The advent of pharmacy-based community health workers has helped to expand and codify the pre-existing community-based efforts of pharmacy technicians to reach even outside of medication access.
In the United States, many pharmacy technicians have been doing community health work for years by helping to solve patient problems surrounding medication access, explained Richard N. (Tripp) Logan, III, PharmD, vice president at SEMO Rx Pharmacies and SEMO Rx Care Coordination, in an interview with Pharmacy Times. Yet formalized education in this type of community-based work in the pharmacy is far more recent, with certification programs developing only within the past 3 years. Because of their recent establishment, these pharmacy-based certification programs have pulled from the previously established role of the community health worker (CHW).
“Pharmacy-based CHWs are a relatively new expansion of pharmacy technician duties,” Logan said. “Given the extensive patient access granted by working in a community pharmacy environment, the CHWs working within pharmacy are in a unique position to recognize and address many social determinants of health [SDOH] issues patients have that stand between them and quality health care. We feel that adding these pharmacist-CHW teams to already readily accessible pharmacies positions pharmacy providers very well for current and upcoming value-based arrangements.”
Although the utilization of pharmacy-based CHWs is relatively new and the formalized education even more recent, the CHW role has been present globally for almost 100 years. In the 1930s in China, the first CHWs were farmer scholars and were the forerunners of a type of health care provider role termed “barefoot doctors.” These health care providers worked in rural villages in China and underwent basic medical training to provide primary health care in rural areas that were far from established medical centers. By 1972, there were an estimated 1 million barefoot doctors working in rural China and providing care for a rural population of approximately 800 million people.1
In the 1960s and 1970s, China worked to institutionalize this type of CHW role throughout the country, the success of which brought international attention and prompted an emergence of CHW programs abroad.2,3 The interest in a community-based health care role in the developing world, in particular, was sparked by a reaction to a Western medical model of university-trained physicians serving the health care needs of an entire country, including those of rural and lower-income populations. This Western medical model was proving ineffective in these countries, as disadvantaged populations were continuing to experience extensive health care access issues.1
The barefoot doctor model gained attention as a type of alternative health care worker who could complement the efforts of more highly trained staff to better reach and support rural and lower-income populations. During this period, the barefoot doctor approach was used as a guiding concept for early CHW programs in countries such as Honduras, India, Indonesia, Tanzania, and Venezuela.1
In 1975, the World Health Organization (WHO) published a book entitled Health by the People, which contained a series of case studies from different countries where CHWs were the foundation for community health programs. Although many of the programs outlined were smaller in scale, the book served as part of an intellectual foundation for the International Conference on Primary Health Care at Alma-Ata, USSR—now Kazakhstan—in 1978, which was sponsored by WHO and the United Nations Children’s Fund (UNICEF). This conference was attended by official government representatives from all WHO and UNICEF member countries, making it the first global health conference of this broad-reaching scale.1
The conference resulted in the Declaration of AlmaAta, which called for the achievement of “Health for All” by the year 2000 and explicitly defined a role for CHWs. Article VII.7 of the declaration states: “Primary health care … relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries, and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”1
Within this definition, CHWs were established as an important provider of health care in applicable circumstances on the global stage.
CHWs in the United States
The ongoing success of CHW programs abroad helped to provide a framework for the United States to develop CHW programs starting in the 1970s.1,2 During this period, a CHW-led section of the American Public Health Association (APHA) was created called the New Professionals Special Primary Interest Group. By 2000, the APHA group changed its name to the Community Health Worker Section and established a definition for the CHW role in US health care: “A [CHW] is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the [CHW] to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”2
Additionally, the Community Health Worker Section further established as a part of this definition that CHWs have a focus on building individual and community capacity by increasing health knowledge and self-sufficiency within communities through outreach activities, such as community education, informal counseling, social support, and advocacy. However, the CHW role was noted as being separate from the role of a health educator, although there remained overlap in scope.2
In 2010, the Bureau of Labor Statistics (BLS) assigned an occupational code to CHWs—one that identified and codified it as separate from the role of a health educator. The assignment of an occupational code by BLS supported the acquisition and collection of further information on CHWs’ work throughout the country, allowing for a more effective and timely exchange of accurate information.2
In the same year, the Patient Protection and Affordable Care Act (PPACA) was passed, identifying CHWs as an important component of the health care workforce. This supported the further development of CHW roles and CHW-led programs across the country due to greater access to federal funding. The PPACA act also officially acknowledged CHWs as legitimate health care professionals, opening a variety of new employment pathways.2
Then, in July 15, 2013, the Centers for Medicare and Medicaid Services (CMS) established a new rule that allowed state Medicaid agencies to reimburse for preventive services provided by professionals that may fall outside a state’s clinical licensure system, as long as the services were initially recommended by a physician or other licensed practitioner. This rule, for the first time, offered state Medicaid agencies the option to reimburse for community-based preventive services, including those of CHWs. This CMS rule took effect on January 1, 2014, and helped to diversify streams of funding for CHWs and CHW-led programs.2
With further resources for the establishment of these roles and further data available on CHW-led programs, BLS was able to begin recording data on the number of CHW roles held by individuals across the country. In 2014, the Bureau of Labor Statistics reported that there were approximately 115,700 employed CHWs practicing in the United States.2
CHWs in US Pharmacies
In US pharmacies, the presence of CHWs has been far more recent, with formalized education for this role established during the past few years.
“While many pharmacy technicians have for years been doing ‘community health work,’ solving patient problems surrounding medication access, etc, the utilization of pharmacy based CHWs are relatively new, within the last 6 or 8 years,” Logan said in the interview with Pharmacy Times. “The formalized education and pharmacy CHW certification are much more recent, within the last 3 or so years.”
Logan noted that pharmacy-based CHWs have the capacity to recognize and address multiple SDOH issues facing patients that have been more difficult for traditional models to impact. Within a pharmacy context, the development of a role that has a foot in both the pharmacy technician and CHW world can help to act as an effective referral and education source for communities. According to Logan, this role can be especially impactful when partnered with community workers in non-profits and faith organizations based in other areas of the community.
“Within the walls of the pharmacy, we have seen the CHWs become the ‘problem solvers.’ If a patient comes in with a SDOH issue, whether directly pharmacy related or not, the CHW is the person other staff members turn to,” Logan said. “It’s very easy to give this sort of patient issue to someone who had created a resource book of solutions and knows how to apply them.”
Specifically, a pharmacy-based CHW can support some common issues facing patients pertaining to expired insurance, high co-pays, and other care access issues concerning medications within the pharmacy. Further, Logan noted that the advent of pharmacy-based CHWs has helped to expand and codify the pre-existing community-based efforts of pharmacy technicians to reach even outside of medication access. Specifically, pharmacy-based CHWs can advocate for patients by ensuring access to housing, transportation, supplies, financial assistance, and other SDOH barriers.
“Working in the pharmacy gives CHWs extensive access to patients and unique insight into SDOH issues, very often in real-time. If a patient enters the pharmacy and their prescriptions are denied for lack of coverage, the pharmacy CHW may actually know that before the patient and be able to address it before it becomes a true barrier to care,” Logan said. “Some patients respond better to a pharmacy CHW in the support of overcoming their personal barriers to care. This can lead to patients receiving new vaccinations and pivoting to taking their medication as prescribed.”