Community health workers--a local solution to a global problem.

I the face of persistently lackluster job creation, the U.S. health sector is paradoxically seen as both a contributor to torpid macroeconomic growth and a source of local employment opportunities. Labor costs account for more than half of U.S. health care spending, but as payment structures shift from volumebased reimbursement to the rewarding of value in improving health, the locus of health care delivery will expand from facilities to communities. Ideally, patient care will take place not just in episodic encounters but also through continuous, communitybased partnerships that include new entities and workers. Elsewhere in the world, such care has involved the use of community health workers (CHWs) — lay community members with focused health care training. We believe that scaling up the community health workforce in the United States could improve health outcomes, reduce health care costs, and create jobs. In many countries, CHWs are becoming paid, full-time members of community health systems. In sub-Saharan Africa, the One Million Community Health Workers Campaign is training, deploying, and integrating CHWs into the health system.1 In India, 600,000 CHWs are paid through a fee-forservice system to perform a specific set of primary care functions, such as immunization. In Brazil, community health agents are part of family health teams that now care for 110 million people. And growing evidence reveals the effectiveness of interventions by CHWs in multiple health arenas, such as maternal and child health and chronicdisease management.2 CHWs have been part of the U.S. health care landscape for decades, serving as community advocates, social activists, health promoters, and patient navigators, among other roles. In California and other border states, promotoras and promotores de salud address reproductive health, diabetes, and cardiovascular health. In Arkansas, CHWs have been shown to reduce Medicaid spending by reaching out to people with longterm care needs; in Alaska, they’re part of an effective primary care extension system. Multiple states have created formal accreditation programs for CHWs, and in 2009, the Department of Labor recognized CHWs’ jobs as a distinct category of employment. Yet despite these gains — and in part because of the organic way in which CHWs have emerged — there is little standardization across health systems in terms of gaining access to CHWs, integrating them into health care processes, and compensating them. There are three models for orment of the risks and benefits of the study as a whole. This approach often requires analysts to make judgments when comparing one sort of risk to another. The communication of information on these various forms of risks and benefits to potential study participants requires a balancing act. Detailed explanation of each separate risk may be overwhelming and confusing. Summaries of the risks may oversimplify or underemphasize particular risks.5 Evaluation of the acceptability of studies and of the adequacy of consent forms must reflect consideration and communication about these potential risks and benefits both separately and as a whole.