Chapter 3, Community Health Workers: A Successful Strategy for Restoring the Health of a Community

Moisés Pérez, Jacqueline Martínez, and Laura Frye

Community Voices gave us (Alianza) the opportunity to build on what we had, plan for scaling up the work we did, [and] an opportunity to reconcile relationships and restore trust among the community and the big institutions, like Columbia University.

When I (Moisés Pérez) saw the request for proposals for Community Voices I thought, "Community Voices, that's us!" It was a perfect match for Alianza Dominicana, the largest multiservice, community-based organization in Washington Heights. Since I founded Alianza Dominicana in 1987 as a nonprofit community development organization, we had been working with youth, families, and public and private institutions to revitalize economically distressed neighborhoods. We were already implementing successful programs that were fueled by our community voices -- voices teaching about pregnancy, voices sharing information about HIV, voices speaking out against drugs and violence. Our voices were demanding to be heard, and our voices offered tactical, feasible solutions to the problems facing this community.

So we raised our voices further and became one of the three partners, along with Columbia University and Harlem Hospital, of the joint application to the W. K. Kellogg Foundation. The grant offered immediate and dedicated talent that could sit, listen, and plan with us. The support would allow us to expand the agenda we had been working on and amplify our efforts to connect our work to a national agenda. And, just as important, we recognized that the Northern Manhattan Community Voices Collaborative presented an opportunity to reconcile relationships and restore trust among the community and the big institutions, like Columbia University. Partnering with Community Voices would help reconcile relationships with the very institutions that had seemed to fall silent during our ongoing struggle to reclaim our community.

The mission of Community Voices was to increase access to health care for the underserved. Well, we were certainly underserved and needed access to health care. But we also had a collective vision of health and wellness for the community that stretched far beyond access to a doctor for medical care. It was about the mental well-being of our community residents, the security and safety of our children, and greater educational opportunities for our youth. The NMCVC became an opportunity for us to hone in on multiple topics and plan for comprehensive solutions to the needs of our community.

In this chapter we tell the story of how community health workers (CHWs) became one of the key strategies we used to further our wide-reaching goals. In the initial years, the Health Promotion and Disease Prevention working group, one of the four working groups for the Community Voices Collaborative, focused on three priority health areas: facilitated enrollment for health insurance, child immunization promotion, and asthma management. These three programs became the pilots for the CHW initiative described here. We also describe how Alianza created the Center for Health Promotion and Education to serve as a community hub for insurance outreach and enrollment and numerous health care initiatives. Under the stewardship of Alianza, Community Voices staff formed a working group consisting of other agencies, community leaders, community health workers, university faculty, and health care providers. The CHW initiative, including development of training materials, training workshops, and structure of the program, was developed under the guidance of the working group and integrated into ongoing programs at partner community organizations.

But before we tell that story, we need to tell the story of Washington Heights, the largely Dominican community that lived there, and the birth and early work of Alianza Dominicana.

A Community Under Duress: Internal and External Forces Threaten the Livelihood of Community

During the 1980s and into the mid-1990s, Washington Heights experienced one of its darkest trials, threatening the very fabric of the social, familial, and economic well-being of the community. It started with the decline of jobs during the recession of the 1970s when manufacturing jobs went flying out of New York City in search of cheap labor in other parts of the world. Factories that were once thriving in midtown and employed many of the newly arrived immigrants from the Dominican Republic began to close their doors in the mid-1970s and early 1980s. The ripple effect of a downturn of the economy was also beginning to be felt in ritzy restaurants and hotels that had once flourished in midtown Manhattan and, more important, had been secure places of employment for an upcoming generation of Dominicans that had settled in the northern tip of Manhattan. Little by little, and then faster and faster, families that had come to New York with the promise of that better life began to feel the ill-effects of being a marginalized population that was of value only when jobs that no one else wanted were available.

Yet there remained a remnant of hope in the early 1980s. The early saving graces of this period of economic downturn that would keep the core of the community alive and hopeful were the Dominican-owned bodegas, hair salons, cleaners, restaurants, bakeries, and even day-care centers. The entrepreneurial spirit of the people back in the island had remained a part of them. They worked midnight shifts in the hotels in midtown, in factories or as dishwashers in the elegant restaurants in lower Manhattan, and with their meager savings pooled by entire families and friends, they financed their own businesses back in the Heights. But as the economy continued to worsen, the mid-1980s did not seem so promising.

