This section explores initial data considerations for designing CHW/P programs, which include determining what data CHW/Ps will collect and how they will collect these data. It describes how to support CHW/Ps in collecting data with technology and other methods, as well as how to evaluate CHW/P programs.
For the full “Key Implementation Approaches” (PDF) section on engaging CHW/Ps in data collection and outcome measurement, access the Resource Guide.
Initial Data Considerations for CHW/P Program Design
CHW/P programs will need to collect and exchange data to address members’ health and social needs, share data with other partner organizations, and evaluate the effectiveness of CHW/P activities. With these broad goals in mind, there are key considerations for MCPs to address in designing data strategies for CHW/P interventions.
- Goal setting. Whether MCPs design their own CHW/P intervention, contract directly with CHW/Ps, or partner with CBOs or other social service entities, they will need to establish what data are required for effective CHW/P activities. Key questions to guide this assessment include the following:
- What is the goal in collecting data?
- What is the best method of data collection to meet that goal?
- What data are most important to support care coordination?
- How can data flow between CHW/P programs and their related providers and MCPs?
- How can health information technology (HIT) or electronic health record (EHR) systems facilitate effective data sharing from the health care setting back to the MCPs?
- How can MCPs and CBOs partner with CHW/Ps as they work to obtain the necessary authorizations and consents, as required by CalAIM?
When CHW/Ps feel empowered to inform what data are being collected, help map data-collection protocols, and lend their expertise in member screening processes, not only do they experience better job satisfaction, but such input from them leads to systems that better serve members.
—Deiter Crawford, CHW
- Information CHW/Ps require to meet member needs. CHW/Ps and care teams are committed to improving member health and social needs by focusing on member-centered goals. MCPs and organizations that employ CHW/Ps should collaborate on the scope of data collection to ensure that the right information is shared and available to meet member needs. If too little information is made available, then the care team may miss out on CHW/P insights and feedback. If too much information is shared, there is a risk of “information overload” whereby CHW/Ps spend valuable time sifting through paperwork or multiple digital apps.
- Shared data agreements in CHW/P programs. MCPs will benefit from establishing data-sharing agreements with CHW/P programs that collect data in the field. For CHW/Ps embedded in a primary care setting, health care delivery entities such as primary care providers and health systems will need to consider how to share data between entities and with the MCP. To support CHW/Ps, providers should not only authorize “read-only” access to EHRs, but also give CHW/Ps time in their day to record social determinants of health (SDOH) and other social needs data into EHRs. With this information and access to these tools, CHW/Ps can accelerate care coordination, highlight potential red flags, and inform care delivery.
CHWs could be really helpful to collect data as part of the assessment. There are a lot of questions that are uncomfortable — and can feel judgmental — so there is a real benefit to identifying and integrating CHWs into the assessment process.
—Managed care plan representative
Infrastructure and Supports to Help CHW/Ps Collect Data
To successfully incorporate CHW/Ps within health and social service delivery, MCPs, providers, and health systems need to build infrastructure that equips CHW/Ps to collect and analyze data, track improvements, and participate in intervention design. CHW/Ps also need the appropriate tools and training to do this work. This preparation will support CHW/Ps’ full participation on the care team (PDF), better job satisfaction, and more effective systems to serve members.
MCPs can start by assessing if there are sufficient resources and suitable technology to enable successful data collection and information sharing where CHW/Ps are employed. Further, seamless data exchange across statewide health and social sectors will require significant infrastructure to support data collection and integration.
- Ensure that data collection supports CHW/Ps’ integration in programs and workflows. MCPs, CBOs, and health care delivery systems will need to determine how to embed CHW/Ps into regular program infrastructure and workflows. MCPs and contracted providers will need to define and establish key data-collection features of CHW/P programs, and CHW/Ps should participate in these discussions. Data-collection supports include (1) well-defined roles and responsibilities for data collection across all positions; (2) infrastructure, technology, and tools to carry out effective data collection across settings, as well as data-sharing agreements; and (3) data-collection standards, processes, and workflows for CHW/Ps. These investments will create a more effective system to share data among health and social service providers, give MCPs the population data required to effectively manage patient populations, and create a seamless experience for members.
- Tools to help CHW/Ps support health and social needs assessments. CHW/Ps can help to engage with hard-to-reach members to complete health assessments needed by MCPs, including individual health risk assessments, social needs screenings, and culturally responsive developmental screenings. Through established, trusting relationships, members may provide more accurate data to CHW/Ps than they would to clinicians. Regardless of the tool used, screening tools provide population data that can help meet MCP requirements for health risk assessment completion and inform CHW/P activities, population health programs, targeted community investments, new collaborations, and planning with payers and the state. Further, it is important for MCPs to collect Z-codes so SDOH assessments can be used as part of risk adjustment and, ultimately, rate setting.
RELATED RESOURCES: The “Resources and Tools” section includes links to available behavioral health and SDOH screening tools.
- Sharing member data. Because building trust is a critical component of the CHW/P-member relationship, CHW/Ps should be familiar with how the information they are collecting will be used by the member’s care team. MCPs, CBOs, and other entities will need to ensure that privacy policies and protocols are in effect and clearly understood by CHW/Ps so that they can, in turn, clearly communicate that to members. CHW/P programs will also need to balance building rapport with members with the need for assessments and data collection and be mindful that building and maintaining trust is a priority for CHW/Ps.
