An idea for Montana - State plan endorses community health workers

The Partners In Health, known in Haitian Creole as Zanmi Lasante(ZL/PIH), headquarters resides in a huge state-of-the-art hospital in Mirebalais, about a half-hour drive southwest of Cange. On what has become a typical morning there, hundreds of Haitians crowd onto wooden benches inside. More spill out of the entryways into the tropical sun. Some sleep on blankets or cardboard in the shade of bushes planted along the hospital's white walls. A young woman strolls toward the exit, a newborn in her arms and a gaggle of friends skipping behind her, shouting excitedly, "She's a mom!"

In a cramped office upstairs, Père Eddy Eustache, director of mental health, speaks in crisp, undulating English about why his organization opted to address the needs of this mountainous region with community health workers in the first place.

"When Zanmi-Lasante brought this community-based approach, the main goal was to bridge the rural area to the urban one," Eustache says. "To bridge the destitute to the privileged people. And how can you do that without representatives of these neglected, these outsider people? And we came to find ... this person, men or women, first of all must be living in his or her community of belonging. Physically present. Sharing the daily life of the people. Almost of the same condition."

Similarly, in a June 2016 report on health-care innovation and reform, Gov. Steve Bullock's administration cited community health workers (CHWs') double roles as frontline care providers and community liaisons as a compelling reason for embracing the CHW model. According to the Montana Healthcare Workforce Advisory Committee, 15 of the state's 56 counties contained no licensed social workers in 2017. Thirty-one counties lacked licensed clinical psychologists, and 40 lacked psychiatrists. And with recent mass layoffs of other frontline health-care workers after last year's budget cuts, the need for community-based aid and advocacy has only grown.

CHWs have been implemented by various nonprofit providers throughout the state for years. Researchers often refer to the practice of transferring non-specialist duties to lightly trained community members as "task-sharing," an approach that increases accessibility for patients while decreasing reliance on faraway specialists and urgent-care centers. However, unlike states with robust government-supported CHW programs, including Oregon, Minnesota and New Mexico, official sanctioning via certification or training hasn't come to Montana. Until now.

This June, five state-affiliated area health education centers launched Montana's first-ever online training course for community health workers. Developed over a two-year period with the help of a $140,772 grant from the Montana Healthcare Foundation, the new standardized curriculum is open to anyone with a high school diploma and designed to prepare individuals for engagement in "various activities including outreach, community education, informal counseling, social support and advocacy depending on the needs of the employing facility/organization." Kris Juliar, director of the Montana Office of Rural Health & Area Health Education Center in Bozeman, says Montana CHWs will operate as component parts of broader health-care teams. While she anticipates growing interest in the position, Juliar cautions that it may take some time to see CHWs in action in Montana.

"We're trying to be really careful about not training people for jobs that don't exist," she says. "The job market for community health workers is really in its infancy in Montana. There's definitely some opportunities out there, but if I trained you to be a community health worker, could you go out and find a job in that? Right now I think it'd be difficult."

Mental health is not a primary focus of the training yet, but Juliar says that MHF is already developing additional training material for CHWs tailored to that need.

With a fledgling CHW presence now in the offing here, Partners in Health's work in Haiti offers a window into a possible future of health care in Montana. Partners in Health has gradually grown its cadre of mental health-focused CHWs from 28 to 59, serving an area that encompasses the country's central plateau and neighboring lower Artibonite region. Drawing on a new round of donations, the organization is currently in the process of raising that number to 81. ZL/PIH's community health workers receive one week of in-person training - about half the length of the 85-hour online course in Montana - covering the basics of physical health, ethics, communication skills, sanitation and detection of infectious diseases. CHW candidates focusing primarily on mental health are also trained in depression screening and how to deal with patients displaying psychosis, agitation, epilepsy and suicidal ideation. They do not diagnose, but are able to refer patients to more specialized care if needed. ZL/PIH's mental health director, Père Eddy Eustache, does not see CHWs as representatives of the organization, despite the financial incentives they receive. Instead, he says, people like Joseph Benissois are advocates for their own communities, people who must be above political and moral suspicion, not only trusted by patients, but able to spur local community leaders, religious leaders and traditional healers to bring about change in public attitudes toward mental health.