Washington Heights quickly became the largest, most overcrowded, fastest growing, and youngest community in the state of New York. The school district was the most overcrowded in the state, and there was not a single comprehensive program to support the needs and concerns of a population of young people under the age of 18 estimated at sixty-six thousand. The city simply did not have the resources nor the political will to address the needs of the community. With overcrowded, failing schools, little to no work opportunities, no after-school or recreational programs, a stressed housing stock owned by slumlords, and a host of other ills, the community became a prime candidate for the proliferation of drug sales. While heroin was popular as a drug of choice from the 1950s through the 1970s, the 1980s saw the onset of cocaine use. What started as a fad drug among the wealthy downtown or in New Jersey across the George Washington Bridge seeped in and began to strain the fabric of Washington Heights.

How the creeping dependence on this drug by a wealthy group of white-collar workers and a thriving hobby for a myriad of wealthy kids living across the bridge connected with an army of a younger generation of Dominicans living in the Heights has not been well documented. However, it does not take a sociology degree to connect the dots and figure out how Washington Heights became an epicenter to one of the deadliest drug trades in America. For the younger generation of Dominicans -- who were watching their dreams of a better life slowly evaporate, unemployed or turned off by the failing school system -- the business prospects were clear. All of a sudden, one year's salary in a factory or one month's income from a bodega could be earned in fewer than five hours -- if you were in the right corner at the right time.

But even as the small, yet growing, cadre of local drug dealers was being self-selected into a rising drug business, the majority of residents turned their faces and pretended that nothing was happening. It was easier this way. It was less dangerous. And they were not the only ones in denial. Washington Heights had grown in popularity as an epicenter for drug deals. It was quite obvious to the police department, political leaders, and others in power who could have acted instead of watching passively on the sidelines. The effects of an unchecked illicit industry began to surface pretty quickly and proved devastating to the community. Turf wars became increasingly violent, gunshots became a familiar background noise, and police brutality was becoming more and more visible. All of this ate away at the integrity and resolve of the community and bred more and more fear.

The 1990s brought more trouble. Now it was not the wealthy that were hooked on the white powder—local residents, perhaps ailing from the breakdown of their community, began to find solace in the drug. The drug industry found a new market. The task at hand for those in search of profit was to make it more accessible and less expensive. The answer was to transform cocaine into "crack." Now it was a drug less wealthy could afford. This was the drug that would begin to claim hundreds, eventually thousands of lives in Washington Heights. The number of families torn apart because a daughter, son, cousin, nephew, or neighbor was steadily growing. Familiar faces were seen in the streets strung out from a high. It had caused an endemic wave of fear of walking in the very streets of a community once known as a home away from home for so many Dominicans.

The fear was crippling. Mothers did not allow their children to walk outside their apartments, and business owners dreaded the evening hours and opted to close earlier, leaving a more fertile ground for isolated streets now dominated by drug businessmen who ruled with terror.

All of these conditions were made worse by years of political neglect by leaders in Albany and in City Hall, and the growing corruption among those charged with the task of keeping the law. The men in blue, New York's Finest, were often associated with the very same people causing havoc in this economically and socially devastated community. A select few police officers had found a niche for themselves and began to benefit financially from the drug industry -- setting back any trust built with community residents.

In fact, the community felt completely abandoned and often betrayed by the major institutions. Imprisoned by fear in their own apartments, many would sit before their television sets and hear the evening news tell of the horrific stories of murder, drug raids, and robberies occurring in the community. The question that remained in the minds of people was: Could we ever reclaim our neighborhood? The question was central to any conversation between neighbors, family members, a hair salon owner and their regular customers. Some would say, "Esto no lo arregla nadie" (No one could ever fix this). Underneath the pain, fear, and growing distrust of the authorities, there was a steady heartbeat of hope fueled by a desire to reclaim the streets for the younger generation who had a right to live outside the confines of small apartments.

This was the ailing neighborhood -- with an underground and resilient ache for change -- in which Alianza Dominicana was born. We, the community members, decided to find that underlying heartbeat and amplify it to drown out all the other noise. We could organize and mobilize with shouts of slogans and feet stomping as we marched forward in search for change -- determined to be heard! Washington Heights could surely have used an influx of capital to bolster the dying businesses. It could have benefited from a redoubled effort to reduce crime. Instead it got an even more powerful catalyst of change: a mobilized community. We created an army of our own foot soldiers to attack the problems at hand. This army was composed of leaders from block organizations, churches, tenant associations, and, most of all, those who would later be called "community health workers."

