By: Gail Hirsch and Geoff Wilkinson
There are an estimated 3,000 Community Health Workers in Massachusetts. The Massachusetts Department of Public Health is developing a statewide certification process for CHWs and CHW training programs to recognize and professionalize this cadre; regulations should be available in the fall of 2014. Various stakeholders beyond the state agency are fully involved. CHW Central interviewed Geoff Wilkinson (GW), DPH Director for Policy and Planning and Certification Board Chair, and Gail Hirsch (GH), Director, DPH Office of Community Health Workers, to bring to light the lessons learned for other states and countries embarking on a similar journey.
Why are Community Health Workers so important to Massachusetts?
GW: Community Health Workers serve some of the most vulnerable members of our society, and they do it with singular effectiveness. CHWs typically come from the communities they serve, or at least share similar cultural experience and understanding with people they serve. They’re able to form trusting relationships quickly and have time to talk with people about what’s really going on in their lives—so they can learn about the daily realities and practical challenges that may prevent people from accessing services or following medical advice. They help people find new resources, build new relationships, and solve basic problems. CHWs make connections between clinical care and community prevention; they provide a bridge—or often are the bridge—between providers, patients, and community organizations. CHWs help reduce health disparities and promote health equity. They help improve quality of care, increase access to insurance and preventive services and contain costs or actually save costs, by reducing unnecessary urgent care, or by helping people manage chronic disease.
The Massachusetts Department of Public Health has been promoting and supporting the CHW workforce for over 20 years. Through its contracts with community-based service providers, DPH is the largest employer of CHWs in the state.
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CHWs are at the heart of the discussion about how to achieve the so-called “triple aim” of health care reform—improved quality of care, containing costs, and improved health outcomes, including health equity. |
Under the Affordable Care Act (ACA) and the most recent Massachusetts payment reform law (Chapter 224, 2012), provider systems are organizing new integrated care models and health care finance is moving away from fee-for-service toward global budgeting and bundled payments and the like. CHWs are at the heart of the discussion about how to achieve the so-called “triple aim” of health care reform—improved quality of care, containing costs, and improved health outcomes, including health equity.
How did you decide on a path to certification?
GW: Our certification program is the first in the country to be organized under a state health department’s division of health professions licensure. It is a voluntary program, a “title act,” meaning people who want to work as Certified CHWs need to go through the process, but can still be employed as CHWs without certification. For example, community health leaders in emerging immigrant groups would still be able to get jobs without certification.
We got on this path as a result of organizing by CHW leaders in MA going back at least 15 years. Our 2006 health care reform law included a provision requiring DPH to conduct a workforce study and make recommendations for a sustainable CHW program. That led to a CHW advisory council that met for almost two years with about 40 stakeholders from all different sectors. They all agreed about the need for a certification program. Payers said that without one, reimbursing for CHW services was a non-starter. Employers wanted some assurance of a standard skill set and knowledge base for CHWs. And CHWs saw an opportunity for increased respect, improved employment stability, and better compensation and professional support.
Following that, the Massachusetts Association of Community Health Workers (MACHW), one of the first CHW-led professional associations in the country—worked with other stakeholders to draft legislation to create our certification program. MACHW led an advocacy campaign that succeeded in getting the bill passed in one legislative session, which is very unusual in this state. The timing was just right. The ACA had recently been signed into law; Massachusetts was working on another major health care reform; and legislative leaders recognized the value and opportunity certification represented.
What are some of the benefits you expect to see?
GW: We hope to achieve better clarity about who CHWs are and why they’re so valuable, agreement about CHW scope of practice and core competencies, increased integration of CHWs into care systems, improved workforce surveillance, better stability, pay, benefits, and support for CHWs, and progress on triple aim objectives, particularly better health outcomes for vulnerable populations.
GH: We knew developing regulations was going to be challenging with so little national infrastructure to draw upon. We’re all learning from one another. We have to make sure the regulations we develop are relevant to the realities of care coordination in large hospitals, and that certification covers all CHWs, including those who address the social determinants of health by working in public safety, public housing, or environmental justice organizations. Defining the core competencies has taken a lot of care, but thankfully there has been a lot to draw on nationally for that.
GW: And it’s been challenging to take the long view, to define regulations that will hopefully stand the test of time, understanding that the health care system and the relationship between public health and health care is changing rapidly. For instance, we’re setting certification standards for CHW training programs, as well as for individual CHWs. The training infrastructure for CHWs may change, perhaps in ways hard to imagine.
What other challenges need to be addressed?
