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"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.

Jackie LeGrand
CHWs graduating from Rutgers University

This blog was originally posted on the State Refor(u)m website.

Community health workers (CHWs) are often employed to improve health equity, cultural competency, health literacy and access to care, among other issues. Because they have such varied roles, there are many definitions of CHWs; however, they are commonly identified by their in-depth understanding of the population they serve.

On a recent State Refor(u)m webinar, speakers from Massachusetts, New Mexico, South Carolina and the Center for Medicare and Medicaid Innovation spoke about the role of community health worker models in changing state health care systems. We asked our audience of over 900 listeners to identify the biggest challenge to integrating CHWs into state health care systems. Financing was voted the biggest challenge, followed by defining roles and scope of practice for CHWs, ensuring appropriate training and certification of CHWs, and forming effective partnerships across state government, health plan and provider roles. There are many ways to approach these challenges; every state has unique circumstances and has a unique way to seek solutions, but there are commonalities that enable other states to learn from leaders.

Several states’ models for financing CHWs were discussed. Medicaid has traditionally only paid for care provided by Medicaid licensed providers, which has precluded payment for CHWs. New Mexico uses near-universal managed care for Medicaid recipients and these managed care providers are required to offer the services of community health workers to their members, as part of the capitation contract. Each Medicaid Managed Care Organization then finances CHW-provided care through direct-hire, contracting with groups that hire CHWs, covering the costs, via a flat-fee or per member per month payment, as part of a care team or fee-for-service. This model ensures that Medicaid recipients have access to CHWs.

Massachusetts and South Carolina rely mostly on grants to finance their CHWs. Massachusetts is currently exploring the new SPA to allow for billing of preventive care by non-clinicians based on recommendations from Medicaid providers, allowable under a recent Medicaid rule change. South Carolina warned that defining an encounter as being face-to-face, either with an individual or a group, under their fee-for-service model, has been a barrier to wider use of CHWs. Non-face to face activities such as contacting patients who miss a recommended cancer screening test may not be reimbursed with this definition.

Defining the roles of CHWs, along with certification and training, are also big challenges to integrating CHWs into state health care systems, since their roles can vary widely. In Massachusetts, many stakeholder groups, including relevant state agencies, came together to identify ten core competencies that CHWs are expected to have, no matter their specific role within the health care system. The state is expecting to promulgate regulations during 2015, allowing certification to move forward.

South Carolina has already moved forward with a certification program. The program, offered at a number of public technical colleges, is six weeks long and involves 120 classroom hours, 120 hours in practice and then passing an exam. Grandfathering is allowed for CHWs with at least three years of experience.

Tensions around formalizing the CHW role, and the fear that the demands of certification and training will drive away community members who act as CHWs has developed as states move forward with a formal definition of roles and a training and certification process. Ensuring process participation by a wide variety of stakeholders can ease some of these tensions.

Additional issues that states are facing while working toward formalizing the CHW profession are the financing of the education and certification process, as well as the need to develop a plan for continuing education for certified CHWs.

There is no right way to incorporate CHWs into the health care system and each state that is considering integrating CHWs into its delivery model must take an approach that fits their unique health care system. While each approach will be different, most states find financing, defining formal roles and certification, and stakeholder partnerships to be key issues that require attention.

How is your state using CHWs or working through financing or certification issues? Let us know in a comment below.

Blog reposted with permission from original poster.

Cover photo courtesy of Rutgets Nursing/Creative Commons.

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