Community Health Workers: A Piece of the Health Care Puzzle

1. Community Health Workers: A Piece of the Health Care Puzzle Presenters: Alicia Young, Claireta Thomas & Michael Anderson Sustainable Funding for Community Health Worker Practice and Utilization in Michigan: Planning the Future Detroit, Michigan - August 18, 2011

2. Purpose • Provide awareness of and information on the: • definition of a CHW • role of the CHW, & CHW profile • issues related to legitimizing and recognizing CHWs at the state and national level • challenges and policy options for sustaining CHW programs • existing CHW support

3. Health Care SystemChallenges/Demands • Growth in the cost of the system • Uneven quality of service • Lower satisfaction rates among consumers • Demographic realities of an aging and more racially diverse population • Growth in technology

4. Emergent Health Care System • more focused on consumer needs and interests; • more often located in the home and community; • welcoming to non-traditional providers; • more culturally sensitive and aware; • better able to delegate care management technology to midlevel and paraprofessional providers; • more aware of costs; • sensitive to a broader array of health outcomes; and • more attuned to chronic care management than acute treatment.

5. Well-trained and compensated community health workers provide a vital missing link to improved health.

6. A CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison / link / intermediary between health and social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.

7. The Final Report Of The National Community Health Advisor Study Outlines Core Roles and Competencies of Community Health Workers

8. Role of CHWs: • Cultural mediation between communities and health and human services system • Advocating for individual and community needs • Assuring people get the services they need • Informal counseling and social support • Building individual and community capacity • Providing culturally appropriate health education • Providing direct services

9. Personal Characteristics • Relationship with the community being served • Caring / Empathetic • Personal strength and courage (healthy self-esteem and able to remain calm) • Persistence • Creativity / Resourcefulness • Respectfulness • Desire to help community

10. Skills of Community Health Workers Communication Interpersonal Teaching Knowledge Base

11. Service Coordination Advocacy Capacity-Building Organizational

12. Community member vs. Health care system/team member • Lay person vs. Credentialed/Professional individual • On the job, tailored training vs. Standardized training • Ill-positioned for RCT studies vs. Will stand up to RCT evaluation • Broad, encompassing approach & roles vs. Tailored, specific roles • Independent vs. Integrated/interdependent • Direct, out-of-pocket payment model vs. Services reimbursable • Volunteer vs. Paid

13. Legitimizing & Recognizing CHWs at the State & National Level Problems undermining CHW’s efficacy and use • Lack of standardized system-wide training and skill development • Lack of acceptance by other health professionals • Lack of established standards of practice and core competencies.

14. Proposed Solution to Meeting Labor Force Demand for Community Health Workers • Develop standardized competencies and assessment tools that at the same time retain the heart of CHWs’ effectiveness—their roots in and knowledge of their communities.

15. Challenges to Recognition of CHWs and Expansion of CHW Programs • Inadequate and unstable funding • Prevents programs from reaching potential and sustaining services • Restrict CHW services to specific disease • Impedes CHWs ability to address client health-related issues

16. CHWs often are not recognized as legitimate providers within the health and human services sectors • Lack official estimates of the # of CHWs • Previously lacked specific occupational code for CHWs, various titles & roles

17. CHW Standard Occupational Classification21-1094 Community Health WorkersAssist individuals and communities to adopt healthy behaviors. Conduct outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. May collect data to help identify community health needs. Excludes "Health Educators" (21-1091).Illustrative examples: Peer Health Promoter, Lay Health Advocate

18. Challenges to Recognition of CHWs and Expansion of CHW Programs (Contd.) • Lack of direct reimbursement for CHW services by Medicaid & other programs • Compounds the first two challenges • Lack of a standardized scope of practice for CHWs • Lack of an outcome evaluation of CHW services from a national perspective

19. Lack of accepted CHW standards – definition, core competencies and scope of practice • Hinders CHWs ability to link families to needed services and supports • Informal on-the-job training, program specific, narrows scope of roles

20. Standardized competencies in education & training would enable CHWs to undertake a broad set of CHW roles. • The push for standards & advancement of the CHW field at the state & the national level requires advocacy from strong organizations & other stakeholders. • CHW organizations are currently working to further develop & strengthen their associations.

