摘要：The Patient Protection and Affordable Care Act (PPACA) affords opportunities to sustain the role of community health workers (CHWs). Among myriad strategies encouraged by PPACA are prevention and care coordination, particularly for chronic diseases, chief drivers of increased health care costs. Prevention and care coordination are functions that have been performed by CHWs for decades, particularly among underserved populations. The two key delivery models promoted in the PPACA are accountable care organizations and health homes. Both stress the importance of interdisciplinary, interprofessional health care teams, the ideal context for integrating CHWs. Equally important, the payment structures encouraged by PPACA to support these delivery models offer the vehicles to sustain the role of these valued workers. The Patient Protection and Affordable Care Act (PPACA), with its interconnected emphasis on improving quality and reducing cost, provides unprecedented opportunities for CHWs to serve more formally as integral participants in fixing a fragmented health care system that threatens not only this country's solvency but also the well-being of its citizens. CHWs, defined by the US Department of Labor as workers who “assist individuals and communities to adopt healthy behaviors” while helping “to conduct outreach” and “advocate for individuals and community health needs,” 1 remain to a large extent an underused workforce. The PPACA recognizes the role of CHWs in achieving the goal of improving health outcomes and containing costs. In Section 5313 of the PPACA, Subtitle B—Innovations in the Health Care Workforce, CHWs are explicitly cited as an important part of the care team for delivery system reform. 2 Similarly, in Subtitle D—Enhancing Health Care Workforce Education and Training, the law authorizes funding through the Centers for Disease Control and Prevention for CHWs to help promote positive health behaviors and outcomes in medically underserved communities. 3 The PPACA, using the definition for CHWs set by the Department of Labor, 1 outlines several activities for CHWs, including education, guidance, and outreach to ameliorate health problems prevalent in underserved communities; education and outreach regarding health insurance; and education about, referral to, and enrollment of people in appropriate health care and community programs to improve the quality of these services and eliminate duplicative care. According to the PPACA, priorities for these services should be given to communities with a high percentage of uninsured but eligible residents, a high percentage of people with chronic conditions, or high rates of infant mortality. 3 These issues often coexist in the same communities and populations. High-need—and often high-cost—individuals require tailored interventions that are responsive to the complex nexus of underlying social and health challenges plaguing these communities. As members of the communities they serve, CHWs are uniquely positioned to deliver these tailored, culturally responsive interventions. These explicit descriptions of CHW activities in the PPACA are important in understanding their role in increasing access to care and improving health behaviors among medically underserved and vulnerable populations. The PPACA also provides timely opportunities for spurring the formal use and integration of CHWs in health systems. Because these workers gain their core experience from local forms of knowledge, 4 which mirror the social class and racial character of the communities they serve, CHWs can provide unique insight in the development and implementation of care delivery models that emphasize patient-centered care and care coordination, specifically for health, behavioral, and social services. Furthermore, the global payment systems to support these new care delivery models, which are encouraged by the PPACA, can help sustain the role of CHWs. Two promising strategies for achieving improved outcomes and cost savings are delineated in the PPACA: accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). ACOs are provider collaborations that integrate groups of physicians, hospitals, and other providers around the ability to receive shared-savings bonuses by achieving measured quality targets and demonstrating real reductions in overall spending growth for a defined population of patients. 5 The PCMH model under Section 3502 highlights the importance of “prevention initiatives and patient education” along with “care management resources … integrated with community-based prevention and treatment resources.” 6 The references to ACOs and PCMHs throughout the law, moreover, capture a recurring, exhortative theme: teams of interdisciplinary, interprofessional health care providers are critically important for treating patient populations. CHWs have much to offer in advancing these principles. As trusted members of the communities where they live and work, with whom they share common racial and ethnic backgrounds, cultures, languages, and life experiences, CHWs are well positioned to help people receive timely care by facilitating access to primary and preventive services and by improving the coordination, quality, and cultural competence of medical care. Despite the demonstrated effectiveness of CHWs, meaningful integration into the health care delivery team has eluded them. Failure to secure sustainable funding sources for reimbursement of services still keeps CHWs at the margins of any health delivery team. The PPACA offers a unique opportunity for the overdue incorporation of CHWs as key members in the health care delivery team.
