The implementation strategies most frequently described by sites were associated with organizational-level adaptations in order to integrate the CHW into the HIV care team. These included revising, defining, and differentiating professional roles and changing organizational policies. Strategies used for implementation, such as network weaving, supervision, and promoting adaptability, were second most commonly cited strategies, followed by training and TA strategies.
3.1 Role Clarification
The most commonly referenced code was the ERIC project organizational change strategy: Revise Professional Roles, which was updated to include define and differentiate for the purposes of this analysis. Sites described having to clarify roles to avoid confusion and service duplication:
… It took a lot of fine tuning to really define specifically how [the CHW role] would complement without... overlapping too much.
Ambiguity with respect to role was frequently raised with respect to how traditional HIV case management activities compared to CHW functions. Case management is described as a CHW function in the literature; however, as was noted by multiple sites, the role of “case manager” is specific in the context of HIV care and different from the non-medical case management provided by the CHW. Similarly, sites found it necessary to clarify the difference between the CHW and the peer role. Peers and CHWs both play a supportive role in HIV care. Shared experience provides peers and CHWs with a nuanced understanding of factors the facilitate and pose barriers to care and treatment seeking. The shared experience for peers is a one of a shared diagnosis, and while this may also be the case for the CHW, it is not always the case. The CHW can also share an experience related to community context. CHWs understand the local landscape and are able to navigate it, serving as a critical bridge between 1) the care team and the community, 2) the patient and health care organizations and 3) the patient and the care team. Sites did see a benefit in having the CHW as a peer, because of the ability to bill the Ryan White HIV/AIDS Program for services that fell under the peer role. In addition, CHWs who were peers had a nuanced understanding of treatment and disclosure, which facilitated their ability to build rapport with patients, especially in the case of newly diagnosed patients.
Organizational leadership emphasized having to educate staff about the CHW role before and throughout program implementation. The term CHW, in and of itself, was seen as ambiguous. Sites described it as unclear, reporting it was not descriptive of the role:
CHW is a vague term and in the agency, we have to get specific with people to help people to see their [CHW] roles.
In some cases, organizations added words to the title in an attempt to clarify the role. Others reported the Ryan White HIV/AIDS Program HIV care roles did not align with the CHW role and tried to fit the CHW responsibilities into the context of existing Ryan White HIV/AIDS Program-defined roles. The CHW role can be difficult to fund and because it was not reimbursable in some cases sites tried to fit the CHW role into an existing title. This was documented by an evaluator during a site visit:
The site calls the CHWs “Community Health Workers/Support Specialists.” The reason for this is that [name] views them as providing support services, which is different from the case manager role, which in their case is a medical case manager. However, their Ryan White Director, [name], thought it was very important that they maintain the community language in the job title because s/he wants it to be clear that they are not clinic-based only, but go into the community. The language also helps clarify that this staff member is connected to the Ryan White job titles [service categories].
Sites approached role clarification in a number of different ways. They commonly defined roles in the context of the workflow, outlining relationships between care team members. Task division also helped sites to clarify roles:
At the start everything was so new, everyone had lots of questions and so we set up the referral processes (where supervisors vetted the request) and that is part of the reason for setting up the referral process. Helped to clarify the role.
For a while, CHWs were not assigned to individual patients and they found there was overlap; the team is now working to address boundaries and clarify which worker will be connected to each patient. They have moved from shared clients to individual caseloads, which is considered much better. The model, however, allows for good flexibility and backing each other up. Essentially the [Blinded University Name] CHW program has really helped them to fix an evolving model and gave structure to the CHW role. The goal is for the program to be transitional and last 90 days with people linked to services, but there is flexibility.
Overall, role clarification highlighted the benefits of the CHW role to the care team, which was seen as contributing to referrals and engagement by team members with the CHW. It also helped to set boundaries around the CHW role, reducing the tendency of providers to “dump” tasks on the CHW. Finally, it reduced territorialism, which occurred when case managers felt the CHW was infringing upon their work and clients.
3.2 Organizational Policy and Procedural Change
The implementation strategy of changing organizational policies was a theme derived from the addition of a new inductive code, Change Organizational Policies, which we determined to be a key strategy utilized by sites but not represented by an existing ERIC project strategy. The new code referred to instances where sites changed organizational policies or procedures to accommodate or facilitate implementation of the intervention. Sites described changing policies and standard operating procedures (SOPs) to facilitate CHW integration. Sites noted developing a number of SOPs related to referrals and workflow, which were instituted to clarify procedures and task coordination across roles. Developing SOPs was more common than changing organizational policies.
So, we're policy light, and SOP heavy. So, we have procedural pieces that are documented around, with some metrics, not very good metrics, to be quite honest with you. We're working on that now. But we have procedural pieces around, this is how you make a referral, this is who's responsible for what. You make a referral, this is how you close it... so the information, the hand-off in the system happens.
