Gerardo Villicana, community health care worker, Monterey, California

Gerardo Villicana met a patient just after she’d learned that she had stage zero breast cancer, meaning the disease was caught before it had grown or spread. “She was already planning her will,” he says. The woman was scared, so Villicana took time once a week to help her understand her prognosis and what treatment would look like. “Now she feels comfortable that she’s done with her treatment, and she’s in remission at the moment,” he adds.

Just a few years ago, Villicana may not have been able to help the woman. His job as a community health worker at Pacific Cancer Center in Monterey, California, wouldn’t have been funded.

Over the past decade, Manali Patel, MD, MPH, an associate professor of oncology at the Stanford School of Medicine, and her team have been working to break down barriers that prevent some patients from getting the highest quality of care. One of her team’s biggest accomplishments is demonstrating to payers across the nation that reimbursing for community health workers saves money in the long run by reducing the need for emergency room visits and more intensive care.

How Community Health Workers Break Down Barriers

“Essentially, we try to reduce cancer health disparities by ensuring equitable, value-based cancer care delivery. Value-based care delivery means the highest quality of care and low cost,” says Patel, who is also a staff oncologist at the VA Palo Alto Health Care System. “Systemic barriers are a key etiology for health disparities. Our work has shown that racially and ethnically marginalized patients do not receive evidence-based care even at the best cancer centers in the nation, but when they do, the cancer outcome disparities are eliminated.”

One problem is that marginalized patients aren’t always offered the tests, such as molecular tumor profiling, that help doctors determine the best treatment plan. Thus, they may end up with suboptimal treatment.

Community health workers like Villicana can help patients advocate for their own care and request more information about such tests before treatment. Over the past decade, Patel’s team has been studying whether community health workers can improve quality of care for cancer patients in  the community — namely, at the end of life — across the United States, with projects in Los Angeles County, Atlantic City, Chicago, Phoenix, New York, and Boston. These studies have shown how effective community health workers have been in improving care, but Patel was shocked by the magnitude of how helpful they were. Community health workers in these prior interventions only spent six months working with each patient. Patel says that patients continued to see improvements in their care 10 years after they’d been paired with the community health worker.

“Patients seem to be using these skills [that they learn from the community health worker], not only in their cancer care, but also in how they engage in their health care overall,” she says. Now, the team is testing whether such approaches can be helpful in improving precision cancer care delivery in Monterey County.

A community health worker is a member of the community trained by Patel’s team to help patients understand the complexities of their care, whether it’s molecular tumor testing or advanced care planning.

“We’re really helping our patients better advocate for themselves and make sure their care is aligned with what’s important to them, their preferences and goals,” says Hector Medrano, a community health worker and researcher in Patel’s lab.

When patients have support from a community health worker who can take the extra time to explain the basics of cancer, the value of precision medicine, and the importance of understanding treatment options in the context of their prognosis, they can ask their doctor to conduct specific tests and adjust their treatments accordingly. They are more confident in asking about side effects and telling their doctor what they are and aren’t willing to experience during treatment.

Community health workers guide patients in conversations that might be challenging at first but ultimately help them receive better care. For example, Medrano helped a patient with esophageal cancer and his wife fill out an advanced directive. “There were so many things going on, and it was such a daunting topic,” says Medrano, “but after I was able to help them understand the paperwork, they were very appreciative.”

We’re really helping our patients better advocate for themselves and make sure their care is aligned with what’s important to them, their preferences and goals.

First the County, Then the Country

The clinics that have worked with Patel’s lab have all maintained community health workers as part of usual care, even after funding has ended, including the ongoing project on precision cancer care in Monterey County.

Now, the team has launched a 3,000-patient, 24-clinic study across the U.S. Patients and community members worked collaboratively to design all aspects of the study, funded by the Patient-Centered Outcomes Research Institute (PCORI). The team will assess whether community health workers are more effective than education provided to patients through electronic health portals and other passive methods. They’ll track patient-reported quality of life, as well as how often the patients are hospitalized or require emergency care, and whether certain interventions are more effective for specific people or clinics.

Still, Patel takes great pride in the fact that her team’s advocacy has already paid off, and community health worker services are now getting reimbursed in California as part of Medi-Cal benefits.

“When we started this approach 12 years ago, a lot of clinics did not understand how a community health worker would benefit patients diagnosed with cancer.” Now, she says, “many cancer clinics across the nation are requesting our team to help them implement community health worker programs to improve precision medicine care delivery and care at the end of life.”

A community health worker is a member of the community trained by Patel’s team to help patients understand the complexities of their care, whether it’s molecular tumor testing or advanced care planning.

“We’re really helping our patients better advocate for themselves and make sure their care is aligned with what’s important to them, their preferences and goals,” says Hector Medrano, a community health worker and researcher in Patel’s lab.

When patients have support from a community health worker who can take the extra time to explain the basics of cancer, the value of precision medicine, and the importance of understanding treatment options in the context of their prognosis, they can ask their doctor to conduct specific tests and adjust their treatments accordingly. They are more confident in asking about side effects and telling their doctor what they are and aren’t willing to experience during treatment.

Community health workers guide patients in conversations that might be challenging at first but ultimately help them receive better care. For example, Medrano helped a patient with esophageal cancer and his wife fill out an advanced directive. “There were so many things going on, and it was such a daunting topic,” says Medrano, “but after I was able to help them understand the paperwork, they were very appreciative.”

We’re really helping our patients better advocate for themselves and make sure their care is aligned with what’s important to them, their preferences and goals.

First the County, Then the Country

The clinics that have worked with Patel’s lab have all maintained community health workers as part of usual care, even after funding has ended, including the ongoing project on precision cancer care in Monterey County.

Now, the team has launched a 3,000-patient, 24-clinic study across the U.S. Patients and community members worked collaboratively to design all aspects of the study, funded by the Patient-Centered Outcomes Research Institute (PCORI). The team will assess whether community health workers are more effective than education provided to patients through electronic health portals and other passive methods. They’ll track patient-reported quality of life, as well as how often the patients are hospitalized or require emergency care, and whether certain interventions are more effective for specific people or clinics.

Still, Patel takes great pride in the fact that her team’s advocacy has already paid off, and community health worker services are now getting reimbursed in California as part of Medi-Cal benefits.

“When we started this approach 12 years ago, a lot of clinics did not understand how a community health worker would benefit patients diagnosed with cancer.” Now, she says, “many cancer clinics across the nation are requesting our team to help them implement community health worker programs to improve precision medicine care delivery and care at the end of life.”