Examining Pre-Release Interventions on HIV Outcomes 12 Months After Release from Louisiana State Corrections.

Louisiana has the highest proportion of people living with HIV (PLWH) in state prison custody. Linkage to care programs minimize odds of HIV care drop-off after release. Louisiana has two pre-release linkage to HIV care programs, one implemented through Louisiana Medicaid and another through the Office of Public Health. We conducted a retrospective cohort study of PLWH released from Louisiana corrections from January 1, 2017 to December 31, 2019. We compared HIV care continuum outcomes within 12 months after release between intervention groups (received any vs. no intervention) using two proportion z-tests and multivariable logistic regression. Of 681 people, 389 (57.1%) were not released from a state prison facility and thus not eligible to receive interventions, 252 (37%) received any intervention, and 228 (33.5%) achieved viral suppression. Linkage to care within 30 days was significantly higher in people who received any intervention (v. no intervention, p = .0142). Receiving any intervention was associated with higher odds of attaining all continuum steps, though only significantly for linkage to care (AOR = 1.592, p = .0083). We also found differences in outcomes by sex, race, age, urbanicity of the return parish (county), and Medicaid enrollment between intervention groups. Receiving any intervention increased the odds of achieving HIV care outcomes, and was significantly impactful at improving care linkage. Interventions must be improved to enhance long-term post-release HIV care continuity and eliminate disparities in care outcomes.

Establishing a health profession: What oncology patient navigators can learn from the National Association of Community Health Workers.

Persons who identify as community health workers (CHWs) may hold other titles and/or certifications, including the title of patient navigator (PN). PN roles first emerged from Dr. Harold Freeman's initiative at Harlem Hospital as a strategy to reduce disparities in access to health care, whereas CHW roles extend beyond health systems and are predominantly found in community-based organizations and nonprofits. Although CHWs' origins in the United States predate those of PNs, the growth of CHWs' professional identity and national representation trails that of PNs despite evidence of CHWs' effectiveness since the 1960s. Barriers to progress have included a pattern of short-term and inequitable funding for CHW positions, a lack of employer support for participation in association business, and broad diversity in CHW roles and work settings. The National Association of Community Health Workers (NACHW) was launched in 2019 and built on earlier organizing efforts by multisector, multicultural CHWs and allies in the CHW section of the American Public Health Association and on efforts to create the American Association of Community Health Workers (2006-2009). Trends in health care financing, increasing calls for racial equity, and the coronavirus disease 2019 (COVID-19) pandemic have amplified the unique abilities and trust that CHWs apply to underresourced, marginalized, and multiethnic populations to address both the social determinants of health and health system access, cost, and quality. As a result, the NACHW has been at the forefront of efforts to improve federal funding for COVID responses, to sustain funding for CHWs and their organizations beyond the pandemic, and to drive equity in the rebuilding of public health infrastructure and the transformation of payment models and health systems. Lessons learned from this process that have implications for the oncology patient navigation field include the persistent need to reinforce the value of self-determination for the profession in matters of policy; the importance of actively cultivating unity among diverse cultural and practice groups within the profession; the essential roles of active volunteer leadership, early staffing, and substantial financial support over an extended startup period; the ongoing need for leadership development within a workforce with limited exposure to a professional association culture; the vital importance of ongoing efforts to collaborate with and build capacity among state-level CHW networks; and the value of opportunistic national collaborations in a rapidly evolving policy environment.

Mixed Method Evaluation of Louisiana's Prerelease Medicaid Enrollment Program, 2017-2019.

BACKGROUND: Over 600,000 people leave US prisons annually. Many are eligible for Medicaid upon release but may need support to enroll. Carceral facilities in nearly half of states have implemented systems to facilitate Medicaid access for those leaving incarceration, but there is limited information on program implementation models or outcomes. OBJECTIVES: To evaluate implementation and initial outcomes of Louisiana's prison-based Prerelease Medicaid Enrollment Program. METHODS: In this mixed-methods study, we assessed enrollment in Louisiana Medicaid at time of release from prison in the 2 years (2017-2018) after Program implementation, as well as reasons for Medicaid closure (ie, loss of coverage) and health services use 6 months postrelease. In May-June 2019, we conducted interviews statewide with program implementers (n=16) and focus groups in New Orleans, Louisiana with formerly incarcerated Program participants (n=16). RESULTS: A total of 4476 people were included in the quantitative analysis. There was a 34.3 (95% confidence interval: 20.7-47.9) percentage point increase in Medicaid enrollment upon release. Nearly all (98.6%) attended at least 1 outpatient visit and almost half (46.7%) had 1 emergency department visit within 6 months of release. Not responding to information requests was the most common reason for Medicaid closure. Program implementers and formerly incarcerated participants identified Program strengths, barriers, and suggestions for improvement. CONCLUSIONS: The program was successful in rapidly increasing Medicaid enrollment at the time of prison release and facilitating the use of health care services.