The most commonly referenced policies were related to working in the field, specifically related to home visiting and transporting clients. Policies associated with home visiting included safety procedures for working in the field:
I had to put a whole new transportation policy in place with the car logs, the patient logs, and safety – the patient and the staff had to go to the safety classes and what not.
… One issue that relates to this program is trying to standardize things across roles such as CHW and have policies and issues that are consistent for people who go into the field, such as policies around home visiting, use of cars, etc.
In some cases, there were existing policies at the organizational level that needed to be adapted to accommodate the CHW role. There were cases in which sites tried to establish policies at the program level that needed to be adopted at the organizational level. In some cases, organizations were less flexible in accommodating the CHW role and field work outside of the organization, which limited the role of the CHW. Sites also referenced human resource (HR) and labor related policy changes relevant for the CHW program implementation. It was important for sites to look at HR policies related to hiring and degree requirements. In some cases, a CHW position’s educational requirements needed to be changed, such as the previous requirement of a college degree. In others, all positions required a driver’s license, but this was changed because the CHW, like many clients, navigated the community on the bus. Sites also described needing to look at policies related to work hours to accommodate the CHW role. This included policies like flexing the CHWs’ schedule so they could work more when clients were available (e.g., evenings), and policies that allowed CHWs to work more flexible hours compared to other staff.
3.3 Network Weaving
Sites used the implementation strategy of Promote Network Weaving, which the ERIC project describes as building on existing high-quality working relationships and networks within and outside the organization to promote information sharing and collaborative problem-solving, to facilitate CHW integration. Network weaving allowed CHWs to strengthen relationships both within and outside of the organization. Internal network weaving operated through referral mechanisms, care team co-location, care team huddles, and personal relationship building as well as communication that occurred through the electronic medical record between CHWs and other care team members. Internal network weaving amongst the care team improved CHW-client interactions, helped CHWs in their professional development (e.g. supervision), and self-care:
Well, now we're partnering. We have now an intake committee meeting to address the initial intake, the first impression, and she's [the CHW] part of that group because it's essential that she keeps the people linked, especially if she's tested them in the field. They already know her. We have DOH. They cannot always approach our clients appropriately and she is the bridge for that. So, she's very involved with the day to day medical care. And as a referral, she gets flags all the time from staff, "I think that this is someone that [you should see]. It would help if you could reach out to him. I think this is a person who would benefit from your services.” So, she's part of the holistic picture from the beginning.
In addition to the daily huddle, they have other meetings. There is regular case conferencing, done together with both the administrative and clinical supervisors. There used to be case review meetings …. There is also a monthly sexual health team meeting and a wellness meeting at another HIV agency that the CHWs attend. There is an annual [agency] half-day clinical services meeting and a monthly case conference meeting about Spanish-speaking clients.
CHWs performed a great deal of internal network weaving in their role, particularly as a liaison between providers and clients. Network weaving also enhanced role clarity and improved care team cohesion.
In some health centers, there was not as much evidence of internal network weaving. When it was present, it was from CHWs engaging in informal network weaving with coworkers through the development of positive working relationships, which allowed them to find the right people to ask questions of and get things done for their clients outside of the formal organizational structures:
There are no other regular meetings in which she [CHW] has participated. The providers have monthly meetings at the [name] site. The staff report that it is very difficult to get on the agenda for the provider meeting. There has also been discussion of working with the VP of nursing to have a care coordination meeting (with Medical Assistants). … The care team does not participate in huddles either. As soon as the providers arrive at the clinic, they start seeing patients.
In this case, formal internal network weaving was more difficult to achieve. The health care delivery system was large with variety of specialized sub-groups. Not having formal network weaving opportunities hindered integration. The CHW had to seek out ways to develop a network, engage with team members and develop relationships independently.
External network weaving was utilized in the context of building a positive image of the clinic in the community, connecting clients to external resources and assistance, and facilitating communication between different local care settings and community-based organizations (CBOs).
… [The CHW] is aware of so many more resources than perhaps somebody who would be stuck in a building 40 hours a week.
…We want them to link outside of us. We never want to think of [our agency] as the only resource a patient knows. We want them to know and utilize [outside agency], which has housing assistance, has bus pass assistance, has all the other stuff that we don't have, and we can refer them to [another outside agency], if needed, which is another CBO that that has other services.
Well, I usually just work with the HIV program. The other community health worker, she actually is housed in the office I'm housed in. So, I see her from time to time, she is out and about a lot too… She is trying to connect me with other agencies as well. Agencies that she's already connected with. So, that has been helpful and so we bounce ideas off of each other about community activities that's happening or agencies that have questions about stuff. It's easy to refer people, agencies to me, just so I can get I there and share the information that I know.
External network weaving also contributed to professional identity development and role clarity for CHWs, enabling them to connect with other CHWs through local and national professional organizations and build professional skills.
