways to deliver quality survivorship care for cancer patients has become a tremendous challenge for oncology nurse navigators (ONNs). It will become even more overwhelming with the estimated 20 million cancer survivors expected by the year 2020. Being willing to forge new relationships will help meet the expected increase in demand for cancer care.
An Idea Forms
In October 2010, I attended the 6th Annual Breast Health Summit of Texas and had the opportunity to participate in a roundtable session pertaining to the topic of community health workers (CHWs). CHWs are members of a community who have been chosen by various entities to provide basic healthcare within the community in which they reside.
The roundtable session was presented by faculty and CHW students from the Houston Community College (HCC) Coleman College for Health Sciences. Concepts related to disparate populations frequently having mistrust of hospital “white coat” workers and perceptions that hospital professionals often “talk down” to impoverished clientele were discussed.
Since CHWs frequently reside among the populations they serve, they have built trust with the members of their community. This can afford CHWs the opportunity to help decrease feelings of mistrust experienced by the populations they help.
Following the session, I was excited by all of the possibilities that could result from establishing a collaborative bond between the CHW and the ONN, not the least of which could be referral of community residents to a known entity—the ONN.
Having spent the last 32 years working primarily in hospital and home care settings in Pennsylvania, Louisiana, Nevada, and Texas, I had never heard of the CHW role. I was even more astonished to learn there was a CHW program in Houston that offered formalized college credit to CHW students and included a practicum option—the first such college program in the state. In fact, the current CHW cohort was even partially sponsored by the Houston chapter of Susan G. Komen for the Cure. Therefore, the curriculum was designed to provide some emphasis regarding the breast cancer patient population and the importance of breast health awareness.
The idea of a collaborative relationship between the ONN and the CHW began to formalize (in this case, through a preceptor/student practicum), but first, I had to learn more about the CHW role and also explain the ONN role to college faculty, who were not familiar with the position.
Researching the CHW Role
To start the process, I met with the program faculty lead instructor for the HCC CHW program and learned the following:
- CHWs have been recognized in both the United States and worldwide for the past 50 years.
- In the United States, CHWs were first documented in the 1950s as an entity that worked with farm workers in Florida.
- In the 1960s, the New York City Health Department included CHWs in helping them with a tuberculosis program.
- In the late 1960s, CHW programs were developed to help with Native American populations.
- In 1978, the World Health Organization recognized CHWs as becoming a “symbolic milestone” that would become part of the healthcare workforce.
- The CHW officially arrived in Texas in 1989.
During the meeting, I provided a brief history of the patient navigator role as developed by Harold Freeman, MD, more than 20 years ago. I then presented the hospital system’s job definition of the ONN; required qualifications, which included being an oncology certified nurse; and the ONN’s role delineation/description. I further explained that there were 9 ONNs located at 7 out of the system’s 11 acute care facilities—the ones with cancer programs accredited by the American College of Surgeons Commission on Cancer.
Table. Community Health Workers and Their Delivery
|China||1940s||Barefoot Doctors||Initiated by Chairman Mao Zedong due to a lack of medical care for the rural population|
|Brazil||1990s||Community Health Agents||Family Health Program; used to reduce infant mortality rates|
|Iran||1984 – ongoing||Behvarz||Used to reduce infant mortality rates, monitor child growth, and for family planning in the underserved population|
|India||2010 – ongoing||Community Health Workers||Used to increase mental health service utilization|
|Tanzania||2004 – ongoing||Village Health Workers||Community-based safe motherhood approach; assisted pregnant women with safe birth planning|
But this was just the beginning. The information learned in the meeting with HCC faculty provided the impetus for a further review of the literature. In fact, I learned that CHWs had been utilized to help get necessary healthcare to rural populations all around the world. It also seemed that the CHW role was quite similar to the initial navigator role started by Freeman out of Harlem Hospital; both positions were dedicated to helping impoverished populations get the care they need. International examples of the use of CHWs are listed in the Table.
More recently, the US Department of Labor created a job line (DOL-21-1094) for the CHW. It defines the role to include “assisting individuals and communities to adopt healthy behaviors, and conducting outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. They also may provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. Finally, they might collect data to help identify community health needs.”
The Texas Department of State Health Services (DSHS) defines the CHW as a person who may or may not receive compensation but whose duties include some or all of the following:
- Provides cultural mediation between their communities and health and human service systems
- Provides informal counseling and social support
- Provides culturally and linguistically appropriate health education
- Advocates for individual and community needs
- Assures people get the services they need
- Builds individual and community capacity
- Provides referral and follow-up services.
Using the 8 core competencies developed by DSHS—advocacy, capacity building, communication, interpersonal relations, knowledge, organization, service coordination, and teaching—the CHW can work within a community and collaborate with the ONN to assist cancer survivors or possible future cancer patients to navigate the healthcare system throughout the care continuum.
