Advancing community health worker models to support youth and families’ mental health

It was clear in many parts of the world that the dominant medical and public health models were not meeting the most urgent needs of poor and disadvantaged populations […] Out of necessity, local communities and health care workers searched for alternatives to vertical disease campaigns […] [I]t was thought that locally recruited community health workers could, with limited training, assist their neighbors in confronting the majority of common health problems¹.

Community-based health approaches of the 1960’s and 1970’s emerged in response to dominant medical models that, although effective, were largely inaccessible. Today, the U.S. is facing a similar crisis in youth mental health wherein dominant service models are insufficient. The field has developed many evidence-based treatments (EBTs), the gold standard for addressing mental health disorders, and meta-analyses show similar EBT outcomes across racial and ethnic groups^2,3. However, only 20% of youth with mental health needs receive care⁴, and when in treatment, 28%-75% prematurely drop out⁵. The treatment gap is even more pronounced for systemically minoritized youth, with 8% of Black and Brown youth receiving services compared to 18% of White youth⁶. Disparities also exist for adults⁵, meaning the family unit is doubly impacted by inequities as both children and their caregivers face challenges to treatment access. Therefore, we have mental health treatments that are effective but inaccessible, resulting in a mental health system failing to meet the needs of our most marginalized children and families. This necessitates a turn toward innovative, community-driven approaches for delivering mental health supports⁷.

One such approach is integrating community health workers (CHWs) in mental health services. CHWs are known by a variety of terms, including paraprofessionals, lay health workers (LHW), peer support specialists (PSS), and promotores de salud, amongst others. We use the CHW term to refer to trusted individuals from the community served who have no formal mental health training, and who act as a bridge between the community and health and services⁸. CHWs can occupy a range of roles in mental health services, including: direct interventionist, stepped-care (i.e., CHWs treat lower acuity cases while licensed providers treat higher acuity cases), auxiliary care (i.e., CHWs provide psychoeducation and address barriers to care), and outreach/navigation. As interventionists⁹, CHWs have demonstrated effectiveness and feasibility in delivering mental health interventions⁸. Primarily studied in low-and middle-income countries⁸, there is growing interest in integrating CHWs into mental healthcare in the U.S. The near-peer aspect of CHWs’ positionality facilitates engagement in ways that traditional mental health providers cannot. As community members, CHWs share key social identities with the families they serve, which can allow them to provide more culturally and linguistically relevant services, promote trust and treatment buy-in^9,10. As described by Mehta et al., CHWs’ social positionality is a key strength that promotes engagement via social network processes¹¹. Trusting a trained community member may lead to increased adherence to treatment and better health outcomes¹², chipping away at the disparities in access to care for minoritized populations. Thus, CHWs increase both the accessibility and cultural relevance of services.

For the purpose of this Comment, we focus on models in which adult CHWs take on a direct interventionist role. It is important to note that CHW models offer an extension to the spectrum of care; they are not meant to supplant specialty mental health services. These CHW models should not act as a substitute for advanced services and licensed providers given the risk of over-extending the CHW role and perpetuating existing inequities for marginalized communities. Though beyond the scope of this paper, we strongly assert that advances still must be made in specialty treatment access, particularly for populations impacted by systemic inequities.

CHW mental health models: what will it take?

While CHWs have demonstrated effectiveness in their ability to deliver EBTs, CHW models have not achieved mainstream integration into mental health services. The reasons for this sit at the nexus of practice, research, and policy considerations.

Practice

To advance CHW models into clinical practice, we must determine where and how to integrate CHWs into the spectrum of care, and specifically examine (1) in what settings do youth and families most stand to benefit from CHW integration, (2) what level of support is necessary for CHW models, and (3) what cases are appropriate for CHW services. Because youth are situated at the center of intersecting family, school, and community systems, leveraging CHW models in support of youth mental health becomes a question of how to support the integration of CHWs into systems that are most relevant to youth. This is critical given that youth engagement in treatment may be largely dependent on other systems, such as parents or schools.

