Community health workers (CHWs), also known as promotoras de salud, community health representatives, and peer navigators, are frontline public health professionals who share lived experience with and often come from the same communities as the people they serve. CHWs use this shared background to build trust with patients and support connections between health systems and communities. A strong and growing evidence base demonstrates that care models engaging CHWs are an important strategy for addressing the needs of populations with complex health and social needs.
To better understand the CHW policy landscape as it relates to supporting people with complex needs and considerations for policymakers seeking to advance these efforts, the Better Care Playbook spoke with Carl Rush, principal consultant for Community Resources, LLC, and senior technical advisor to the National Association of Community Health Workers (NACHW). Carl Rush has advised on CHW policy initiatives in more than 20 states, directed a community college CHW program, and authored multiple reports related to supporting the CHW workforce. He recently authored a National Academy for State Health Policy brief on Medicaid approaches for CHW financing and supported development of resources for the NACHW Document Resource Center.
Q. What is the range of roles that CHWs can play to support populations with complex health and social needs?
A. The roles CHWs play to support populations with complex needs are similar to the roles they play with any population, though individuals with complex health and social needs may particularly benefit from CHW services. CHWs support health promotion, coaching, and, increasingly, care coordination and management. Some of their activities include assistance with adhering to treatment plans, connecting individuals with social supports and health education. Another foundational aspect of CHWs is shared lived experience with the population they serve; this doesn’t necessarily mean the same health condition and often includes shared experiences of poverty and racism. A big challenge for health systems is establishing relationships, effectively communicating, and building trust with patients with complex health and social needs, especially among populations with low-income. A unique strength of CHWs is they can be a broker between the system and individuals. For example, individuals are often more comfortable being candid with CHWs than physicians and CHWs often have more time than clinicians to build relationships. CHWs are also well positioned to be advocates for patients — either internally within the health system or on behalf of the patient at other organizations to which they are referred.
Q. What is the opportunity for CHWs to play a role in advancing health equity?
A. While advancing health equity is a common public sector priority, policymakers often do not know how to improve health and social outcomes for individuals experiencing health disparities, including those with complex health and social needs. CHWs can play a role in addressing inequities since they uniquely understand the needs of communities and know what it takes to effectively reach those populations. CHWs can also get patients candidly talking about how the system is not working well. For example, CHWs can provide feedback like “the organization is not meeting the needs of patients because it is only open from 9am to 5pm.”
Q. What are key barriers to implementation and sustainability of CHW programs?
A. Many people in the health system don’t understand what CHWs do. For example, as part of making CHWs a billable service under Medicaid, states often specify the types of providers who may refer patients to CHWs. Some state staff are under the impression that only certain medical professions (e.g., doctors, nurses) should make these referrals. Creative design of referral procedures (e.g., using tools like standing orders) can allow other professionals, like social workers who may have a better sense of when CHW services are valuable, to make the referral. It can be challenging within the culture of health care organizations to shift from the medical world view, where power and authority are based on medical training.
Financial sustainability is another challenge, because there is currently no ideal source of ongoing funding for CHWs. Medicaid is an important component of CHW payment, but it is nearly impossible to design a payment and employment structure where all of a CHW’s time can be reimbursed under Medicaid. Payment systems will need to account for the significant time required for activities like developing and maintaining relationships and travel. Also, Medicaid, of course, will only pay for services to enrolled Medicaid beneficiaries.
Stakeholders need to accept that other sources of payment are also needed. One positive development is that CMS recently announced their intention to pay for CHW services under Medicare. Additionally, people are exploring models for blended or braided funding (i.e., combining funding from different sources) to support CHWs as many non-health care organizations (e.g., housing authorities, correctional facilities) benefit from CHW programs. One example is the Pathways Community HUB model. Under this model, multiple payers provide funding for a network of CHW employers; the “hub” documents services provided and bills each payer as appropriate. This allows the CHWs to address whatever issue is most pressing for a family, without concern for how their time is being paid for.
