Interprofessional Teamwork and Collaboration Between Community Health Workers and Healthcare Teams: An Integrative Review

Interprofessional Teamwork and
Collaboration Between Community Health
Workers and Healthcare Teams:
An Integrative Review
Catherine M. Franklin 1 , Jean M. Bernhardt 2 , Ruth Palan Lopez 2
,
Ellen R. Long-Middleton 3 , and Sheila Davis 4
Abstract
Objectives: Community Health Workers (CHWs) serve as a means of improving outcomes for underserved populations.
However, their relationship within health care teams is not well studied. The purpose of this integrative review was to examine
published research reports that demonstrated positive health outcomes as a result of CHW intervention to identify inter-
professional teamwork and collaboration between CHWs and health care teams.
Methods: A total of 47 studies spanning 33 years were reviewed using an integrative literature review methodology for evidence
to support the following assumptions of effective interprofessional teamwork between CHWs and health care teams: (1) shared
understanding of roles, norms, values, and goals of the team; (2) egalitarianism; (3) cooperation; (4) interdependence; and(5)
synergy.
Results: Of the 47 studies, 12 reported at least one assumption of effective interprofessional teamwork. Four studies
demonstrated all 5 assumptions of interprofessional teamwork.
Conclusions: Four studies identified in this integrative review serve as exemplars for effective interprofessional teamwork
between CHWs and health care teams. Further study is needed to describe the nature of interprofessional teamwork and
collaboration in relation to patient health outcomes.
Keywords
community health, access to care, community health worker, interprofessional teamwork, collaboration
Background
Community health workers (CHWs) can improve outcomes for
underserved people. 1,2 Evidence exists that CHW interventions
in underserved populations improve health care management,
disease prevention, and health promotion. Community health
workers improve management of chronic illnesses such as
asthma, diabetes, maternal–child health issues, increase health
promotion activities such as vaccinations and cancer screening,
and demonstrate net costsavings. 1-3 Based on this evidence,
interest in new CHW models has grown. Delivery systems
strive to improve health care access, improve cultural congru-
ence, and address quality and cost among the growing immi-
grant population and other underserved, isolated, and
vulnerable people. The CHW model presents an opportunity
to achieve these goals.4-6
Presently, there is a national call for greater use of CHWs to
improve the nation’s health. In 2011, the Center for Disease
Control and Prevention (CDC) and the Division for Heart
1 Department of Family Medicine, East Boston Neighborhood Health Center,
East Boston, MA, USA
2 School of Nursing, MGH Institute of Health Professions, Boston, MA, USA
3 College of Nursing and Health Sciences, University of Vermont, Burlington,
VT, USA
4 Partners in Health, Boston, MA, USA
Corresponding Author:
Catherine M. Franklin, Department of Family Medicine, East Boston
Neighborhood Health Center, 20 Maverick Square, East Boston, MA 02128,
USA.
Email: [e-mail]
Health Services Research and
Managerial Epidemiology
1-9
ª The Author(s) 2015
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Disease and Stroke Prevention published Addressing Chronic
Disease through CHWs: A Policy and Systems-Level
Approach7 which recommended that states integrate CHWs
in high-risk communities to prevent chronic disease. Likewise,
the Institute of Medicine (IOM)8 recommended CHWs as part
of their strategic plan to prevent, control, and reduce the impact
of hypertension. In addition, the Patient Protection and
Affordable Care Act more commonly referred to as the
Affordable Care Act (ACA) 9 identified the need to encourage
CHW engagement in health promotion and improving health
outcomes for the medically underserved. Moreover, the CDC10
has called for stronger support for CHW programs to help
eliminate health disparities for the prevention and management
of diabetes.
At the same time, several national and international organi-
zations began calling for interprofessional teamwork and team
training as part of the redesign of the health care system. In
2001, the IOM issued ‘‘Crossing the Quality Chasm . . . ,’’11
initiated this early call. Nearly a decade later, the World Health
Organization12 identified the urgent, global need to integrate
interprofessional education and collaborative practice into ser-
vice, education, and health policy globally in order to
strengthen primary care health systems. Finally, in 2011, an
expert panel of the Interprofessional Education Collaborative
introduced core competencies for interprofessional collabora-
tive practice. 13 Moreover, many national health care organiza-
tions14-18 have endorsed the establishment of community-based
interprofessional teams as part of patient centered medical
homes (PCMH), a model for primary care redesign.