Schools are the most common access point for youth mental health services¹³, and youth from low-income households and minoritized racial/ethnic groups are most likely to only receive services in educational settings¹⁴. Integrating CHW mental health models into schools would both increase access to mental health services while also supporting overburdened school systems. This aligns well with the multi-tiered systems of support (MTSS) that embeds interventions of varying degrees of intensity to match the ranging needs of students in schools¹⁵. In MTSS, supports range from universal mental health promotion and prevention efforts such as improving school climate (Tier 1), to early-intervention initiatives such as small group-based programs to improve emotional awareness (Tier 2), to targeted interventions such as individual counseling for those students with higher levels of need (Tier 3). A breadth of research has demonstrated the success of these prevention services, particularly for promoting mental health among minoritized youth¹⁶. Having a spectrum of interventions ultimately increases the capacity of the service system; this similarly applies CHW models in mental health. For example, the Parents Achieving Student Success (PASS) program embedded CHWs in schools to support Latine and Black children’s social, emotional, and behavioral functioning in school, and their parents’ use of positive parenting strategies; integrating CHWs into the school setting allowed them to more easily access both children and parents, and engage parents in their child’s schooling and mental health promotion.¹⁷

Outpatient settings are the second most common treatment setting for youth¹³; thus, similar to school integration, adding CHW mental health interventions to these settings promises to reach a large portion of youth. Additionally, home visiting and telehealth services play an important role in increasing treatment options for families for whom traditional clinic-based services may be inaccessible, e.g., those in rural communities and other mental health service shortage areas. CHW home visiting and telehealth models can be implemented as stand-alone services (e.g., refs. ^18,19), or as a flexible extension of services based in clinics or community-based settings (e.g., ref. ²⁰). Across these settings, CHW integration will require training and support at the staff and organizational levels, as well as sustainable funding mechanisms to support their work.

A second consideration is around supervision and support for these CHW models. Even for advanced licensed providers, uptake from training in new EBTs is low unless followed by ongoing practice and supervision, and often adherence is not maintained at follow-up²¹. Therefore, it is all the more necessary that CHWs receive both training in EBTs^22,23 as well as robust ongoing supervision to support their implementation of EBTs. Indeed, supervision from licensed mental health providers is a common feature of CHW mental health models¹⁵, and we assert that this is a critical component for their feasibility, as it supports the provision of quality care and provides an in-built safety net for triaging higher acuity cases. For example, CHWs may encounter clients with presentations beyond the scope of their abilities, and supervision from a licensed clinician provides a mechanism through which to ensure cases are staffed with the appropriate provider. Given the severe mental health provider shortage²⁴, supervision by licensed providers is particularly impactful as it expands the reach of mental health providers who are able to serve more clients through supervising CHWs than they could by seeing clients individually. For licensed mental health providers, their role may already include the provision of supervision to trainees. Thus, training in the supervision of CHWs would be a natural extension of their role that would prepare licensed providers to meet any unique needs of CHWs. It is also important to acknowledge that because CHWs are members of the community served, they likely face similar systemic stressors as their clients, and as such, CHWs may face additional burden during EBT delivery. Therefore, beyond clinical supervision, CHWs may benefit from additional supports, including from those who have a shared understanding of the CHW role (i.e., peer consultation from fellow CHWs and supervision from advanced CHWs)²², to prevent vicarious trauma and burnout.

Lastly, we propose that CHWs are optimally positioned to provide prevention and early intervention services with lower acuity cases, and serve as a bridge while patients await specialty care. Long wait times for mental health services are consistently cited as a barrier to care by both youth²⁵ and their parents²⁶, which presents an opportunity for CHWs to intervene during a period in which patients typically go without care. Mobilizing CHWs during this time capitalizes on their ability to effectively deliver EBTs, as well as serving as a bridge between the community and health services. In turn, this potentially increases access for lower acuity cases, preventing youth from needing a higher level of care, while also allowing higher-need cases to be triaged to providers with more advanced training, ultimately making for more judicious use of limited provider resources (for an example of this type of auxiliary care model in adults, see ref. ²⁷). Consistent with serving lower acuity cases, the EBTs that are best suited for CHW delivery will likely be time-limited and follow a structured, manualized format to facilitate ease of delivery. Indeed, a systematic review of CHW-delivered EBTs found that interventions had a mean duration of approximately 10 weeks, and the majority used manualized protocols²⁸.

Research

Addressing these practice considerations requires strong academic-community partnerships that center the voices of CHWs and other key community partners, including youth, parents and other important youth-facing community members (e.g., school and after school staff). Academic researchers and community partners should work together not only for the purpose of program evaluation, but throughout the process of development, implementation, and sustainment. Dissemination and implementation science (DIS) is well suited to examine how to optimize the implementation process. DIS seeks to understand how to effectively translate evidence-based practices and policies into real-world settings, closing the evidence-practice gap. DIS can be used to understand the necessary steps to adopt, implement, and sustain practices (process models); pinpoint the underlying mechanisms of successful dissemination and implementation (explanatory models); and examine implementation outcomes (outcome models)²⁹. For example, these models can be used to understand what factors impact the implementation of CHW interventions across different contexts, what level and mode of supervision is necessary for CHWs, and best practices for how CHWs can triage clients. Barnett and colleagues³⁰ specifically used RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), an outcome model, to describe ways CHWs can expand reach of services while contributing to the effectiveness, uptake, implementation, and maintenance of EBTs.

