摘要
背景：社区保健员（CHWs）是扩展医疗保健服务的关键，尤其是在边缘化社区，以减少与获得医疗保健相关的挑战。本研究旨在从定性角度探讨社区保健员在弥合医疗补助管理性医疗机构（MCO）成员与医疗服务提供者、管理性医疗机构和社区组织之间的差距，以满足与健康相关的社会需求（HRSN）方面的综合作用：我们对社区保健工作者关于其角色和医疗补助成员生活的叙述进行了回顾性专题分析。一家 MCO 在宾夕法尼亚州匹兹堡市四个以黑人为主的社区派驻了三名 CHW，为期六个月（2017 年 1 月至 6 月），将其成员与管理式医疗、医疗保健系统和 HRSN 联系起来。在整个项目中，共有 46 名 MCO 成员参与其中。作为质量改进项目的一部分，CHW 为 13%（n = 6）的 MCO 成员编写了叙述。这些记录在案的叙述成为本研究的原始数据：MCO 成员的年龄从 25 岁到 58 岁不等，均为黑人（n = 6）。叙述中男性和女性各占 50%。在关于 CHW 角色的叙述中，有三个最重要的主题，即改善会员使用医疗保健系统（医疗服务提供者和药物）的机会、帮助会员使用 HRSN，以及将会员与管理式医疗保健个案管理和会员服务联系起来：社区保健工作者作为融入社区的 MCO 工作人员，可以帮助改善其成员的医疗保健连续性、护理协调和 HRSN 获取。我们的研究表明，社区保健工作者在为医疗补助 MCO 成员弥合不同系统之间的差距方面发挥着重要作用。他们在将会员与初级医疗服务提供者、专科医生、处方药、MCO 福利、个案管理以及解决他们的 HRSN（如食品、托儿和住房）联系起来方面发挥着至关重要的作用。未来的研究应通过衡量医疗补助管理性护理环境中的成员体验、医疗保健利用率、健康结果和成本来关注计划的有效性。Background: Community Health Workers (CHWs) are key to extending health care services, especially to marginalized communities to reduce challenges related to health care access. The study objective was to qualitatively explore the comprehensive role of CHWs in bridging the gap for Medicaid managed care organization (MCO) members' access to health care providers, managed care, and community-based organizations to address health-related social needs (HRSN).
Methods: We conducted a retrospective thematic analysis of narratives developed by CHWs on their role and Medicaid member lives. Three CHWs were embedded in four predominantly Black neighborhoods of Pittsburgh, Pennsylvania, by an MCO for six-months (January-June 2017) to connect its members with the managed care, health care system, and HRSN. In total, 46 MCO members remained throughout the program. The CHWs developed narratives on 13% (n = 6) of MCO members as part of a quality improvement project. These documented narratives became raw data for this study.
Results: The age of MCO members ranged from 25 to 58 years and were Black (n = 6). The narrative had 50% of males and females. Three overarching themes in the narratives about CHWs' role were improving members' access to health care system (providers and medication), helping members with HRSN, and connecting members to managed care case management and member services.
Conclusion: CHWs as MCO staff embedded in communities could help improve its members' health care continuity, care coordination, and HRSN access. Our study demonstrates that CHWs are instrumental in bridging the gap between different systems for Medicaid MCO members. They play a crucial role in connecting the members to primary care providers, specialists, prescription drugs, MCO benefits, case management, and addressing their HRSN such as food, childcare, and housing. Future research should focus on program effectiveness by measuring member experience, health care utilization, health outcomes, and costs in Medicaid managed care settings.
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