Community Health Worker Activities in Public Health Programs to Prevent Violence: Coding Roles and Scope.

In multiple and related forms, violence is a serious public health issue with lasting impacts on health and wellness in the United States. Community health workers (CHWs) are frontline public health workers and trusted members of communities. We aimed to analyze recent examples of CHW activities in violence prevention public health programs with a goal of informing future programs and research. We collected more than 300 documents published between 2010 and 2020 to identify public health programs to prevent violence including CHW activities. We used an iterative process to develop and apply a coding scheme to the CHW activities. We identified 20 public health programs to prevent violence which included CHW activities. CHWs most often addressed community violence, youth violence, and family violence and played an average of 8 of 10 core roles per program. Fewer than a third (i.e., 6 programs) reported community-focused CHW activities to address upstream and structural determinants of health inequities. This first examination, to our knowledge, of the intersection of the CHW and violence prevention literature shows that CHWs have played many of their core roles in public health programs to address multiple forms of violence. (Am J Public Health. 2022;112(8):1191-1201. https://doi.org/10.2105/AJPH.2022.306865).

Action to Improve Social Determinants of Health: Outcomes of Leadership and Advocacy Training for Community Residents.

Racial and ethnic disparities remain a public health problem and are largely due to social determinants of health (SDOH). Using an adapted 36-hour community health worker (CHW) curriculum, we trained 42 lay community residents in New Orleans, Louisiana, neighborhoods experiencing disparities in leadership and advocacy skills to address SDOH. Six months posttraining, 29 participants completed a follow-up survey and interview. Participants described increases in knowledge, self-efficacy, and activities related to leadership and advocacy at all levels of the social ecological model. We also found a significant increase in communicating with Louisiana state senators or representatives (p < .0339). Our findings show that an adapted CHW training curriculum focused on SDOH, leadership, and advocacy can be used to train lay community residents in how to make changes in the community conditions that affect health and prompt new engagement to address SDOH at all levels of the social ecological model. Future efforts to increase lay community participation in addressing SDOH may benefit from providing ongoing support to participants such as organizing meetings with residents interested in similar topics, offering opportunities to "shadow" experienced CHWs, or hosting additional skills building workshops.

Promoting Community Health Worker Leadership in Policy Development: Results from a Louisiana Workforce Study.

Community health workers (CHWs) are effective in improving public health, and many states are developing policy to support the workforce. In 2019, the Louisiana legislature created the CHW Workforce Study Committee (Committee) of at least half CHWs to study the workforce and provide the state with policy recommendations. The Committee followed national best practices in CHW engagement. A CHW and an academic team identified CHWs and employers statewide, administered a survey in partnership with a CHW professional association, and conducted in-depth interviews with CHWs and employers. Descriptive statistics were used to summarize survey data and applied thematic analysis was used to interpret interview transcripts. Sixty-five CHWs and 37 employers participated in the survey. Twenty-one CHWs and 15 employers completed interviews. Survey data indicated that Louisiana CHW roles and activities are consistent with national research. Interviews revealed a lack of knowledge about CHWs among key stakeholders, CHW workforce challenges including lack of community and professional resources, and differing ideas about the value of common workforce development practices such as standardized training and credentialing. Findings suggest a need for widespread education about CHWs and support for CHW participation in professional associations to address common workforce challenges. CHW co-leadership and partnering with a CHW professional association enabled successful study execution and full participation of CHWs in the formation of Committee recommendations. A subset of Committee members, made up of at least half CHWs, continues to meet to expand and support the workforce.

Training Community Residents to Address Social Determinants of Health in Underresourced Communities.

Disparities in chronic disease and life expectancy remain a significant public health problem and are largely attributable to social determinants of health. Community health workers (CHWs) promote health equity through individual- and community-level activities, and leadership and advocacy skills training make CHWs more likely to catalyze structural change. CHWs are increasingly being integrated into clinical practices to support care management, creating a need for new grassroots community-level advocates. We adapted for community residents an existing CHW training curriculum focused on social determinants of health and effecting community change. We offered 36 hours of training at community-based locations in New Orleans, Louisiana. We assessed baseline civic and community participation and pre- and postknowledge for each lesson. Among 43 enrollees, 42 completed the program. The majority were Black (92.7%), female (92.7%), and retired or unemployed (77.5%), with a median age of 61.5 years. In the past year, 85% of participants had volunteered, 57.1% had been involved with a community organization, and 32.4% had contacted the city council. Participants demonstrated statistically significant increases in knowledge in 5 of 6 lessons. Our success in increasing knowledge of advocacy among a civically engaged group suggests that trainees may become community leaders in addressing social determinants of health.