GW: Funding for core competency training is an immediate priority. We have several well established and nationally respected CHW training programs in MA. They’ve traditionally depended on grant funding for core competency training, and grants and contracts to develop specialized health topic trainings. Grant dependency for CHW core competency training is not the best business model for a changing, statewide health system that’s trying to develop integrated care models and promote community prevention. Are employers going to step up to the plate? What’s the emerging business model to support this growing need?
The Board of Certification is influencing market development through policy decisions such as increasing the minimum number of hours certified training programs will be required to provide in core competencies. All stakeholders want a rigorous, meaningful program, but we can’t set the bar so high that it becomes impractical or unsustainable.
GH: We also have to look at the challenges of implementation; for example how do we handle the certification requirements of long serving and experienced CHWs versus those newly graduated? We are currently proposing a grand-parenting approach to address this.
GW: There is an increasing body of scientifically rigorous research about how CHWs are effective, with whom, and in what roles and care models to address different diseases and conditions. There’s a lot of interest about CHW cost effectiveness and return on investment. It’s outside the scope of the Board of Certification’s authority to regulate employers, but we know providers see the Board’s work as critically important to their own efforts to ensure that providers increasingly work at the top of their respective licenses. When that happens, it’s more likely that patient outcomes improve and system costs are contained. Payers share this interest.
We are concerned from the perspective of workforce development about what happens to the savings that CHWs help to achieve. Will CHWs become better compensated? Will providers hire more of them? Or will the benefits of their unique contributions accrue elsewhere in provider systems? We hope the certification process will lead to increased utilization of and support for CHWs, with all the benefits we expect that will bring.
GH: Another challenge is how to retain the grassroots nature of what CHWs do, but also create an integrated role that fits into the bigger picture? We have a fragmented, medicalized, technological health care system. Where is the role for CHWs? That’s where public health comes in! We don’t want to see ourselves in 20 years needing to promote a CHW-like workforce because today’s CHWs got taken out of the community when they got brought into clinical care teams.
What are some requirements that should be considered in deciding to certify CHW training programs?
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CHWs are at the heart of the discussion about how to achieve the so-called “triple aim” of health care reform—improved quality of care, containing costs, and improved health outcomes, including health equity. |
GW: It is important for CHW training programs to use adult learning theory and methods and to employ experienced CHWs as trainers, along with other faculty or professionals. We’re willing to certify mixed online and in-person training programs, but don’t expect to certify on-line-only programs, at least not initially. We think “the human touch” is too fundamental to the CHW role. Training programs will have flexibility in designing their curricula; our focus will be on how effectively programs prepare trainees to gain proficiency in the ten core competencies the MA Board of Certification of CHWs defines as the core practice and knowledge base for the profession.
What advice or lessons learned do you have for other states?
GH: Nurturing and including CHW leadership requires a significant amount of time and resources, but it is critical. CHWs have to be involved in the process. If states develop policy or programs without CHWs, they are sure to encounter problems.
GW: Our program has had the benefit of proactive engagement by payers, providers, training programs, advocates, and academics, as well as CHWs. I would say to other states, “Take the time it takes.” Building a strong foundation for policy development, with strong stakeholder engagement and buy-in, should result in a stronger program with long term benefits.
Should the federal government be involved?
GH: Federal government support through its multiple public health and workforce development agencies is very important to the states. The federal government can also be a major convener of states and other partners—like foundations, academics, and public health organizations—to advance work on CHW activities. There’s no national accreditation for CHW training. Models for integrating clinical and community prevention and for promoting primary prevention with the help of CHWs are still in the early stages of development.
Any final thoughts?
GW: We’re particularly concerned about sustaining the “CHW voice” in CHW policy development. None of this would have happened in Massachusetts without CHW leadership. We operate by the CHW principle, “Nothing about us without us.” CHWs have to be at the table, participating in every step of policy development and implementation. It’s challenging to engage CHWs in policy development, because their work roles don’t normally allow time “off” to engage in policy development. It’s easy for policy professionals to get excited about the possibilities and make recommendations and decisions without CHW input, even with good intentions. So we really have to adopt expectations and develop structures to facilitate CHW engagement in this process as it moves forward. That’s true, I would argue, within clinical settings, as well as within state health departments.
Thank you!
Interested in learning more? Check out this Resource for an extended interview with Gail and Goeff. And watch this video of Geoff Wilkinson speaking on the importance of CHWs.
About the interviewees:
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Gail Hirsch, MEd, Director Office of Community Health Workers Division of Primary Care and Health Access Massachusetts Department of Public Health |
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Geoff Wilkinson, DPH Director for Policy and Planning and Certification Board Chair |
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