To optimize the fit of an EBT within specific settings and populations, DIS work must engage community partners. Community-engaged research (CEnR) is the process of engaging key community partners throughout the research process from the conceptualization of the project to the dissemination and translation of the research to practice³¹. When determining where and how to integrate CHWs into the spectrum of clinical care, it is imperative that CHWs are co-leading these efforts. This will not only optimize implementation, but ensure that these practices are sustainable. It is also important that youth have a seat at the table to inform the development of CHW mental health models. Youth participatory approaches, such as youth participatory action research (YPAR), empowers youth to use research and evidence to improve conditions in their lives and communities³¹. Like CHWs, youth partners can serve as co-researchers, becoming actively involved in research and decision making regarding how CHWs are integrated into mental health services.

One specific framework that integrates both DIS and participatory methods is community-engaged dissemination and implementation (CEDI) research. CEDI centers community voice by engaging stakeholders in determining barriers and facilitators to dissemination and implementation³². The combination of DIS and CEnR will promote the advancement in CHW models in clinical practice.

Policy

A major impediment to mainstream integration of CHW mental health models is the lack of reliable funding mechanisms. In 2022, only 7 states covered CHW services under the state Medicaid plan. The specific services covered varied across states, but the common factor was a limited scope of coverage³³. Only one state covered CHW counseling, and this was only for smoking cessation and substance use screening. Thus, coverage for CHW mental health services is virtually nonexistent despite evidence demonstrating CHWs’ efficacy in this domain. However, more states are moving to include coverage of CHW services, which presents an opportunity for developing reimbursement models for CHW mental health services. For example, in 2021 and 2022, Illinois³⁴ and California³⁵ respectively passed legislation creating pathways for Medicaid coverage of CHW services. As states work through delineating the implementation of this legislation, it is critical that (1) CHWs be included so that their expertise informs policy implementation, and (2) coverage for mental health services be included in these policies.

It is also necessary to center the needs of youth mental health to inform policy considerations. This entails supporting the systems most important and accessible to youth. Therefore, insurance policies should include coverage for CHWs to work within schools, homes, and community-based organization settings, in addition to traditional outpatient clinic settings. Coverage should encompass delivery of EBTs as well as the other components of the CHW role that promote youth mental health, such as addressing barriers to treatment (e.g., case management to address social determinants of health), mental health education (e.g., psychoeducation provided via community outreach and family engagement), and navigation (e.g., facilitating connections to other mental health services). From a systems-level perspective, such policies not only increase the accessibility of mental health supports for youth, but they also strengthen communities via increasing community capacity to care for its community members. Investing in these CHW models through insurance coverage is ultimately an investment in community mental health infrastructure.

Longstanding inequities in access to mental healthcare for youth, particularly youth from systemically minoritized communities⁶, requires a turn toward community-driven solutions. Embedding CHWs into the mental health spectrum of care offers a promising means through which to address these inequities⁹. Advancing CHW mental health service models will require careful consideration of the supports needed for optimal integration across home, school, and community settings, as well as delineating the types of cases most appropriate for the CHW role (i.e., low acuity presentations). DIS and participatory methods are critical to advance evidence on how to best implement CHW-led mental health interventions. Finally, changes on the policy level are necessary in order to ensure that CHW services are billable, contributing to increased access and long-term sustainability. Of note, responding to the practice, research, and policy needs of CHW mental health models will require engaging with a range of ethical considerations. For example, it will be necessary to grapple with questions of role boundaries for CHWs as an interventionist and near-peer; supporting CHW wellbeing while in an interventionist role; maintaining quality of care for clients; power sharing in intervention development, implementation, and evaluation; and ensuring fair, living wages for a workforce whose credentials differ from those in traditional health and mental health service systems. Beyond the scope of this Comment, these ethical questions merit thorough examination in future scholarly works. Ultimately, practice, research, and policy considerations must center the lived experiences of CHWs, parents, and youth partners. This will ensure that these services are equitable, shrinking the evidence-practice gap and addressing the multifaceted nature of youth mental health.