I would have liked to be connected to the Ryan White Council sooner too. So, I think that has been really useful to understand HIV in Houston as a whole and Ryan White as a whole. So, I'm on one of the committees and I did their Project Leap, which is a 17-week training course.
…last year, right around this time, we were invited to present at the AETC Regional Conference. And we got to do a presentation, and [CHW name] spoke on how we were integrating a CHW in HIV care.
Some CHWs had personal relationships with individuals working for other local care settings or CBOs so they could facilitate connections for their clients. Some noted working closely with the housing programs in the area and the city’s housing authority. Sometimes communication occurred between organizations; for example, one clinic had a pharmacy that would contact them when a client was not picking up their medication, which would trigger a call from a CHW to the client. External network weaving occurred in terms of other local stakeholders (e.g. the county health department) learning that a CHW was working out in the community and could help them facilitate some of their own activities with clients (e.g. reporting and informing partners). CHWs sometimes attended events hosted by other local stakeholders.
Sites also referred to the ERIC project implementation strategy of Provide Clinical Supervision, which was updated to encompass administrative supervision as well. Sites generally conducted formal supervision meetings with CHWs at least once a week, but most supervisors were also in contact with CHWs on a daily basis through informal interactions. Some sites held monthly group supervision meetings. Open and comfortable communication between CHWs and supervisors was seen as positive, while micro-managing was seen as negative. Interactions were usually more related to administrative, rather than clinical, supervision. Not all sites viewed the clinical supervision as necessary or helpful, while almost all of the sites had administrative supervision.
Sites varied in how they perceived the importance of clinical supervision. Clinical supervision most often referred to work with a social worker or other behavioral health provider, and addressing mental health concerns appeared to be the most common topic of supervision meetings. However, team members at one site noted how clinical supervision could encompass training and supervision in both mental and physical health care. They noted that while their CHWs were not involved in clinical practice, their involvement with the care team meant they were often learning about clinical aspects of clients’ treatment for HIV and other chronic conditions. At another site, the team members did not have formal clinical supervision, which they perceived as unnecessary based on the CHW’s role in their organization. However, the CHW did have access to an MSW for supervision if needed.
The ERIC project implementation strategy of Promote Adaptability also featured prominently in this analysis. Sites found they needed to be adaptable both in implementation of the CHW programs and in response to external changes. A common adaptation was making changes in eligibility criteria and the population of focus for the CHW program, usually to widen the scope of the program. Making changes to the referral process in order to facilitate communication and coordination amongst care team members was also common:
I think it's we're learning as we're going, … it's kind of hard to say what we would do differently until we've actually done it. It's like, "We should have done that differently." But in hindsight, I think we did a fairly good job. Of course, there were lessons learned, and things that we could tweak, but I think part of getting to where we're at now, is because we've changed. … We were able to be fluid. So, I think definitely that would be something to keep, being able to be fluid. … I think that because we do remain flexible, like even sharing with you today, Dr. [Name] had a patient and he wanted someone to talk to him and the nurses already working the schedule, and so someone called me and said, "Will you come down and talk to the patient." So, I think that that being flexible is a prerequisite for everything that we try to do around here to keep a balance.
One site was exploring the use of virtual encounters for CHWs and clients. They noted this could help CHWs reach clients when they have barriers to coming in to the clinic, such as the need for child care. They suggested that by adapting to virtual encounters, this could help with program sustainability. Being adaptable in terms of policy changes was also key, as previously discussed. Sites found that program length did not work for all clients. This was perhaps the most common example of adaptability, in that sites moved toward flexible program lengths as their programs evolved, and the length of time clients spent in the CHW program was dependent on their individual needs. Finally, CHWs themselves emphasized the importance of being adaptable and flexible in their role. At some sites, the role of the CHW within the wider care team evolved over time:
Flexibility allows for urgent things to be addressed - say if a client is in the clinic and there is an urgent need.
3.6 Training and Technical Assistance
A variety of ERIC project strategies related to training and TA for stakeholders were discussed by sites, such as Distribute Educational Materials, Conduct Ongoing Training, and Create a Learning Collaborative. In particular, training was an important implementation strategy for CHW integration. Sites received ongoing dynamic training from a centralized TA team at [Blinded Name of University] and participated in a learning collaborative across the 10 sites. Educational materials that site team members received through the learning collaborative and centralized trainings were subsequently shared with other site staff and site leadership. They also enjoyed the training for the most part, finding it beneficial with respect to the information and materials provided and the relationships developed through the process:
I met some great people. We learned different ways of doing things. Working with other teams and other places gave us a bigger outlook of what was possible, what we could do. What we maybe need[ed] to [tweak] or do differently. It showed us that we weren't the only ones…
There was some variation with sites feeling as though the training could have been handled in-house. Meanwhile, others expressed some components could have been online. These issues speak to the challenges of making training relevant for sites with differing levels of infrastructure and experience. Sites appreciated sessions where they could learn from one another over those that were content heavy. The training format provided an opportunity to network work with and learn from peers across the country.