Equity, Community Health Workers, and the Quintuple Aim

 

The Institute for Healthcare Improvement (IHI, 2025) developed the Quintuple Aim as a framework to improve health system performance. Originally introduced as the Triple Aim in 2012, the framework emphasized improving population health, enhancing patient experience, and reducing per capita cost. The Triple Aim has since evolved to the Quintuple Aim with five interdependent dimensions: population health, patient experience, cost, provider well-being, and health equity.  Health equity is not an “add-on” to the Quintuple Aim.  It is the foundation that determines whether improvements in the other four domains are meaningful and sustainable. This month, we focus on equity and the Community Health Worker role.

 

What Does “Equity” Mean in the Quintuple Aim?

 

Health equity is the attainment of the highest level of health for all people (Centers for Disease Control and Prevention, 2024).  Health equity means that everyone has a fair and just opportunity to attain their highest level of health. Achieving equity requires us to value everyone equally, adjust resources for disadvantaged groups, and remove systemic barriers such as poverty, racism, discrimination, language barriers, geographic isolation, and other social and structural factors.  This concept moves beyond disparities and aims to create an even playing field for all populations. 

 

                        Figure 1.  Advancing the Quintuple Aim (Matheny, et. al)

 

 

The Agency for Healthcare Research and Quality (AHRQ, 2025) examines and documents persistent health disparities on an ongoing basis.  As we reviewed in our cost discussion, the United States experiences significant disparities in maternal health, chronic condition outcomes, and access to care.  These disparities persist, despite spending more per capita on health care than any other developed nation (Organisation for Economic Co-operation and Development, OECD, 2025).  Health equity requires system transformation and a population health (rather than individual or sub-population) focus.

 

Equity and Social Determinants/Drivers of Health (SDOH)

 

Health inequities are rooted in upstream social and structural factors, often referred to as Social Drivers/Determinants of Health (SDOH): 

• Housing stability
• Food security
• Transportation access
• Education and health literacy
• Employment and income
• Access to culturally responsive primary care

 

When these upstream drivers are unmet, individuals are more likely to delay care and use emergency departments for non-emergent needs, resulting in fragmented care.  These patterns are the result of structural inequities and result in adverse health outcomes.

 

Moving to an upstream care model is essential to achieve equity.  The Chronic Care Model (Wagner, 1998) emphasizes proactive, coordinated, community-linked systems.  However, without explicitly focusing on equity and justness (the concept of being fair in action or treatment), upstream efforts may fail to reach communities and populations experiencing the highest levels of structural inequity. 

 

The Role of Community Health Workers in Advancing Equity

 

Throughout this series, we have focused on the role of Community Health Workers (CHWs) and their unique position as members of the communities they serve.  CHWs are uniquely positioned to operationalize health equity within care teams, applying lived experience, focusing on cultural norms, and understanding systemic barriers within communities and systems of care.

 

CHWs advance equity by:

• Identifying and addressing SDOH barriers that disproportionately affect marginalized populations
• Providing culturally and linguistically appropriate education
• Using evidence-based techniques such as motivational interviewing and teach-back to improve understanding and engagement
• Building trust in communities historically at odds with health systems
• Supporting navigation of complex systems such as Medicare, specialty referrals, and social services

 

By addressing root causes rather than symptoms alone, CHWs help ensure that improvement efforts reach populations most affected by inequities.

 

Equity and Physician/Provider Well-Being

 

Equity is also directly tied to physician and provider well-being. When health systems lack adequate infrastructure to address patients’ social determinants/drivers, physicians/clinicians may experience burnout.  Integrating CHWs into care teams takes advantage of the most appropriate team roles, physicians and team members practice at top of license, and patients’ and caregivers’ non-clinical barriers are addressed.  This creates an equity-centered practice model and supports workforce sustainability consistent with the Quintuple Aim.

 

Equity and CHW Investment

 

Investing in CHWs is a strategic way to improve effective, integrated, equity-focused care.  CHWs contribute to: 

• Reduced disparities in preventive service utilization
• Improved chronic care management in targeted, high-risk populations
• Improved prenatal care and postpartum follow-up
• Improved patient and family experience among marginalized populations

 

The Practice Transformation Institute (PTI) CHW educational programs are designed to strengthen CHW knowledge, performance, and measurable impact. PTI is an approved provider of CHW training by the Michigan Department of Health & Human Services (MDHHS) and holds IACET accreditation, reflecting a commitment to training excellence.

 

PTI’s CHW program teaches the nationally recognized C3 Council competencies and prepares participants to function effectively across community and health care settings. This structured training supports CHWs in advancing equity while simultaneously improving outcomes, cost performance, and care coordination.

 

Advancing the Quintuple Aim Through Equity

 

Equity is not separate from cost, quality, or experience; it determines them. Systems that ignore inequities may temporarily improve performance on certain metrics, but disparities will persist or widen. Sustainable transformation requires embedding equity into workforce design, care coordination, community partnerships and value-based models.

 

Investing in equity has the highest potential to achieve the full intent of the Quintiple Aim.  Community Health Workers are central to this transformation and effort to deliver just, equitable care.

References

 

Agency for Healthcare Research and Quality (2025). National Healthcare Quality and Disparities Reports.

 

Centers for Disease Control and Prevention (2024).  Retrieved from https://www.cdc.gov/health-disparities-hiv-std-tb-hepatitis/about/?CDC_AAref_Val=https://www.cdc.gov/nchhstp/healthequity/index.html. 

 

Institute for Healthcare Improvement. (2025). The Quintuple Aim.

 

Johns Hopkins University (2022).  The difference between health equity and equality.  Retrieved from https://www.hopkinsacg.org/health-equity-equality-and-disparities/.

 

Matheny, M., Israni, S.T., & Whicher, D. (Editors, 2019).  Artificial intelligence in health care:  The hope, the hype, the promise, and the peril. NAM Special Publication. Washington, DC: National Academy of Medicine. 

Organisation for Economic Co-operation and Development (2025). The OECD: Better policies for better lives.

 

Wagner, E. H. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1, 2–4.

 

Practice Transformation Institute (2025). Community Health Worker Training Program.