Despite the strong evidence to support the use of CHWs and
the nationally recognized need for collaborative practice in
care provision, the nature and degree of teamwork and colla-
boration with CHWs within health care teams is not well under-
stood. Therefore, the purpose of this integrative literature
review was to examine interprofessional teamwork and colla-
boration with CHWs in research demonstrating positive health
outcomes as a result of CHW intervention
Interprofessionality and Teamwork
Research suggests that interprofessional teamwork and colla-
boration improve patient outcomes and access to health
care.12,19-30 In addition, those health care workers who serve
as part of a team are more effective and have higher job satis-
faction than those who do not.28,31,32
The concept of ‘‘interprofessionality,’’ coined by D’Amour
and Oandasan 33 as a response to fragmented health care prac-
tices, is defined as ‘‘the development of a cohesive practice
between professionals from different disciplines. It is the pro-
cess by which professionals reflect on and develop ways of
practicing that provides an integrated and cohesive answer to
the needs of the client/family/population.’’ 33(p9) Interprofes-
sionality is distinguished from multidisciplinary, which refers
to a process whereby multiple disciplines work on the same
project in an independent and parallel fashion, 33 reflecting a
lower degree of collaboration on the spectrum.
The concept of ‘‘collaboration,’’ identified as critical to
ensure quality health care,33 is important to understand within
the context of interprofessional teams. Collaboration is described
as conveying ‘‘the idea of sharing and implies collective action
oriented toward a common goal, in a spirit of harmony and trust,
particularly in the context of health professionals.’’ 57(p116)
Interprofessional collaboration is a ‘‘negotiated agreement
between professionals which values the expertise and contribu-
tions that various healthcare professionals bring to patient
care’’34(p2) and is most effective when there is good communi-
cation and a value for diverse opinions among team members.35
In a review of the literature on collaborative practice, D’Amour
et al 33 identified the following four concepts related to
collaboration: sharing, partnership, interdependency, and power.
A team is defined as ‘‘a group of people working together to
achieve common purpose for which they hold themselves
mutually accountable.’’ 36(p3) The establishment of teams
assumes that teams can outperform individuals when the task
is complex, members have a stake in the outcome, and where
efficient use of resources is necessary. Key elements of team-
work include members having a shared work product, interde-
pendent tasks, shared responsibility for producing results,
commitment to a common approach, and collective manage-
ment of relationships across organizational boundaries.36
Successful teamwork is necessary for collaboration to occur.
Teamwork creates the environment to support the work that has
the potential to result in collaboration. Collaboration is most
closely related to the synergy created by those on the team.
Collaboration requires two constant and key elements, namely,
(1) construction of collective action that addresses the com-
plexity of client needs and (2) the construction of a team life
that integrates the perspectives of each professional where each
member experiences respect and trust. 33
Model for Integrative Review
Rice 37 links teamwork and collaboration by identifying
teamwork as ‘‘a mechanism for putting collaboration into
effect.’’37(p62) Rice identified five assumptions of teamwork that
served as the conceptual framework for this integrative review.
These assumptions are (1) a shared understanding of roles, norms,
values, and goals of the team; (2) team functions in an egalitarian
manner; (3) team functions in a cooperative manner; (4) team
functions in an interdependent manner; and (5) combined efforts
of the team and shared decision making are of greater benefit to
patients than the effects of the individual disciplines alone.
The assumptions for effective teamwork that will result in
successful collaboration described by Rice 37 were operationa-
lized for this review as follows:
1. Shared understanding. Shared understanding of roles,
norms, values, and goals of the team: Evidence of
clearly defined goals for project interventions, team
member roles, or congruence of values or mission of
team members. For this review, the word ‘‘shared
understanding’’ will be used to refer to this assumption.
2 Health Services Research and Managerial Epidemiology

2. Egalitarianism. Team functioning in an egalitarian
manner: Patients and families are part of the health care
team as evidenced by respect for their input into pre-
ferences, decision making, or goal setting.
3. Cooperation. Team functioning in a cooperative man-
ner: A working together that recognizes and respects
involvement and contributions of all members 38 as evi-
denced by team meetings or joint training.
