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James R. Knickman

James R. Knickman

Posted: October 4, 2010 10:00 AM

While the current debate on health reform has focused on whether it is too much big government, too expensive, or too intrusive, a key challenge is how we will find the medically trained people to take care of our everyday health care needs. Finding people who focus on primary care--especially for the chronically ill--predates the passage of health reform, but will become crucial as 32 million people become newly insured.

On Tuesday, October 5, 2010, an important Institute of Medicine report examining the challenges of developing a health workforce to care for an aging society with more insured Americans will grab headlines.

While the report focuses much of its attention on impending nursing shortages, I hope the national discussion--and the New York State discussion--can focus on the broader issue of developing primary care teams to better manage health needs. The days are ending when a physician, or even a physician and a nurse, do all of the work to manage the care of people with complex chronic conditions.

In our discussions about primary care, we should include a part of our health workforce that plays an important role in improving outcomes and efficiency in managing people with chronic health problems: community health workers.

The Federal health reform law recognizes community health workers as important members of a redesigned health care system that includes more attention to team-based care and community-based services to prevent and manage chronic conditions, like diabetes and asthma. These workers provide a range of services, educating their clients about health issues, like smoking or nutrition, and helping them navigate complex health care and social services systems.

Community health workers have been particularly effective in facilitating enrollment in public health insurance programs and in connecting uninsured clients to the care they need, when they need it. Both of these competencies will be in high demand as an estimated 1.2 million New Yorkers gain health insurance coverage under Federal health reform, but hundreds of thousands remain uninsured.

At a meeting I attended last week, someone asked, "Why community health workers, specifically? What makes them different?" One of my colleagues explained that anyone can read about what it means to go to bed hungry, but a community health worker in a low-income neighborhood has herself or himself gone to bed hungry.

Community health workers are effective because they are members of the communities they serve; they and their clients have a shared experience, language, and understanding that allows for real trust to flourish.

Among the several obstacles to formally integrating community health workers into health care teams, the most daunting is a lack of a mechanism in New York State to reimburse for the services community health workers provide. Other states, like Minnesota, have secured Medicaid reimbursement; New York would be wise to follow suit. Developing a standard scope of practice for the profession and instituting uniform core competencies for training and certification are important first steps to take.

Federal health reform gives us an unprecedented opportunity to reshape the health care system in New York State and to reimagine what a high-quality team of health care providers looks like. Educational institutions, policymakers, health insurers, community health workers, and other health care providers all have a stake in achieving that vision and ensuring that community health workers are an integral part of our shared goal to improve patient care and reduce health care costs.