Alianza Dominicana: A New Vision for the Community

Alianza Dominicana (literally translated as "Dominican Alliance") grew out of the determination of the Dominican American community to emerge, flourish, and contribute to the development of American society. The struggles of day-to-day living gave rise to our purpose and challenged us to succeed. We saw a future where Latinos, immigrants, women, youth, and working and poor families were valued contributors to the culture and essential life of our nation. We worked to strengthen communities and affirm the value of family and community life by initiating and implementing programs and services that responded to the full spectrum of community needs and utilized community assets.

The community health workers were the key to this vision. They drove our programs forward, reached out to those people and families who had been marginalized, advocated for necessary change, and shared their knowledge and experience to achieve a wide range of positive health outcomes. We did not label them "community health workers" when we began. (Nor did we know that they were to become central to the success of many of the Community Voices programs -- that was all in the future.) At the time, they were part of a team of community members who came from the same class and culture as the people they were trying to reach. They were "ordinary people" who were intricately woven into the fabric of our lives and sought to create a healthier environment, address social issues, improve community leadership, and reclaim hope for future generations.

Years after we began Alianza's CHW initiative, we wrote a paper on the project that was published in the Journal of Health Care for the Poor and Underserved Community (Pérez et al. 2006). In the background section of the article, we wrote that

"health workers typically share racial and ethnic backgrounds, cultures, languages, and life experiences with members of the communities in which they live and serve; therefore, they are much better able than people from outside the community to build the trust necessary to succeed and to provide a cost-effective bridge within health care systems and social services. Numerous studies, reports, and experiences in diverse settings show that having CHWs as part of the health delivery system can produce a wide range of benefits, including increased access to care; increased revenue and cost-savings through more effective use of primary care services; decreased inappropriate utilization, increased appropriate utilization, and improved health outcomes; increased trust between communities and health care providers; and increased flexibility in the health care system."

The Institute of Medicine recognized the importance of CHWs in a 2003 report, stating "Community health workers offer promise as a community-based resource to increase racial and ethnic minorities' access to heath care and to serve as a liaison between healthcare providers and the communities they serve."

Top Priorities: Pregnancy, AIDS, Violence

Teen pregnancy was high, and Alianza's very first funded project as an organization sought to prevent teen pregnancy by mobilizing young people to be leaders within their peer groups and to address sexual health issues. By providing a safe space for young people to unite and using the opportunity to equip them with knowledge and information, we aimed to help young people meet their full potential -- before getting pregnant so that when they undertook parenthood, they had all the tools they needed. This task could not have been accomplished by a set of outsiders, coming in and preaching to our youth. It required people with familiar faces and familiar backgrounds, people who could relate to the everyday lives of teens, people who understood the full range of barriers to protecting oneself from precocious pregnancy. A trained cadre of community health workers was the ideal group to undertake this task.

Yet, preventing teen pregnancies was only one part of this larger social concern. We also had women who were experiencing unnecessary risks during their pregnancies because they lacked support as they embarked on parenthood. This led to the creation of Best Beginnings. A group of dedicated community women, trained on early childhood intervention, went into the homes of pregnant women to assess their risk for complicated pregnancies. They would then work with them intensely throughout the pregnancy and birth and stay as a support for the family until the child entered the school system. This home visitation model was completely run by community health workers -- women who understood the trials of pregnancy, knowledgeable in the constraints of poverty, trained to provide the necessary support.

But the layers of the problems confronting this community were thick and many. We had a responsibility, funding or no funding, to collectively identify solutions. As an organization, Alianza could not ignore the epidemic that stole so many of our community members in the late 1980s and early 1990s. AIDS had become another agent claiming the lives of people, and the disease fed on unawareness, fear, and misinformation of the people. We formed a program called AIDSRAP, where our community health workers trained young people in "HIV 101" and theater techniques so they could go forth into the community and talk to other young people about safe sex. They served as the start of a cascade of knowledge sharing through mechanisms that were tailored to the intended audience.

The reproductive and sexual health needs of our community were great, but our conception of health did not stop at these issues. Even more pressing were the drug and violence problems that had imprisoned our communities with fear and relegated us to our homes.