4. Interdependence. Team functioning in an interdepen-
dent manner: Absence of independence or lack of
autonomy 39 as evidenced by team discussions and con-
sultation between role groups.
5. Synergy. The combined efforts of the team and the shared
decision making result in a greater benefit to the patient
than the effects of the individual disciplines alone. For this
review, the word ‘‘synergy,’’ defined as a way of working
that creates an outcome that is better than the outcome any
one participant could create alone,39 will be used to refer
to this assumption as evidenced when outcomes of
interventions are attributed to the collective team effort.
Aim
The aim of this integrative review was to examine interprofes-
sional teamwork and collaboration with CHWs in research
demonstrating positive health outcomes as a result of CHW
intervention. Key questions that guided the review process
were (1) did the CHW function as a member of the healthcare
team? and (2) were assumptions of teamwork between CHWs
and health care teams present as defined by Rice?37
Methods
An integrative review methodology 40 was used to identify evi-
dence of Rice’s five assumptions of effective teamwork
between CHWs and providers from two major systematic
reviews of the literature. 1,2 A review of the literature was con-
ducted to identify peer-reviewed research reporting health out-
comes of CHW interventions. These studies were published in
English from 1996 to 2013 using the following electronic data-
bases: MEDLINE, PsychINFO, Cochrane Reviews, CINAHL,
and the World Wide Web. Key search terms included primary
care, health outcomes, community health worker(s) and syno-
nyms for CHW including lay health worker, outreach worker,
health advocate, and promotora de salud. Using these terms, we
found two comprehensive systematic reviews of research
assessing the effect of CHW interventions.
The first systematic review, conducted by the Agency for
Healthcare Research and Quality, (AHRQ), 1 identified
research conducted between 1980 through November 2008 that
examined cost, outcomes, and characteristics of CHW inter-
ventions. Its review included all studies conducted in the
United States and published in English. It excluded studies that
had fewer than 40 participants, were not original research, and
did not report on topics relative to the key questions of the
study. It rated the quality of the studies as good, fair, or poor
based on the AHRQ Comparative Effectiveness Guide.41 In
total, these authors identified 53 original research studies.
The second systematic review reported by The New Eng-
land Comparative Effectiveness Public Advisory Council2 con-
ducted an update to the AHRQ study 1 systematic review from
January 2008 through April 2013 focusing on the impact of
CHW interventions on health outcomes using the same rigor-
ous search criteria and quality ratings based on the AHRQ
Comparative Effectiveness Guide. 41 This search yielded 18
studies. From these, a new database of 47 studies of good and
fair quality spanning the time frame of 1980 through 2013 was
created. The new database was comprised of 29 of the 53
AHRQ studies that focused solely on CHW interventions with
the newly added 18 studies that met criteria in their update.
Excluded from their review were studies that focused on
improved patient knowledge or satisfaction. These 47 studies,
representing the best evidence in the literature reporting posi-
tive health outcomes as a result of CHW interventions over a
period of 33 years, form the database for this integrative
review.
Data Abstraction
The following data were abstracted from each of the 47 research
reports: study aim, presence of a team that included the CHW,
and assumptions of teamwork (shared understanding, egalitar-
ianism, cooperation, and interdependence, and synergy). Studies
that reported the same intervention in more than one publication
were examined separately and counted as one study.
Data Reduction
Each study was examined to identify whether or not the CHW was
a member of the health care team. A study was coded as having
evidence of team if the CHW was reported to be a member of a
multidisciplinary or interprofessional team or work with at least
one member from any other health profession. Thirty-five studies
did not report the inclusion of a CHW working as a member of a
health care team and thus these studies were excluded. The
remaining 12 studies, which created the database for the review,
were examined for evidence of effective teamwork-shared
understanding, team functioning in an egalitarian, cooperative,
and interdependent manner, and synergy. The previously
described assumptions for effective teamwork were used as the
coding schema, namely, (1) shared understanding, (2) egalitarian-
ism, (3) cooperation, (4) interdependence, and (5) synergy.
Results
Analysis of the 47 best evidence studies revealed 12 studies that
reported the CHW functioning as part of a health care team.42-56
See Table 1 for data display. The composition of the teams was
most often CHWs with nurses, physicians, and dietitians. Less
frequently, teams consisted of CHWs with social workers, proj-
ect coordinators, research assistants, psychologists, community
Franklin et al 3