Q. What types of payment policies are Medicaid agencies implementing to support adoption of CHWs into care teams?
A. There are a variety of approaches states can take to cover CHW services, such as state plan amendments (SPAs), waivers, and incentivizing CHW adoption through MCO contracts. Recently, there has been a lot of momentum around states financing CHWs through SPAs. As of July 2023, 13 states have SPAs to support Medicaid payment for CHW services (in addition to 10 states highlighted in this brief, Arizona, Kansas and Kentucky had SPAs approved in 2023) and 12 of these pay for CHWs through fee-for-service reimbursement. Across states there is a lot of similarity in types of services covered, mostly falling into the categories of health promotion and education, coaching, and care coordination. There are some significant differences across states in terms of implementation such as in billing rates (above and beyond cost-of-living differences), what types of providers can refer individuals to CHW services, and eligibility criteria for CHW supports.
A positive development is that most states recently implementing CHW SPAs have adopted a broad definition of medical necessity, which allows a range of Medicaid enrollees to be eligible for CHW services. For example, in addition to clinical categories of medical necessity (e.g., having a chronic disease, being pregnant) states are also considering factors like social needs, proxy measures of limited access to care (e.g., missed appointments, multiple hospitalizations, emergency department visits), or even patient declaration of need to determine medical necessity.
A key ongoing challenge is that fee-for-service billing, the dominant method of paying for health care services, is a poor fit for the way CHWs work. For example, CHW activities are not easily broken down into discrete services and billing for small time increments can be administratively burdensome. At the same time, states generally do not have sufficient data (e.g., costs of CHWs, utilization of CHW services) to implement other forms of payment such as value-based payment models. One exception is Maine, where payment for CHWs is being integrated into their primary care payment model.
Q. Beyond payment considerations, are there other types of state policies that are key to supporting CHW uptake?
A. There are a variety of basic policies related to training and workforce infrastructure that need to be in place. One is that states need a recognized definition of CHWs as an occupation. State labor departments have a catalogue of occupations within a state and to make progress on supporting uptake of CHWs, it is important to have the occupation recognized by the state.
Another key policy is that states need to recognize standards for CHW training. This can be done in a few ways. Some states, like Minnesota, have a standardized curricula for training CHWs. Other states, like Texas, have standards for certifying CHW training programs. States also have voluntary CHW certifications that are based on an individual’s training or work experience. It is also important that states have a workforce development strategy. There have been a lot of federal resources to support this, such as funding from the Centers for Disease Control and Prevention and Health Resources and Services Administration. It takes significant investment in training to make CHW programs work; some states have started to reimburse for CHWs in Medicaid, but had low uptake because they didn’t have the needed training infrastructure.
Q. Are there key lessons or considerations you would highlight for states in the process of developing policy strategies for supporting CHWs?
A. In terms of educating state policymakers about CHWs, it is important to collect quantitative and qualitative data. Concisely presenting numbers and results related to CHW programs can be an important way to build the case. Anecdotes are also important for describing the impact of CHWs and the good news is many CHWs are great storytellers.
Another big lesson is that CHWs themselves need to be involved in policy decisions. A lot of people assume because CHWs are an entry-level position in most organizations that other stakeholders can just impose a program on them. That is not acceptable — no other profession in the country would let other people make decisions for them. Indeed, the American Public Health Association has a policy urging that policymaking bodies related to CHWs should consist of at least 50 percent CHWs.
Relatedly, states should consider how to adopt flexible policies that allow CHWs to work effectively. A key principle is to “let CHWs be CHWs.” State programs should not put CHWs in a box and overly silo or overly medicalize their work. For example, narrowly scoping CHW programs to focus on one condition or one activity, such as health education, does not make the best use of CHW capabilities. Instead, a whole-person approach in which CHWs do not have a set agenda and can work with patients and families to address their priorities is ideal.
Q. Are there particular considerations state Medicaid agencies or other payers should consider to support CHWs in rural areas?
A. Rural areas can pose some unique challenges for CHW program implementation. One consideration is smaller communities may not have enough residents who are appropriate candidates for being CHWs. Such areas may need to leverage CHWs with similar backgrounds from outside the immediate community. Another consideration is that rural areas often require lots of travel on the part of CHWs and travel time is not billable under fee-for-service, so it needs to be considered as an indirect cost. For example, if one hour of service requires four hours of travel, payers need to set billing rates accordingly to reflect that. Agencies may also consider what type of billing flexibility their regulations allow. For example, CHWs sometimes provide transportation for patients, which itself isn’t a billable service; but depending on program rules, time spent coaching or educating clients during a trip may be reimbursable.