- Technology considerations. There are important considerations for MCPs to weigh in integrating a CHW/P workforce into their health information technology infrastructure. At a minimum, MCPs should use standardized tools and data-collection methods, as well as platforms, to connect CHW/P encounter data with members’ EHRs. Despite the tremendous challenges of seamless and meaningful integration of health and social data, there are promising signs of innovations that will achieve these goals. The IMPaCT model’s use of HOMEBASE and the Pathways HUB model are two examples of technologies that support CHW/P data collection while integrating health and social service data (see box below).
Models and Technologies to Support CHW/P Data Collection and Integration
The Pathway Community HUB model. One approach that integrates health and social sectors in hubs across the country is the Pathways Community HUB 2.0 Model, which helps communities work together to support their vulnerable populations. This model is used by MCPs to standardize quality measures and outcomes for CHWs related to risk mitigation across clinical and social categories. The HUB acts as a community care coordination system focused on reducing modifiable risk factors for high-risk individuals and populations by engaging a community-connected health workforce, including CHW/Ps, to link members to needed health and social services. These critical member connections to community services are achieved through closed-loop referrals and streamlined data collection, communication, and information exchange.
IMPaCT model. The Penn Center for Community Health Workers is a national center of excellence focused on advancing health equity through effective, sustainable community health worker programs. This center developed IMPaCT, a standardized, scalable model to implement CHW/P activities across the country. The IMPaCT model uses HOMEBASE, a secure, cloud-based platform for CHW workflow and evaluation. This technology integrates with EHRs to pull real-time patient data such as hospital admissions. It also provides patient updates to other members of the care team and allows CHW/Ps to document patient interactions in an easy-to-use format. HOMEBASE includes automated reports that allow supervisors and directors to track triple-aim metrics such as chronic disease control, patient satisfaction, and hospital admissions. Reports also include CHW caseload, frequency of contact, and achievement of patient-centered goals.
Strategies and Metrics to Evaluate CHW/P Activities
After identifying the priority population and conducting a needs assessment, an MCP will need to identify which quantitative and qualitative measures to use to demonstrate the program is meeting individual member needs or population health goals. In addition, evaluation data can track both the level of engagement of individual members and the access to services and overall health and wellness of the priority population. This section outlines considerations for quantitative and qualitative data to evaluate CHW/P interventions and CHW/Ps’ role in quality improvement.
- Using quantitative measures to evaluate CHW/P activities. Metrics established before the launch of a program and adapted over time enable plans and providers to measure quality, evaluate the program, and identify and close gaps in care. For example, CHW/Ps are experts in engaging members in primary care. Measuring member engagement is a good marker to determine greater access to services and opportunities to address health equity. Examples of outcome measures to evaluate CHW/P activities can be found in Exhibit 10 of the Resource Guide (PDF).
- Collecting anecdotal data to evaluate CHW/P activities. Through their ground-level, patient-focused work, CHW/Ps amass extensive qualitative data, including changes in a member’s self-reported health status, employment, housing, involvement with the justice system, or health conditions. These changes in status can be shared with team members to inform treatment, and also shared with plan leadership. MCPs can also use a variety of strategies to gather qualitative data, including surveys, interviews, and focus groups to collect anecdotal information and stories. Collecting data on CHW/P activities and measuring the impact of the program is also about refining the CHW/P model to ensure that the model adapts and evolves.
- CHW/P value in achieving better quality metrics. MCPs can identify what measures will be used to track health outcomes at the population and individual levels. One programmatic best practice (PDF) is to create a treat-to-target model that looks for improvements within the population and in individuals. Anticipated targets are set, and if they are not reached, the provider adjusts the intervention (for example, more education for staff on specific conditions or changing the type of treatment). The MCP can also ask providers to adjust how they are delivering services. If there are no population-level improvements, CHW/Ps can be part of a treat-to-target approach as part of a larger team. On a systems level, CHW/Ps can provide MCPs and other entities with valuable data to analyze community health trends.
- Establishing evaluation metrics for CHW/P programs. Conducting an evaluation to measure the impact of CHW/P programs can help improve quality of care. While there are no standard clinical quality measures specific to CHW/P activities, there are promising models across the country. The Pathways HUB model standardizes quality measures and outcomes for CHWs related to risk mitigation across clinical and social categories. Transitions Clinic Network, which uses a CHW/P-based model of care, deploys a fidelity tool to evaluate clinics that have successfully implemented the model of care to assure they are following the evidence-based model and have similar outcomes. The Common Indicators project provides a set of measures (PDF) that could help MCPs standardize their programs.
Expert Insight on CHW/P Role in Data Collection: Transitions Clinic Network
At the age of 23, Joe Calderon started serving a life sentence. After nearly 20 years incarcerated, he knew he wanted to meaningfully give back to his native San Francisco community upon his release. He currently works as a senior CHW and trainer at the Transitions Clinic Network, a national organization dedicated to improving health and reentry outcomes for those returning to the community from incarceration. His lived experience allows him to deeply connect to his clients who find it challenging to reenter society. His clients look up to him as a role model and trust him as a resource, as he navigated similar challenges.
Given the reentry community’s negative experiences with unjust institutions, collecting people’s data is often a challenge. Joe understands the nuances of this and emphasizes that hiring those with lived experience is the key to building trust with populations that have been most marginalized by systems of oppression. He elaborates: “One question that could be liberating for one could be disrespectful to another. When you’re asking about the social determinants of health, some people are prideful — they might not want to tell you they’re hungry at night. When we think about using community health workers to collect this social health data, we must do so correctly by hiring people from the community they serve. They’ll understand how to walk on that rice paper, make it happen, and get the data most useful for the health system and MCPs.”
It’s important to remember that while the data is out there, the personal connection with somebody – that’s what makes it. That’s where you are able to see the full story.