21. Sustaining CHW Programs: Challenges & Policy Options • Barriers to sustaining CHW programs: • Unstable funding • Need for training and certification • Need to institutionalize and integrate CHW programs into existing health systems

22. Financing Community Health Worker Programs & CHWs • Four Methods to Fund CHW Services: • Medicaid Managed Care—can use the capitated funds they receive from the state to directly employ CHWs or contract with an organization that provides the services; • Section 1115 waivers—allows for the expansion of services statewide through CHW programs, and enables reimbursement for certain of these services;

23. Federal Support for Administrative Costs—community-based CHW programs can receive federal matching funds for outreach and coordination; • Direct Reimbursement—CHWs are defined as billable providers thus allowing them to bill the Medicaid program directly for services. • Evaluate CHW programs and services to capture the outcomes and cost effectiveness.

24. Funding Ideas • Medicare • Block grants and community development • Integrating CHWs into homeland security through community preparedness • Direct hire by consumers

25. Solutions to Advance Career Opportunities • “Mapping the field”—bring clarity as well as recognition to those whose work & contributions have previously been poorly understood – or even classified as part of the same field; • Improving the job—formal recognition, CHW funded by government & third-party insurers, creation of career ladders & standards for employment & advancement, & the creation of educational programs to support skill development & advancement of CHWs;

26. Potential Solutions to Advance CHW Career Opportunities • Certification—could lead to standardizing the field, upgrading the job, & improving CHW’s performance; • Career ladders—“up and out” facilitates the access of CHWs to other established areas of health care such as patient care, clinical technician, or medical administration; or promotion tiers that link increases in skills, education, or competencies to wages & greater responsibility;

27. Potential Solutions to Advance CHW Career (contd.) • Higher education-based programs—offer courses, certificates, and/or degrees in CHW • Link workers to career paths in related health care and administration occupations • Create a career ladder within community health work that links increases in skill, education, and experience to increased responsibility and wages

28. CHW Training & Certification Trends in CHW Training & Certification • Community college certificate & non-certificate programs—provides career advancement opportunities; • On-the-job training that is program specific & provided by employer & sometimes in collaboration with other institutions—improves standards of care, CHW income, & retention; • Certification or licensure by a state department or agency—recognizes the work of CHWs, & facilitates Medicaid reimbursement for CHW services.

29. Outcomes of Training and Certification Programs • Career advancement—enhanced career advancement opportunities & college credit towards other career programs; • Enhanced earning capacity ; • Enhanced CHW retention; • Outcomes—improved standards of care, health outcomes & CHWs skills & competencies; • CHW status—enhanced recognition and earning power; • Improved self-esteem and self-worth.

30. Potential Barriers & Solutions to CHW Credentialing • Fewer CHWS will come from the communities they serve—directly involved CHWs in establishing the program • Erosion of indigenous qualities that make CHWs effective—encourage CHW programs to supplement formal training with education and training specific to the community served.

31. Barriers and Solutions to Credentialing (contd.) • Loss of highly effective CHWs due to volunteer or immigration status or level or education, if these are required to participate in CHW training program and credentialing—create credentialing credits that currently practicing CHWs can obtain, such as on-the-job training, hours of service and other life experiences that contribute to effective service delivery.

32. Barriers and Solutions to Credentialing (contd.) • Credentialing fees & training tuition may be barriers for low-income CHWs interested in becoming certified—encourage organizations that use CHWs to underwrite fees, or arrange for training scholarships; • Other unforeseen problems—involve practicing CHWs in developing & refining a new credentialing program.

33. Potential Benefits of CHW Credentialing • Advance perceived legitimacy within the health and human services communities. • Improve outcomes related to CHW services. • Help open the door for reimbursement for CHW services. • Expand job opportunities for CHWs by making them a recognized provider. • Offer assurances to current and potential CHW employers that credentialed CHWs have basic competencies.

34. Indicators of CHW as an Emerging Profession • 2002 IOM Report (Unequal Treatment) recommends CHWs to address health disparities (Finding and rec. #5) • 2007 national HRSA CHW Workforce Study • AADE (2003) • American MedicalAssociation (AMA 2003) • American PublicHealthAsso. (2001, 2009) • National Center forChronicDiseasePrevention & HealthPromotion (CDC 2003)

35. Indicators of CHW as an Emerging Profession (Contd.) • AACHW Code of Ethics – 2008 • NCSL Policy Brief 2008 • Bureau of Labor Statistics – 2009: distinct SOC for CHWs • Inclusion of CHWs into 2009 SCHIP reauthorization • Inclusion of CHWs into 2010 national Health Care Reform (Patient Protection and Affordable Care Act -- H.R. 3590) • National Action Plan to Improve Health Literacy 2010 recommends use of CHWs

36. To define public policy the following issues need to be clarified: • Selection-Recruitment • Task and Functions, Roles • Education - Training - Certification • Support / Funding - Public/Private • Supervision, Monitoring • Evaluation- outcome effectiveness, cost effectiveness