When the doors to Alianza were opened in a New York City Public Housing Authority project on 176th Street and Amsterdam Avenue, there was a crack house right above us on the secondand sixth floors. These apartments operated twenty-four hours a day, driving the tenants crazy with the constant incursions. The windows of our future offices had been pulled out to make it easy for addicts to crawl into the warm basement space during the cold winter. The day we moved in to clean up we found a shopping bag of crack vials in the electrical closet (it was the warmest room). We cleaned out our space but could not stop there. We needed to tackle, on a community-wide level, the toughest and most profound dangers facing us: drugs and violence. In our eyes this was the first step in restoring our community, nurturing it back to health, and positioning it for a hope-filled future. It seemed like an impossible undertaking, but the cost of inaction was too great. We were losing too many members of our young and vibrant generation, we were losing hope, and the steady heartbeat for change could easily fade if we did not act fast.

One day I just remember thinking, "Wait a minute, the overwhelming majority of people in this community are horrified at this, but no one is talking!" So I called a community meeting to talk about what we needed to do to address the drug problem. Ten people came. At the time I was so impressed -- ten people! At the next meeting we got twenty-five and then fifty, and then, when a critical mass showed up at a weekly meeting, we began to organize a march. On a warm spring day, with a huge group of people, we set out to march from 137th Street up Broadway to 173rd. We pulled together signs, held pictures of our loved ones who had been lost to the drug wars, and carried names of the mothers who had lost a son or daughter to drugs. The media paid attention, and local political leaders such as City Councilmember Stanley Michaels and Maria Luna (the first Dominican to be elected as district leader in New York) heard the cry and demand for change and were willing to join in our efforts to bring about change in Washington Heights.

Another critical moment during this period of mobilization occurred when a young man in our newly formed teen program was killed. His best friend, with whom he grew up and who was engaged to his sister, shot him over a dispute related to drugs. This incomprehensible loss of life spawned Mothers Against Violence -- a group that sought to protect the community from this most ultimate public health issue: violence. We sought to draw on the respect and influence of mothers to discuss violence with their children. These mothers also served as community health workers. But the drug problem had to be addressed from several sides. While Mothers Against Violence sought to raise a new generation of children who would peaceably interact, there were drug dealers and addicts on the streets challenging any progress made. We had to create a safe public space for ourselves. We began a project to reclaim Highbridge Park.

We knew Highbridge Park was an environment ripe for drug use, prostitution, and all the behaviors we as a community would no longer accept. We targeted the 180th Street playground and sought help for the seventy-five addicts who lived under the 181st Street underpass. The people of Washington Heights felt empowered to take control -- enough was enough. A cadre of women of the community went out, locked the playground, and, taking turns, worked hand in hand to guard it. Parents from buildings close by worked out a schedule to ensure that the entrance was always attended. We did not allow people without children to enter. We called a press conference with some of our elected officials on a hot summer evening, and the following day we were on the phone with the parks commissioner. The Parks Department needed to clean up and restore the park's benches, swings, and play equipment, while we took responsibility for security. Again the city could not ignore the people's voice, and the leaders took notice. The residents of our community were gaining traction. The park was forcibly returned to its original intent -- a place for children to play safely and for families to get together and reconnect. It was a small victory to those on the outside but for us it was a major win!

Community Voices: New Opportunities for Organized Change and Development

By the time I (Jacqueline Martínez) joined the leadership team of Community Voices, there was already a common theme woven into these efforts -- a commitment for change -- built on the strength of community organizations and led by resilient and passionate leadership. Having been born in Washington Heights, with strong familial ties to a large extended family (about thirty-five cousins!), I had witnessed firsthand the audacity of hope and survival among a people who had fought against the ravages of poverty, racism, classism, and marginalization. I saw a willingness to stand up to the fight -- both internal and external conflicts -- and boldly say no to defeat and yes to hope. There was a powerful force among the people who lived in Washington Heights, and given the right resources, they could collectively reclaim the life of their community. We had individuals who were ready and willing to assume responsibility for Washington Heights and to improve it by doing their part and taking to the street to demand a better neighborhood. The underlying strategy was one of helping those who "wore our shoes" and "walked our path." Mothers who had successful childbirth could teach others about healthy pregnancies, youth doing well in school could tutor their friends, HIV-positive individuals could counsel their peers who were at risk. All of this amounted to a cadre of community residents who understood the power of a collective voice, who would not tolerate the neglect and marginalization of politicians, decision makers, and the large institutions in the community. We had the resources and tools within our community to make it a better place. We would tap into that community heartbeat that been restored and build upon the strengths we already had.

