Hospitals and health systems are increasingly facing value-based payments with incentives to keep patients healthy. In response, many health care organizations are developing their own cadres of community health workers (CHWs) in the hopes that they will be able to improve outcomes and reduce the need for expensive emergency department and inpatient hospital care. But the optimal specifications for a CHW role are not well understood. As a result, many leadership teams are asking themselves: “How should we define a job for CHWs to maximize their impact on patient health and health care costs?”
CHW is an umbrella term for a number of different job titles (community health advocates, outreach educators, peer leaders, promotores de salud, doulas, and patient navigators) and roles (outreach, health education, client advocacy and empowerment etc.). In many cases, CHWs are charged with the ambiguous task of “keeping people and communities healthy” without applying intensive medical interventions. Commentators frequently cite CHWs relationship with clients or community as potentially unique within the system, yet the precise mechanisms by which CHWs are able to build or maintain these relationships are not clearly delineated.
Evidence to date on the use of CHWs to improve health of low-income communities in the United States has been mixed (see Little, 2014; Palmas, 2014; Kim, 2015), with some studies demonstrating substantial effects and others showing more mixed or null results. However, because studies have not been consistent in their definition of the intervention and the sample patient populations are diverse, the extant literature is of limited use to health care managers looking to build a workforce.
Lacking clear direction, it seems likely that health care managers will write CHW job descriptions (contracts) that resemble others in the health system. These standard contracts reflect the highly regulated nature of health care work, specifying in detail the qualifications, scope, and responsibilities of the employee. The varied and potentially unstructured nature of CHW work invites the question of how best to design an employment contract. Many CHW advocates worry that a prescriptive approach to CHW contracting will specify tasks to such a degree that the aspects of the role that many believe are key to CHWs’ success will be crowded out. For instance, a task-orientation may diminish CHWs ability to build authentic relationships, creatively problem-solve, respond to root causes of illness and provide culturally appropriate individualized solutions to client challenges.
Standard contracting risks short circuiting communication channels between the community and the organization, preventing CHW hires from fulfilling their potential.
An alternative approach to managing CHWs, one that relies on “relational” contract design, could afford CHWs greater flexibility to build trusting relationships with and meet the individual needs of patients. Economists Robert Gibbons and Rebecca Henderson define a relational contract as an understanding between two parties that is based on subjective measures enforced by the shadow of the future rather than threat of legal action. The intention of a relational contract is to avoid distortions of behavior caused by tight linkages between financial incentives and quantitative metrics. The result is that the contract is grounded in the mutual trust of the employer and employee, but the challenge of such contracts is that they can be notoriously difficult to manage as the metrics of assessment are intentionally ill-defined. Economic and game theoretic explorations of relational contracts suggest that they should provide firms with a competitive advantage, but only a few observational case studies are available.
It is not immediately clear whether either of these two approaches—standard or relational contracting—would yield consistently better results for the health system or for CHWs’ patients. When we talk to people about these two approaches, health care professionals tend to gravitate towards a preference for standard, highly-specified CHW contracts. This is a natural reaction given the gains made by evidence-based medicine and the value of clearly specified processes (see: The Checklist Manifesto). However, the CHW community tends to favor a more relational approach. Their thinking is supported by the management literature on task uncertainty, wherein higher task uncertainty calls for greater role autonomy and role flexibility.
Contract design should be top of mind for organizations planning to develop a CHW workforce. If not managed carefully, health care administrators may unwittingly undermine CHW effectiveness. Standard contracting risks short circuiting communication channels between the community and the organization, preventing CHW hires from fulfilling their potential. In particular, CHWs may become frustrated and unhappy if they are limited to task-based work in the face of relational challenges, elevating the risk of burnout and attrition. On the other hand, managers in health care organizations are accustomed to supervising staff with clearly defined tasks, and may not have the skill set—or interest—to undertake a relational management style. Meanwhile, CHWs may perceive managerial support to be lacking or performance expectations to be unclear if working in poorly executed relational contracts.
In sum, health systems would be wise to pay attention to both the skills that CHWs bring to the role and how the organization defines the role for employees. New workforce management strategies may well be needed in order for health care to successfully expand its influence into the community.