Medicaid Utilization Before and After a Natural Disaster in the 2016 Baton Rouge-Area Flood.

Objectives. To understand changes in behavioral health services utilization and expenditures before and after natural disaster with an adult Medicaid population affected by the Baton Rouge, Louisiana-area flood (August 2016).Methods. We examined de-identified behavioral health claims data for Medicaid-insured adults in the affected region for 10 months before and after flooding (October 2015-June 2017). This constituted 273 233 provider claims for 22 196 individuals. Claims data included patient gender, behavioral health diagnoses, treatment dates, and costs. We made adjustments for Medicaid expansion by using monthly enrollment data.Results. Overall, most male patient behavioral health care visits were for substance use disorders (33.6%) and most female patient behavioral health care visits were for depression-related disorders (30%). Both diagnostic categories increased after the flood by 66% and 44%, respectively. Expansion accounted for a 4% increase in claims. Postflood claims reflected 8% to 10% higher costs.Conclusions. Greater amounts of behavioral health care services were sought in all 10 months of the postflood study period. We observed gender differences in use of services and diagnoses. Behavioral health care services following natural disasters must be extended longer than traditionally expected, with consideration for specific population needs.

Preparedness and Community Resilience in Disaster-Prone Areas: Cross-Sectoral Collaborations in South Louisiana, 2018.

Objectives. To determine how community-based organizations (CBOs) define priorities for bolstering community resilience, challenges in addressing these priorities, and strategies to address challenges.Methods. The Community Resilience Learning Collaborative and Research Network (C-LEARN) is a multiphase study examining opportunities to improve community resilience to the threats of disaster and climate change in South Louisiana. Phase I of C-LEARN involved using the National Health Security Strategy and Implementation Plan for directed content analysis of key informant interviews with CBO representatives from 47 agencies within South Louisiana between February and May 2018.Results. CBO interviewees highlighted the importance of forging relationships and building trust through diverse cross-sector collaborations and partnerships before disasters. Such collaborations and partnerships were shown to tailor disaster response to the needs of particular communities and populations as well as address key challenges such as gaps in information, services, and resources.Conclusions. Our results encourage a culture of community resilience and community preparedness through partnerships and community-engaged strategies. C-LEARN will utilize the results of our interviews in the design of phase II of our agency-level coalition-building intervention.

Lessons on Patient and Stakeholder Engagement Strategies for Pipeline to Proposal Awards.

The Patient Centered Outcomes Research Institute (PCORI) supports patient-centered clinical comparative effectiveness research (CER) including health disparities and engagement portfolios. In 2013, PCORI launched the Pipeline to Proposal (P2P) mechanism to support development of novel patient- and stakeholder-centered partnerships focused on designing clinical CER funding proposals. By providing a tiered structure of successive small contracts and technical assistance, the P2P mechanism encourages development of new research partnerships among diverse stakeholders. As a comparatively new field, patient-centered outcomes research (PCOR) has few well-delineated methods for engaging patients and other non-scientists in effective teams with academics or clinicians to develop and implement rigorous, scientific research proposals. Community partnered participatory research (CPPR) provides a useful framework for structuring new partnerships. In this article we highlight the origins, development, and prospects of three current examples of funded P2P initiatives based in New Orleans and Los Angeles. We outline how these projects - Prisoner to Patient, the NOLA Partnership, and Resilience Among African American Men - use CPPR principles. We also describe how they have collaborated with, and contributed to, a two-way learning and knowledge exchange among members of the PCORI-funded Community and Patient Partnered Research Network. Lessons learned may be applicable to other groups planning to create new partnerships focused on implementing PCOR.

Creating Safe Spaces: A Community Health Worker-Academic Partnered Approach to Addressing Intimate Partner Violence.

Intimate partner violence (IPV) is a persistent public health problem in the United States, with an estimated one in three women experiencing rape, physical violence, and/or stalking by an intimate partner within her lifetime. Non-Hispanic Black women disproportionately experience IPV, but there has been limited success in implementing culturally appropriate prevention programs and services for members of this population. Community health workers (CHWs) are trusted members of under-resourced communities who provide reliable health information and improve the cultural appropriateness of service delivery and may be a vital resource for developing new IPV interventions. Guided by the principles of community partnered participatory research, we developed the CHW-led Safe Spaces project, which aimed to establish a strong academic-community partnership to focus on issues related to experiences of IPV and the prevention of IPV in New Orleans. In this article, we describe the development of our partnership including the formation of an advisory board, creation of a broad-based stakeholder coalition, offering a community partnered participatory research training, conducting IPV education and outreach, and establishing a research agenda. Our processes are replicable and lessons learned may be relevant to other groups seeking to address IPV by leveraging the strengths of community-academic collaborations and CHWs.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity.

