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April 18, 2023

CT mulls Medicaid reimbursement for community health workers

YEHYUN KIM / CT MIRROR Roshaun Hoggard, right, shares his health conditions with Monya Sanders. He said having Sanders as a community health worker in the past four years has helped him navigate the medical system since he was released from prison. "Coming home, lots of things have changed in 13 years... If I didn't have the support I had, I don't know where I would be at," Hoggard said.
By Katy Golvala, CT Mirror

Last month, Roshaun Hoggard experienced stomach issues and loss of appetite so severe that he ended up in the emergency room for three days. The ER doctor diagnosed him with diverticulitis, a digestive tract infection, and told him to follow up with his primary care provider. 

After he was discharged, Hoggard reached out to Monya Sanders, the community health worker at Transitions Clinic Network in New Haven. His doctor was booked solid that Friday, but Sanders told him to come in anyway and she’d make sure he got seen.

“She’ll basically do everything but hold your hand out the door when the doctor’s done with you,” said Hoggard with a laugh as he listed all the ways in which Sanders has supported him, with everything from refilling prescriptions to reminding the doctors to get back to him when he reaches out with questions.

Transitions Clinic Network provides primary care to formerly incarcerated people with chronic illnesses. The clinic has three locations in Connecticut — New Haven, Hartford and Bridgeport — with an aim to add more in other cities with high rates of incarceration, like Waterbury, New London and New Britain. Each location employs a community health worker with a history of incarceration.

Sanders said she wishes community health workers had been around when she left prison, nearly two decades ago. Her mother supported her as much as she could, but there was so much about her experience that her parents couldn’t understand. 

“They were preachers and pastors,” said Sanders, who openly discusses her past experiences with mental health challenges, substance use and domestic violence. “They couldn’t really identify with the things I was going through and really didn’t even know how to deal with it.”

Sanders said people coming from incarceration face different pressures, like getting turned down for jobs and reestablishing relationships with children, that only someone who has also been through the experience can understand. “Who better to support them and navigate for them than somebody who has already experienced that?” 

Community health workers, also known as outreach workers, health coaches, patient navigators and promotores de salud, help people navigate health care and social services. They have an encyclopedic knowledge of all the resources available to residents in need, and they are experts in navigating the infinite obstacles that can come up when trying to access them. 

Two bills currently under consideration by the legislature — Senate Bill 10 and Senate Bill 991 — aim to make it easier for organizations to employ community health workers by making their services reimbursable by Medicaid. Currently, the funding for their roles is piecemeal and largely sustained through grants, which can be insufficient and unreliable. 

Puglisi said the change would enable Transitions to hire more community health workers. The New Haven clinic currently sees roughly 240 new patients a year, but the need is far greater.

“We need so many more. Monya is one person in New Haven. We have 900 people coming home a year, 80% of whom likely have a chronic health condition, as best we can tell,” she said.

Community health workers can work at a variety of organizations, including federally qualified health centers, hospitals, community based organizations and foundations, often serving as connectors between systems of care and underserved communities. 

And building trust between the medical system and people it has historically ignored is no small feat, said Lisa Puglisi, a physician and the director of Transitions in Connecticut.

“To help build that trust, it’s full-time effort. It is work,” said Puglisi. “And that’s a lot of what the CHW helps us do.”

Women of color serve as a cornerstone of the workforce. According to a survey, 85% of community health workers in Connecticut identify as women. Forty-four percent and 27% identify as Latino and Black, respectively. 

At Transitions, Sanders assists people with traditional medical needs like refilling prescriptions, scheduling doctor’s visits and arranging transportation to the clinic. She actively participates in appointments, serving as an advocate and ensuring the doctor understands a person’s needs. There’s even one patient who refuses to get a shot without Sanders by her side.

But she also supports people in whichever ways they’re looking to rebuild the foundations of their broader health and well-being, which often starts by getting them ID cards and connecting them to food pantries, job opportunities and housing. 

“Sometimes primary care is at the bottom of the list,” said Sanders. “And I get it because if [someone] doesn’t have anywhere to stay, how is she going to get to the doctor?”

At Transitions, Sanders is particularly passionate about working with the women who come through the clinic’s doors. She runs a weekly support group where women can come together to hang out over pizza and snacks.

Meetings start with everyone sharing “why they’re glad” and “why they’re sad” — a high and low moment from the past week. The conversation hits plenty of serious topics, like preparing for pending court dates or parenting under DCF mandates, but also breaks out into laughter often.

“These women are amazing,” gushed Sanders. “I love them so much.”

One week, a regular attendee walked in with a black eye and bruises from an abusive partner. Everyone in the room offered her hugs and words of solidarity. Sanders encouraged her to see a doctor at the clinic and then went straight to work finding her a safe place to stay.

With Sanders’ help, the woman contacted 211, the state’s hotline for essential services and crisis intervention. She managed to get in touch with someone, but, after a couple days, they still hadn’t found her somewhere to go. By that point, the woman’s abuser was stalking her, said Sanders, so she stepped in, calling 211 herself and asking to speak to the representative’s supervisor.

“I was not taking no for an answer,” said Sanders. “This is domestic violence. We’re trying to prevent a death.”

Within hours, the supervisor found the woman a bed at a domestic violence shelter. Sanders, along with a colleague, made the drive with her and helped get her settled in.

A large body of research shows that community health workers improve outcomes for patients. One California study showed that community health workers increased treatment acceptance by 79% among Latino adults with depression and diabetes or heart disease. Another in Florida showed they increased the likelihood of a follow-up appointment after an emergency room visit by 14% among a group of elderly adults with chronic illness. 

“You think of the chronic health condition, and there’s usually strong evidence for a community health worker,” said Puglisi. “And we still fail to fund this evidence-based, highly effective intervention.”

Both bills proposing Medicaid reimbursement for community health workers passed through the human services committee 14-7, with members voting along party lines. 

Rep. Jay Case, R-Winsted, ranking member of the human services committee, said he didn’t vote against Senate Bill 991 because of particular concerns with the proposal itself but more out of concern that the measure was included in two separate bills.

“You get one chance at the apple, and this was in Senate Bill 10,” he said.

Senate Bill 10 is currently in appropriations and Senate Bill 991 is on the Senate calendar.

Fifteen states around the country, including Massachusetts, provide Medicaid reimbursement for CHW services. In another 10 states, managed care organizations — health systems that treat the vast majority of patients with Medicaid in many other states — either provide reimbursement for CHW services or employ them directly. 

Sen. Matt Lesser, D-Middletown, co-chair of the human services committee, said the proposal theoretically allows for Medicaid reimbursement for strictly medical services that CHWs provide but also for navigation of social services, like finding a job or applying for a housing voucher.

“Those would be allowable in theory but ultimately [it] depends on DSS implementation,” he confirmed in a text message. “Advocates hope [the] answer is yes.”

In the meantime, Sanders will continue her work in the community.

“It’s the small, little gestures that make you feel like somebody really does care,” she explained. 

She keeps spare shirts in her trunk in case anyone needs clean clothes and sends ‘I’m thinking of you’ text messages when she knows someone is struggling. Even though she has a work phone, she gives the women in the weekly group her personal number, too, so they know they can reach her day or night.

“It’s just being [a] support. And not just on their good days, but on their bad days, their frustrated days, their wanna-give-up days,” said Sanders. “That’s who I am. That’s what I want to do.”

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