Community Voices evolved on the heels of these victories, presenting Alianza with the means to take the efforts to another level. The "what and how" Community Voices gave the community was the opportunity to figure out a strategy to sustain this movement and bring about change in other areas, plan for scaling up the work we did, and execute a more defined strategy of engage the residents and leaders of our community into health and health care issues.

The Center for Health Promotion and Education

In 1999 an estimated one-third of the population of northern Manhattan was uninsured, yet at least forty-eight thousand residents were eligible for health insurance. Not surprisingly, one of Alianza's early joint efforts with Community Voices was to increase enrollment in public health insurance programs. To that end, we secured a grant from the state to hire and train "facilitated enrollers" for public health insurance programs. (See below for more about this program.) The workforce we had informally trained and dispatched into the streets and homes of Washington Heights became the groundwork for securing this grant. The next step was integrating the idea of enrolling people into health insurance as part of the work we were already doing.

Working with Community Voices as part of the facilitated enrollment program, we began to design the vision for a Center for Health Promotion and Education for the Washington Heights community. With funding from Community Voices and dedicated time to plan, envision, and execute, we designed the blueprint of this center. The next step was securing the location. We took this opportunity to reclaim yet another space that had been taken over by negative forces in our community. A bar/cabaret that hosted degrading wet t-shirt contests operated on the first floor of the building Alianza called home. Having this business in the same building where our youth came for training and tutoring or simply to hang out was distressing to us. After numerous late-night shootings and three homicides in the bar, the police shut it down under a public nuisance law. The landlord was looking for a new bar operator. However, we were determined to step in and eradicate the public hazard. Without any money to pay for the space, we signed a lease. It was in this space that we coordinated a massive, twenty-four-hour humanitarian relief campaign on behalf of the Dominican Republic and Haiti after a devastating hurricane leveled much of these countries. After this campaign, which brought food, medicine, clothing, and supplies to the poor in the Dominican Republic and Haiti, we formally established a home for community health workers and facilitated enrollers. The space had earned the right!

Together with staff and faculty of Community Voices, we wrote training manuals, designed tools for outreach, and created resources for community members to take with them once they walked out our doors. This new center, now decorated with traditional artifacts illustrating the popular Dominican culture, became a beacon of information, empowerment, and direction for people seeking to live a life to their fullest potential. In keeping with Alianza's "total person approach" and service integration model, our main focus was on training generalists as opposed to experts in one particular health area -- whether it was HIV/AIDS, asthma, violence, substance abuse, or diabetes. People's lives could not be separated into pieces; therefore any support we offered could not be done in a fragmented manner.

The center is continuing to work with the university to train community health workers. We joined forces with Sally Findley in her work to support the development of a formalized CHW training program, both through programs and educationally. Findley is now leading the effort to establish a CHW certificate program at the Mailman School of Public Health of Columbia University, right in our backyard. It will be a collaborative program that would ideally allow people to enroll at Columbia or other partner institutions, such as Hunter College, for a curriculum of up to one hundred hours. The program would cover all the core competencies recommended for community health workers, enabling them to compete for jobs.

Facilitating Enrollment in Public Health Insurance Programs

Community Voices was committed to increasing the number of children and families enrolled in public health insurance programs, as a first step to improve the overall health of the community. Community Voices knew that the training of health promoters and enrollment staff was essential to accomplishing this goal. Alianza was able to coordinate a process based on the conviction that the best way to reach underserved communities is to acknowledge their history and culture. Recognizing that a significant number of eligible northern Manhattan residents were deterred from enrolling due to lack of awareness, fears, and experiences of defeat as a result of the bureaucratic labyrinth, Alianza developed a strategy of facilitated enrollment that combined personal attention in a culturally sensitive setting, individual case management, and an integrated approach to the whole family. This strategy enabled Alianza to engage newly arrived Spanish-speaking immigrants in Washington Heights and French- and Creole-speaking immigrants in central Harlem.

We developed our outreach and enrollment training program in 1999. This six-part training series covered not only the steps for screening and facilitated enrollment, but also strategies for effective outreach, communications skills for working with individuals and groups, how to track outreach efforts and to know what is working (and what is not), and role plays on working as a team in a community. The content and the training approach were built on Paolo Freire's theory of critical pedagogy. This Brazilian educator, who based his work on liberation theology, defined education as a function to bring about the "practice of freedom," the means by which men and women deal critically with reality and discover how to participate in the transformation of their world. It was the perfect sequel for the work that organically evolved from Alianza into the work of Community Voices.