Additional articles were then reviewed to gain further knowledge about CHW interventions with successful outcomes. Examples of CHW-associated successes include:
- Kenya et al. conducted a review of the literature between May 2010 and November 2010 to identify studies carried out in the United States that utilized CHWs to improve highly active antiretroviral therapy (HAART) adherence, and measured HIV viral loads and CD4 cell counts to assess intervention effects. Sixteen studies that met the inclusion criteria were reviewed. It was found that HAART adherence scores improved (defined by a decrease in HIV viral loads and an increase in CD4 counts) in interventional studies of at least 24 weeks, which included frequent contact between CHWs and participants, coupled with a focus on medication management.
- In a study by Krieger et al, 3 CHWs assisted with an asthma management program. CHWs conducted education on management of medications and reduction of in-home asthmatic triggers (after conducting home environmental assessments). They provided ongoing coaching, as well. Services were provided to registered clients in English, Spanish, and Vietnamese. The impact of the CHWs was measured using randomized controlled trials. According to the researchers, the number of days with asthma symptoms was reduced by 4.7 days; the quality of life for caregivers improved by 1.6 on the Pediatric Asthma Caregiver Quality of Life Scale (ranging from 1 to 7, with higher scores indicating better quality of life); children went to the emergency room and hospital less often; and children needing urgent medical attention declined by 64%. From a fiscal perspective, healthcare costs for hospital stays, emergency department visits, and unexpected clinic appointments decreased by an estimated $201-$334 per child (across 2 mo).
- Hunter et al conducted a randomized controlled intervention using promotoras (members of Hispanic communities who promote healthcare awareness and access) on the Texas-Mexico border to increase the use of preventive screening exams among women residing there. The control group received postcard reminders of scheduled screening appointments for pap tests, labs, and blood pressure checks. The intervention group also received reminder visits by the promotoras. The group that received the visits from the promotoras had a 35% increase in actuals visits to get the free screenings.
I went on to query other healthcare providers within my hospital system to see if they were cognizant of this position. Of the individuals queried across 7 campuses, only 1 individual had heard of the CHW and that nurse had “worked with them down in the valley near Brownsville, Texas.” With self-education completed, I now felt more prepared to “pitch” the proposed CHW-ONN collaborative effort.
View Part II of the series.
- Ahluwalia IB, Schmid T, Kouletio M, Kanenda O. An evaluation of a community-based approach to safe motherhood in northwestern Tanzania. Int J Gynaecol Obstet. 2003;82(2):231-240.
- Desimini EM, Kennedy JA, Helsley MF, et al. Making the case for nurse navigators.Oncology Issues. 2011;26(5): 26-33.
- Texas State Department of State Health Services. Community health worker research materials. http://www.dshs.state.tx.us/library/chw.shtm. Accessed February 2, 2012.
- Mushi D, Mpembeni R, Jahn A. Effectiveness of community based motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy Childbirth. 2010;10:14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2858713/. Accessed February 2, 2012.
- Armstrong G, Kermode M, Raja S, Suja S, Chandra P, Jorm AF. A mental health training program for community health workers in India: impact on knowledge and attitudes. Int J Ment Health Syst. 2011;5:17. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169476/. Accessed February 2, 2012.
- Wikipedia. Community health worker. http://en.wikipedia.org/wiki/Community_health_worker#cite_ref-8. Accessed February 2, 2012.
- Huicho L, Scherpbier RW, Nkowane AM, Victora CG; for the Multi-Country Evaluation of IMCI Study Group. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet. 2008;372(9642): 910-916.
- Hunter JB, de Zapien JG, Papenfuss M, Fernandez ML, Meister J, Giuliano AR. The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the U.S.-Mexico border. Health Educ Behav. 2004;31(4 Suppl):18S-28S.
- Isaacs AN, Srinivasan K, Neerakkal I, Jayaram G. Initiating a community mental health programme in Rural Karnataka. IJCM. 2006;31(2):86-87.
- Kenya S, Chida N, Symes S, Shor-Posner G. Can community health workers improve adherence to highly active antiretroviral therapy in the USA? A review of the literature. HIV Medicine. 2011;12(9): 525-534.
- Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. American Journal of Public Health. 2005;95(4):652-659.
- Macinko J, Guanais FC, de Fátima M, de Souza M. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epidemiol Community Health. 2006; 60(1): 13-19.
- Martin M, Hernandez O, Naureckas E, Lantos J. Improving asthma research in an inner-city Latino neighborhood with community health workers. J Asthma. 2005;42(10):891-895.
- Rosenthal MM, Greiner JR. The Barefoot Doctors of China: from political creation to professionalization. Hum Organ. Winter 1982;41(4):330-341.
- Roudi-Fahimi F, Bureau PR. Women's reproductive health in the Middle East and North Africa http://www.prb.org/pdf/WomensReproHealth_Eng.pdf. Accessed February 2, 2012.