What is the Common Indicators Project?
The Common Indicators Project aims to fill an evaluation knowledge gap by creating a common set of evaluation indicators and measures to capture the contributions of community health workers (CHWs) to successful program outcomes and their added value to health care and human services systems. Using key informant interviews with national CHW experts, Michigan-based focus groups with CHWs, and Michigan-based CHW program surveys, we will identify commonly used indicators and measures of CHW roles, activities and impact. We will compare them across programs and assess the degree to which they capture the unique contributions of CHWs, emphasizing contributions that address the social determinants of health. We will design what will be, to our knowledge, the first common indicators evaluation tool that can be used by CHW programs nationwide to better characterize and evaluate the work and impact of CHWs. This will be the first step toward a larger, externally funded project that would test the tool in settings throughout the United States. The ultimate aim will be to support efforts to achieve sustainability of CHW programs and systematic evaluation of their impact on the health of underserved populations.
Our project focuses on identifying and developing measures that can eventually be used across different types of CHW programs in the United States. We propose to develop a common indicators evaluation tool incorporating process and impact measures to fill the evaluation knowledge gap and bolster what many social services professionals know: that CHWs provide unique contributions to addressing the social determinants of health in ways that improve the behavioral and physical health status of clients and communities.
- Identify commonly used evaluation indicators for CHW roles, activities and impact based on existing literature;
- Conduct national key informant interviews with leaders who have advocated development of common indicators to identify their perspectives on key indicators, measures and data collection methods and build support for a larger-scale project;
- Conduct focus groups with Michigan-based CHWs to identify their perspectives on their roles and activities and identify whether and how they document these;
- Survey Michigan-based CHW programs about current data collection methods and how they measure CHW roles, activities, and impact;
- Identify commonalities and gaps in what is collected, especially regarding how CHWs address social determinants of health and how data are collected/analyzed;
- Propose a common indicator data set and collection methods in the form of a tool.
Why a project like this?
While research continues to demonstrate that employing CHWs is a cost-effective means to improve health outcomes, quality and access to health and human services (Rosenthal et al. 2010; Martinez et al. 2011), and reduce health care costs (Johnson et al. 2012; Fedder et al. 2003; Whitley et al. 2006) in vulnerable communities, sustainability challenges plague the field. Many studies briefly describe CHW activities but rarely measure how they address the social determinants of health or other non-clinical indicators. We know social determinants of health affect health outcomes (Walker et al. 2014), but existing published evaluation tools do not often pick up the key role CHWs play in that process. There is little to no commonality across studies on CHW interventions, and the number and quality of CHW cost-effectiveness studies is lacking (Viswanathan et al. 2009). This hinders efforts to demonstrate the unique contributions or “added value” that CHWs make to health programs, policy makers, health and human service systems and health payers who ultimately hold the keys to CHW sustainability.
CHW advocates have called for development of a common set of evaluation measures that will facilitate comparison across studies and for pooled analyses to strengthen the overall business case and to provide consistent performance measurement tools for health systems to use in evaluating CHWs (Viswanathan et al. 2009; Sinai Urban Health Institute 2014). Time-limited grants support the vast majority of CHW programs, leading to diminished opportunities for sustaining these positive outcomes and CHW employment. The latter is, in itself, a social justice issue when CHWs who share many of characteristics as the populations they serve suffer job instability. The Patient Protection and Affordable Care Act allows for the potential of more stable CHW funding (Act 2010; Shah et al. 2014) but, without better metrics to evaluate the content, impact, and quality of CHW services, the return on investment for more stable CHW funding is a difficult case to make. The Sinai Urban Health Institute proposes three considerations central to effectively evaluating CHW interventions: (1) process, i.e., what activities occurred?; (2) impact, i.e., were actions taken as a result of a CHW intervention?; and (3) outcome, i.e., did client health improve (Sinai Urban Health Institute 2014)?
The CHW research community has made progress on outcomes evaluation, but the field is underdeveloped in process and impact measurement and linking them together in evaluation. Success in isolated areas of CHW evaluation domains (e.g., return-on-investment, linking clients to social services, improved clinical outcomes) cannot substitute for the utility of having common measures to evaluate CHW programs more broadly. Without common process and impact measures that programs can use to explain their successful outcomes, it becomes difficult to make an argument for sustaining existing CHW programs and garnering support for creating new ones.
This project was funded in part with support from the Vivian A. and James L. Curtis Research and Training Center at the University of Michigan School of Social Work.
Click To View References
- Act, P. P. (2010). Public Law 111-148, 42 USC 280g-11, § 399v.
- Fedder, D. O., Chang, R. J., et al. (2003). The effectiveness of a community health worker outreach program on healthcare utilization of west Baltimore City Medicaid patients with diabetes, with or without hypertension. Ethnicity & Disease, 13(1), 22-27.
- Johnson, D., Saavedra P., et al. (2012). Community health workers and medicaid managed care in New Mexico. Journal of Community Health, 37(3), 563-571.
- Martinez, J., Ro, M., et al. (2011). Transforming the delivery of care in the post-health reform era: what role will community health workers play? American Journal of Public Health, e1-5.
- Rosenthal, E. L., Brownstein, J. N., et al. (2010). Community health workers: part of the solution. Health Affairs, 1338-1342.
- Shah, M., Kaselitz, E., Heisler, M. (2013). The role of community health workers in diabetes: update on current literature. Current Diabetes Reports, 13(2), 163-171.
- Shah, M. K., Heisler, M., Davis, M. M. (2014). Community health workers and the Patient Protection and Affordable Care Act: an opportunity for a research, advocacy, and policy agenda. Journal of Health Care for the Poor and Underserved, 25(1), 17-24.
- Sinai Urban Health Institute. (2014). Best practice guidelines for implementing and evaluating community health worker programs in health care settings. Chicago: Sinai Urban Health Institute.
- Viswanathan, M., Kraschnewski, J., et al. (2009). Outcomes of community health worker interventions. Evidence Report/Technology Assessment Number 181. Rockville: Agency for Healthcare Research and Quality.
- Walker, R. J., Smalls, B. L., et al. (2014). Impact of social determinants of health on outcomes for type 2 diabetes: a systematic review. Endocrine, Epub.
- Whitley, E. M., Everhart, R. M., Wright, R. A.. (2006). Measuring return on investment of outreach by community health workers. Journal of Health Care for the Poor and Underserved, 17((1 Suppl)), 6-15.
National Common Indicators Project Collaborative
In October 2015, a group of national experts from five states gathered in Portland, Oregon to discuss the Common Indicators Project. Building on work conducted by the Michigan Community Health Worker Alliance (MiCHWA), and under the auspices of the Oregon CHW Consortium, staff from the Multnomah County Community Capacitation Center (CCC) organized the two-day Summit to make progress on identifying a set of common process and outcome evaluation indicators that can be used by CHW programs around the US, and potentially around the world. The 16 CHWs, researchers, evaluators and program staff from five states who participated in the Summit brought both substantial experience measuring the process and outcomes of CHW programs, and new and fresh perspectives to the work. Participants reviewed MiCHWA’s common indicators work as well as CHW program and evaluation work from their states and engaged in processes leading to consensus on the following proposed list of process and outcome indicators.
National Workshop at APHA 2016
The national group continues to meet and gather data from programs across the country. In October 2016, they hosted a pre-convention workshop at the American Public Health Association’s Annual Meeting. This workshop gathered over 90 CHWs and stakeholders (including researchers/evaluators, supervisors/program managers, and other allies) together for a half day of discussions on CHW evaluation. The program team was overwhelmed by the positive response! Thanks to all who attended.