Under the Facilitated Enrollment Program we were able to:• Identify barriers to enrollment• Revamp existing training materials and standardized enrollment forms• Centralize the hiring and training of enrollment staff• Improve the documentation-gathering process• Create a faster turnaround for obtaining documentation• Increase the number of applications submitted and approved

As a result, enrollment in Medicaid and Child Health Plus (CHP) increased by 63 percent over the previous year. By 2003 CHWs had facilitated the enrollment of thirty thousand individuals.

Soon after launching its outreach and enrollment project, the NMCVC realized certain individuals and families were more difficult to engage than others. There were many misconceptions about Medicaid and Child Health Plus. These included people assuming that they do not qualify for Medicaid or CHP, that they might be billed later for services they receive, or worse, that Medicaid is a form of "welfare," which they should avoid so as not to be labeled or perceived as dependent on the help of the government. One enroller said: "Many parents still believe that Medicaid is public assistance. They don't want to fill out the absent parent form, or they don't want their children's father to get in trouble. They want to avoid going to the Medicaid office and the lines and dealing with people who don't speak their language. Some actually withdraw because of this. I'd say 8--10% 'disenroll' because of the stigma of being on Medicaid." Another said, "The CHP population is afraid of INS [the Immigration and Naturalization Service]; they want to know the 'catch.' They don't believe it could be free. . . . We have to tell them that there is no need to fear INS and that this is either a free or low-cost plan." Still another said that hardest parts for parents is choosing a doctor and plan for Child Health Plus: "If they just came from Latin America, it is difficult because they don't know any plans or doctors, so they just don't know."

We found that by applying a systematic case management model, even the most difficult individuals and families could be engaged. This model, which was designed to build trust, engages the individual or family first through an outreach worker and then through linking the individual to a facilitated enroller. Because community health workers are often immigrants themselves, they can address the concerns of immigrants about applying for government-subsidized insurance. In addition, rather than just passing out flyers, outreach workers go to schools, after-school programs, adult education centers, immigrant rights programs, health centers, and door-to-door to talk to residents about insurance. Their main job is to engage people and build a level of trust with them. After outreach workers locate individuals in the community who need insurance, they give them an open appointment slip, referring them to Alianza's facilitated enrollment workers. The facilitated enroller then calls the person within twenty-four hours to set up an appointment.

Once the participant decides to apply for insurance, the facilitated enroller screens for eligibility and works with the individual to complete the application. After notification of acceptance, the facilitated enroller continues to work with the participant. This is especially important considering that having an insurance card is not enough to access and use health services. During the first three months, the facilitated enroller calls the family once a month to find out if the beneficiary is using the health system and if not to offer advice and guidance on where and how to begin the process. These follow-up steps are critical, especially since the community health workers are aware of the complexities of a families health and health care needs. For instance, if a child is asthmatic or a family member has a mental health concern, the community health worker can assist the family in identifying the right team of providers for their specific circumstances. After the first three months, the facilitated enroller contacts the participant at six-month intervals. Another main advantage of the follow-up process is that it allows the facilitated enroller to keep track of each individual's date of recertification. The follow-up calls and visits are also a time when the facilitated enrollers encourage their participants to tell their friends about the Community Voices facilitated enrollment program. This level of contact with the individual builds trust in the community enrollment system, to which the individual turns for continuing advice and administrative assistance.

Throughout all areas of the Community Voices project, but especially in the area of outreach and enrollment, the concept of building relationships of trust with existing service providers was of fundamental importance. Since its inception, we have collaborated with the New York State Department of Health, New York Presbyterian Hospital, and the Greater New York Hospital Foundation, which has enabled us to both sustain and expand our outreach and enrollment efforts.

Inspiration from Far and Near

The national Community Voices program wisely inserted international learning excursions as part of the work to plan and execute programs that would impact an entire neighborhood or city. The opportunity to travel to Latin America to experience the work of community health workers was of transcendental importance in the development of our work. Our staff traveled to Nicaragua, to Trujillo, Peru, and to Colima, Mexico, spending close to two weeks in these communities. The lessons we brought back from these countries helped us widen our vision for the role and function of community health workers as key partners in transforming a community and changing the policies that were working against it.