Objective: We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans. Setting: A community-academic partnership across Los Angeles County and New Orleans. Methods: Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN. Findings: Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings. Conclusion: The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

Community Health Workers in the United States: Challenges in Identifying, Surveying, and Supporting the Workforce.

Community health workers (CHWs) are members of a growing profession in the United States. Studying this dynamic labor force is challenging, in part because its members have more than 100 different job titles. The demand for timely, accurate information about CHWs is increasing as the profession gains recognition for its ability to improve health outcomes and reduce costs. Although numerous surveys of CHWs have been conducted, the field lacks well-delineated methods for gaining access to this hard-to-identify workforce. We outline methods for surveying CHWs and promising approaches to engage the workforce and other stakeholders in conducting local, state, and national studies. We also highlight successful strategies to overcome challenges in CHW surveys and future directions for surveying the field.

Community Health Workers Promote Civic Engagement and Organizational Capacity to Impact Policy.

Community health workers (CHW) have historically served to link structurally vulnerable populations to broad support systems. Emerging evidence suggests that CHWs engage in various forms of advocacy to promote policy and systems change. We assessed the impact of CHW community advocacy on community change, defined as civic engagement, organizational capacity and policy and systems change. Data are drawn from the 2014 National Community Health Worker Advocacy Survey (N = 1776) aimed to identify the state of the CHW profession, and their impact on health disparities through community advocacy and policy engagement. Our primary analysis used multiple linear regression to assess the association between CHW advocacy and community change. As predicted, there was a significant, positive association between CHW advocacy and change in community conditions. Additionally, both adjusted and sensitivity models had similar standardized beta estimates for advocacy, and adjusted R 2 statistics. CHW advocacy predicts positive change in community conditions and further advances the CHW Community Advocacy Framework designed to support and monitor CHW community advocacy to reduce health disparities through advocacy and policy change.

Do State Community Health Worker Laws Align with Best Available Evidence?

Community health workers (CHWs) are expected to improve patient care and population health while reducing health care costs. Law is a tool states are using to build a supportive infrastructure for the CHW workforce. This study assessed the extent existing state law pertaining to the CHW workforce aligned with best available evidence. We used the previously developed Quality and Impact of Component (QuIC) Evidence Assessment method to identify and prioritize those components that could comprise an evidence-informed CHW policy at the state level. We next assessed the extent codified statutes and regulations in effect as of December 31, 2014 for the 50 states and D.C. included the components identified in the evidence assessment. Fourteen components of an evidence-informed CHW policy were identified; eight had best, three had promising, and three had emerging evidence bases. Codified law in 18 states (35.3 % of 51) pertained to the CHW workforce. Fifteen of these 18 states authorized at least one of the 14 components from the evidence assessment (maximum: nine components, median: 2.5). The most frequently authorized component was a defined scope of practice for CHWs (authorized by eight states) followed by a standard core competency curriculum and inclusion of CHWs in multidisciplinary health care teams (each authorized by six states). States could consider the components presented in this article when developing new or strengthening existing law.

Integrating community health workers into a patient-centered medical home to support disease self-management among Vietnamese Americans: lessons learned.

There is evidence that patient-centered medical homes (PCMHs) and community health workers (CHWs) improve chronic disease management. There are few models for integrating CHWs into PCMHs in order to enhance disease self-management support among diverse populations. In this article, we describe how a community-based nonprofit agency, a PCMH, and academic partners collaborated to develop and implement the Patient Resource and Education Program (PREP). We employed CHWs as PCMH care team members to provide health education and support to Vietnamese American patients with uncontrolled diabetes and/or hypertension. We began by conducting focus groups to assess patient knowledge, desire for support, and availability of community resources. Based on findings, we developed PREP with CHW guidance on cultural tailoring of educational materials and methods. CHWs received training in core competencies related to self-management support principles and conducted the 4-month intervention for PCMH patients. Throughout the program, we conducted process evaluation through structured team meetings and patient satisfaction surveys. We describe successes and challenges associated with PREP delivery including patient recruitment, structuring/documenting visits, and establishing effective care team integration, work flow, and communication. Strategies for mitigating these issues are presented, and we make recommendations for other PCMHs seeking to integrate CHWs into care teams.