Health-reform Lessons from Haiti and Peru

We hear a lot of talk these days about national health care reform. The new lingo includes phrases like ‘public option’ and ‘global fees.’ Perhaps the most interesting phrase is ‘patient-centered medical home,’ the concept that all medical care should be patient-centered and that clinics and hospitals should be revamped to create a home-like atmosphere for patients and provide wraparound services that address patients’ most complex needs.

I find this concept particularly interesting because I am director of the Prevention and Access to Care and Treatment project, a joint effort of Brigham and Women’s Hospital and Partners in Health. Adapting a model that Partners in Health pioneered to fight HIV in rural Haiti and drug-resistant tuberculosis in Peru, PACT employs community health workers to provide home-based services to the sickest and most marginalized HIV/AIDS patients in Boston. And now, based on our success at improving health outcomes and reducing the costs of HIV treatment, we are adapting the same model of care to treat patients with diabetes and other chronic diseases throughout Massachusetts.

Because they come from the same communities as their patients, community health workers are uniquely qualified to bring sophisticated medicine to patient homes and deliver individualized care within the conditions and belief systems that shape their patients’ lives.

We don’t need to start fresh to create patient-centered medical homes. We just need to look to community-based models of care that are effective but often go unrecognized, perhaps because much of the care is being delivered by paraprofessionals who have not been extensively schooled in the biomedical model and don’t practice office-based care. Their schooling and expertise is in the art and science of what we call ‘accompaniment.’

What do we mean by accompaniment? We mean that you walk with the patient — not behind or in front of her — lending solidarity, a shoulder, a sounding board, a word of counsel or caution. Empowering, not enabling. Together facing and managing challenges that neither you nor they can fix — poverty, racism, illiteracy, social isolation — so that you can help them swallow their pills every day, get to their appointments on time, and renew their Medicaid applications.

I asked my PACT community health workers recently what accompaniment means to them. They answered mainly by telling patient stories.

Sori Santana told the story of Maria. A young woman with significant mental illness, and a cocaine user, Maria was referred to PACT with her immune system ravaged by uncontrolled HIV. For four years, Sori rode life’s ups and downs with Maria, always encouraging, never forcing. Yet she was never able to help Maria consistently take her medications. Then one day, something clicked. Maria began taking her pills. She’s now getting stronger and has voluntarily taken on the role of accompanying her boyfriend, showing up in his room with a cup of coffee in one hand and his psych pills in another, telling him that if he doesn’t get up and take his meds, she is going to “pull a Sori on him.”

Sori and other PACT community health workers have demonstrated the power of accompaniment. Not only have we documented significant clinical improvements in the majority of our patients, we have reduced preventable hospitalizations by 40{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} and cut overall medical expenditures of our Medicaid patients. We have been creating — to borrow a phrase — patient-centered medical homes that offer quality care at lower cost.

Over the next five years, PACT is expanding its scope of work to utilize community health workers to care for patients with other chronic diseases, including diabetes, heart disease, pulmonary disease, and mental illness. A managed-care organization that works for Medicaid here in Massachusetts will subcontract with PACT to provide services to its highest-risk patients: those with the worst outcomes, the poorest health care utilization patterns, and the highest costs.

Accompaniment is a beautiful thing. As practiced in the central plateau of Haiti, the shantytowns of Peru, or Boston, it may just be what is needed to reform health care, here and abroad. –

Dr. Heidi Behforouz is the director of the Prevention and Access to Care and Treatment project in Boston.

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