An anecdote comes to mind. The town of Moche is rich in red soil -- so much so that its forebears built the largest mud cities ever conceived on the planet and some of the most beautiful pottery ever produced. During dry and breezy days the air is filled with damaging particles. As a result Moche had a very high incidence of respiratory illness and a number of related mortalities. The local and regional authorities were highly concerned for they had no solutions to the problem. A group of community health workers met to discuss the problem. One noted that when it was really breezy she would pull out her hose and spray her surroundings and that this really helped. Another agreed, noting that she too sprayed, and chimed in suggesting that perhaps this could be done in the entire community. Lacking the resources to do this, they asked for a meeting with the town mayor and made their request. The mayor was intrigued and deployed a water truck to spray the streets of the town during the dry and breezy season as a preventive measure. Within two years the town experienced a dramatic decrease in respiratory illness and no mortalities. Local wisdom won the day. This story confirmed for us that local residents are better able to identify solutions to larger community problems.

The impact of these projects on the health of the public, utilizing very limited material and technological resources and an abundance of humanity, was highly inspiring. The history of community health workers in Latin American countries is deeply rooted in the notion that health is a right and not a privilege. Building and rebuilding broken systems with equity and justice was at the centerpiece of the work of human rights leaders, and educators like Paolo Freire. According to Freire (2003), educational programs can be effective only if they respond to the self-identified priorities of community residents. If people are concerned about illegal drugs and crime, then the window of opportunity for education about health or other issues is around drugs and crime. In addition, Freire advocates education that is applied to solve problems in people's lives. Our exposure to community health workers in these countries deepened our commitment to the implementation of the role of community as key players in policy reform and transformational changes in how health care is to be delivered.

Alianza's integrated outreach and enrollment strategy involves three interacting components: outreach, referral, and facilitated enrollment. The program relies on an integrated team of paid and volunteer workers who are responsible for outreach and facilitated enrollment. The outreach is conducted primarily by community volunteers: high school students, participants in New York City's Welfare Employment Program (WEP), and promotoras. Building on the notion that a satisfied participant will attract more participants, members of the community successfully enrolled in health insurance through facilitated enrollment are asked to help in the effort by becoming community health workers, also known as promotoras, that is to say, residents in the community who promote health insurance enrollment among their neighbors and acquaintances, in their building, among their friends and relatives, and so forth. All the outreach workers speak Spanish, and all live in the northern Manhattan/Washington Heights community. Like the majority of the Washington Heights community, most are either recent immigrants or the children of immigrants, and most are of Dominican heritage. The most effective element of the outreach strategy is the face-to-face outreach contacts made by the promotoras. A remarkable one out of three people contacted through the promotora outreach is successfully enrolled.

By the fifth year of the Community Voices initiative, we had trained a cadre of 1,504 community health workers and established three model programs addressing health and health care needs of the community. The vast majority (98%) of those trained have been women, predominately between 20 and 29 years old. Most have been Latina (67%), and the balance African American. Seventy-three percent live in the community while the rest live in nearby neighborhoods in the Bronx. The community health workers facilitated health insurance enrollment for nearly thirty thousand individuals, assisted eight thousand children to become completely immunized (see chapter 5), and supported four thousand families in improving asthma management (see chapter 4). Although impressive, these figures tell only part of the story. Just as important was the transformative effect the promotoras initiative had on the people in the community and on the community health workers themselves.

During the Community Voices evaluation process, extensive interviews were conducted with many community health workers. They expressed enormous enthusiasm for the work -- by the residents because they were so grateful for the insurance to cover their medical expenses, and by the community health workers themselves because, although the work could be quite challenging, they derived much satisfaction from their work.

Built upon the years of experience working to help rebuild the social fabric and human capital of a community, the most successful elements of this work appear to have been:

• The long history of Alianza in the community and the trust that people have in it as a resource for their families.• Proactive and culturally relevant training of the staff. People working at the Center for Health Promotion not only are from the community but have received comprehensive training in health insurance and enrollment procedures, cultural sensitivity, and advocacy. The training was meant to empower the workers and the community at large.• A culturally relevant working environment, in which people feel comfortable and safe, and flexible hours that take into account the needs of working families.• An integrated outreach and enrollment strategy, with an extensive network of volunteer and paid outreach workers referring insurance inquiries to the trained enrollment staff.• The satisfied user as a recruiter. This strategy benefits from a burgeoning pyramid of satisfied insured families making referrals to Alianza for insurance and other services.• Integrating community health worker training and programs into existing community organizations because this approach builds on existing resources and maximizes community assets.• Going beyond insurance and offering the necessary support and guidance to navigate the health system, use services for timely intervention, and prevent interruptions in care.