"Here, for instance, people say if I hit you as a crazy person, you need to hit me back, otherwise you'll get mentally sick as well," Eustache says. "There's another aspect of stigma. It's underlining, for instance, the total impossibility for someone to recover 100 percent from mental illness. They'll say who got crazy once was always that crazy. Can you see how solid it is, a belief that is tied to stigma?"

For Montana, the obvious question becomes one of efficacy. A 2007 policy report by the World Health Organization warned that the failure of numerous CHW programs worldwide due to poor planning and underestimation of the effort required to execute them has "unnecessarily undermined and damaged the credibility of the CHW concept." The effectiveness of CHWs across the globe has been the subject of considerable research in recent decades. Those studies have focused on CHW work on a variety of health conditions - tuberculosis, HIV, diabetes - as well as their integration into more robust health teams made up of various specialists and lay caregivers. One such study, conducted in Zaire, found that over a two-year period in the late 1990s, 65 percent of malaria cases in 12 villages were treated by CHWs and documented a 50 percent decrease in morbidity compared to a control area with a single health center with no CHWs. Many of these studies have been conducted at project sites in poverty-stricken countries, and among the most commonly cited deficiencies in the body of CHW research is the need for greater focus on the longer-term results of CHW application.

"Without data across years, researchers cannot look at global trends and progress made over time," the Frontline Health Workers Coalition, a global alliance of healthcare NGOs, wrote in a 2014 report on the need to improve CHW data. "Further, lack of data on CHWs prevents CHWs and their supporters from being able to effectively advocate in the policy arena."

Research on CHW programs in the United States is even less robust. A 2007 Community Health Worker National Workforce Study compiled by the U.S. Department of Health and Human Services estimated there were 121,206 CHWs employed nationwide - a 41 percent increase over 2000. However, the study, the only one of its kind the agency has published to date, offered the caveat that there is "no statistical evidence, of the size and direction of change in the community health worker workforce." Papers that have been published indicate that wider use of CHWs holds promise for increased access to and utilization of health care. A 2016 study in the Journal of General Internal Medicine found that in most cases involving chronic conditions like diabetes, asthma and hypertension, CHW interventions drove down patient costs and reduced hospitalizations and urgent care visits. On the mental health front in particular, a 2018 review of literature by several California-based researchers found that CHWs could, domestically, be mobilized to serve as primary providers of evidence-based treatments in areas with "severe workforce shortages," and even be involved in the delivery of those treatments in more resource-rich settings. "CHW-delivered prevention and early intervention services would allow trained mental health professionals to focus their expertise on individuals who require more intensive services," the study continued, though the authors cautioned that additional research is needed to understand how to sustain CHW-centric efforts.

In Montana, the project launched in 2015 has repeatedly cited the potential for CHWs to engage in community education and outreach, informal counseling and the linking of medical and social services as reasons to not only develop a standardized training curriculum, but to establish mechanisms for data collection and continued discussion among various individuals, organizations and state agencies. And based on six years of fieldwork and research in Haiti's central plateau, Bonnie Kaiser, professor of anthropology and global health at the University of California San Diego, agrees that community health workers like those employed by ZL/PIH could similarly benefit rural Montana when it comes to mental health access and treatment.

"Reaching people in the communities they live in is a much more successful model for actually linking to care," Kaiser says. "And having it be people who are trusted community members when it's an issue that can be really stigmatized is really important, because it's the kind of thing people might not seek care for a number of reasons. But they'd be fine chatting to a friend or neighbor, because that just feels a little bit safer and less stigmatizing than saying, 'I'm going to a psychiatrist.'"