Projecting Our Voices Nationwide

Just as the community health workers program transformed the people who were in it, Alianza and Community Voices reached a new stage of maturity and vision. Having accomplished a number of victories in our local neighborhood, the next obvious step for us was to take it to a national platform. Aligning with the goals of the third phase of Community Voices, which we had just secured with an additional grant from the W. K. Kellogg Foundation, I (Jacqueline Martínez) was charged with the task of taking what we had learned and informing a larger audience. One of our most important goals was to sustain the role of community health workers with state and national support. With a strong core of local community health workers, we were in a good position to achieve this goal.

The stages that followed were of research and discovery. While we were collecting our own data and documenting our work, we took on the task of taking the pulse of the rest of New York and other states as it related to community health workers. First, in New York City we began to build relationships with a newly formed group called the Community Health Worker Network of New York City. Together we sought opportunities to collaborate to unite and to organize community health workers from around the city. We cosponsored a citywide conference and funded a survey to take stock of the number of workers in the city, their employers, and funding sources. This market-based analysis was important to us as we aimed to tap into the other financial resources of the state of New York dedicated to improving access and reducing cost.

Energized by our local work in New York City, we then took on the leadership role of documenting the work of community health workers across the country in the eight Community Voices sites. We documented the similarities and differences across sites on issues of training, workforce development, funding sources for CHW programs, and collaborations with community organizations, hospitals, health systems, and universities. Our findings were produced and disseminated to multiple stakeholders.

After this extensive process was completed, we were not quite satisfied that we had found answers to some of our most critical questions: How can we sustain this model of delivering care, addressing social and public health concerns, and increasing access to care? What are the models of reimbursement for the community health workers that most make sense in our fragmented payment system? These questions drove the Community Voices leadership to submit another proposal to the Community Voices National Program Office and the Kellogg Foundation to seek additional support. After successfully securing the resources, we commissioned an assessment of financing mechanisms for community health workers and convened a national conference to bring together thought leaders and decision makers to discuss opportunities to explore funding mechanisms through mainstream sources, like Medicaid and other third-party payers. We united a core set of leaders to begin formalizing a national community health worker trade association with the goal of organizing the profession at a national level.

Our early stages of research and discovery during the third phase of Community Voices connected us to various movements across the United States aiming to organize, support, and sustain the role of community health workers as part of a larger effort to build a more equitable and accessible health care system. States like California, Texas, Ohio, Minnesota, and Massachusetts, in addition to the Community Voices states (Florida, New Mexico, Colorado, Michigan, Maryland) were leading efforts to strengthen and sustain the role of community health workers. We learned from each of these sites and began to mobilize a national agenda in the United States.

It was time for community health workers from Alianza to spread their wisdom and join forces with other communities throughout New York City and the United States. Washington Heights's community health workers started as the natural answer to the call from a sick community and then developed into a formal model for health promotion complete with a training program. They are the embodiment of what the dedication and spirit of a community can produce.

A New Chapter for Washington Heights

Today, you can safely stroll down 180th street, hearing music playing in bodegas and savoring the tantalizing smell of Dominican cuisine as you turn a corner of St. Nicholas Avenue or Broadway. For the past twenty years, Alianza had led the charge in reclaiming the streets of Washington Heights and unarming the fear that held people captive in their homes, unable to enjoy these simple pleasures.

For ten of those twenty years, we joined forces with the Northern Manhattan Community Voices Collaborative, a local initiative with a national platform and international audience. During those years we built up the infrastructure of the community, organizing the human capital and building a collective vision of a healthy community. Now, another challenge awaits: today, in 2009, we face an economy that has turned downward. The same underlying issues of neglect and marginalization that plunged us into despair in the early 1990s may be at work again.

Yet, we remain hopeful and stand determined that this community, resilient at its core, having survived one of the most violent and destructive periods in its history, will in fact weather the economic recession. The dedication and innovation that birthed the local community health worker programs still exist and are capable of engendering a new solution to today's trials. Challenges remain but, more important, our commitment remains. With a stronger community infrastructure and the same heartbeat pushing us along, we will not slip back to the deafening cries of the 1980s.

***

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Mobilizing the Community for Better Health

9780231151665

0231151667

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