Authors: 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 Community Health Workers and CHW training programs to recognize and professionalize this cadre. Various stakeholders beyond the state agency are fully involved. Regulations for certifying CHWs and CHW training programs are expected to be ready in the fall of 2014. 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 are important because they 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 they at least share similar cultural experience and understanding with people they serve. They’re able to form trusting relationships quickly. They have time to talk with people about what’s really going on in their lives—they’re not limited to a few minutes of “contact time,” so they can learn about the daily realities and practical challenges that may prevent people from accessing services they need or following medical advice they receive. I don’t mean CHWs just learn about those realities. They help people deal with them, find new resources, build new relationships, and solve basic problems. In the context of health care reform, CHWs are making the connections between clinical care and community prevention. They provide a bridge—or they 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 in numerous ways. They help increase access to insurance and preventive services. They help contain costs or actually save costs, by reducing unnecessary urgent care, for instance, 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. We’ve been involved in a lot of policy development over the years with CHW leaders and other organizations, like the state affiliate of the American Public Health Association and the Blue Cross Blue Shield Foundation, and other supportive advocates and funders.
The famous 2006 Massachusetts health care reform law involved a big push to enroll people in health insurance plans. CHWs played a major role in our success. We have close to 98 percent of the population enrolled in insurance plans, by far the highest of any state. CHWs demonstrated they can play a strong role in expanding access to care. 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’s important to note this is a voluntary program. It’s called a “title act,” not a “practice act,” meaning people who want to work as Certified CHWs need to go through the process, but people can still be employed as CHWs without certification. We’ve put a lot of thought and attention into avoiding unintended negative consequences that could come as a result of increased professionalization of the CHW workforce. We don’t want to restrict access to community health work for people who have the unique attributes that can make them effective and attractive to employers. Community health leaders in emerging immigrant groups, for instance, would still be able to get jobs without certification.
Overall, we got on the path to certification as a result of organizing by CHW leaders in Massachusetts 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 in the state. That led to creating a CHW advisory council that met for the best part of two years with about 40 stakeholders from all different sectors. The report of that council to our legislature is available on DPH’s website, and it contained almost three dozen recommendations. The one that got the most support from payers, employers, and CHWs was the need for a certification program. Payers said that without one, the idea of 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 release of that report, 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. MACHW had to work hard to make sure the program that passed was good for CHWs, rather than a mandatory licensure program that would have restricted access to the field. But they got the job done, and then we got to work actually developing the program.
What are some of the benefits you expect to see? And what challenges have been encountered?
GW: We hope to achieve the benefits that everyone who supported certification envisioned: 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.
We knew developing regulations was going to be challenging, because there’s very little national infrastructure to draw upon. It’s an emerging profession. We’re all learning from one another as we go. Besides what we could have expected, it’s been challenging to reckon with the fact that we’re both driving and responding to system change. We have to make sure the regulations we develop are relevant to the realities of care coordination in large hospitals, for instance. We also have to make sure we develop certification for all CHWs, not just those who work directly in health care. CHWs, after all, work in a variety of settings. They address social determinants of health, like working in public safety or public housing, or environmental justice organizations. So defining the core competencies for CHWs has taken a lot of care. Thankfully, there has been a lot to draw on nationally for that.
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. We expect there will be new training entities entering the field. The training infrastructure will change, perhaps in ways that are 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 the state. They’ve traditionally depended on grant funding for core competency training, and they’ve received grants and contracts to develop specialized health topic trainings. Well, grant dependency for CHW core competency training is not a good 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. We’re looking at what other states are doing and trying to lead and follow at the same time. All stakeholders want a rigorous, meaningful program, but we can’t set the bar so high that it becomes impractical or unsustainable.
Another challenge is capacity at the state health department to operate the new certification program and address what I’d call an explosion of opportunities for CHW policy and program development that’s going on now. This is an exciting time. CHWs have become kind of “hot” in health care policy circles lately. A lot of states are exploring how to use and pay for CHWs. Legislation is moving in a number of places. New Mexico, for instance, just passed a CHW certification program and allocated $500,000 per year for implementation. We did not receive that kind of dedicated support for implementation, but we are using existing resources creatively and effectively.
GH: Certification will be voluntary, but DPH’s belief is that a strong certification system will lead to more stable and equitable pay and jobs, insurance reimbursement, better understanding and recognition of CHWs, better training opportunities – and ultimately more effective CHWs helping to improve health outcomes.
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 explicitly outside the scope of the Board of Certification’s authority to regulate employers, and we’re not getting into issues such as the metrics that should be used to evaluate CHW impacts. We know, however, that 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.
A concern we have, from the perspective of workforce development, is 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? It’s beyond the Board’s role to get directly involved in those matters, but we hope the certification process will lead to increased utilization of and support for CHWs, with all the benefits we expect that will bring.
Another challenge in certification involves defining who a CHW is. Massachusetts uses a functional definition that combines recognition of a CHW’s “unique understanding” of the experience, language, and/or culture of the people she or he serves with a description of core roles CHWs serve. Well, that begs the question of whether you have to literally come from the community you serve to be a CHW. People are passionate about this question, and the implications are significant. Can anyone become a CHW, regardless of where they come from? The question means different things to different people and in different regions of the country. As a board created through statute, developing a certification program under the auspices of the state health department, we have a responsibility to create an open process. But we also have to take care to ensure that the process preserves the essence of what makes CHWs effective and valued to community members and employers. We’ve had a lot of discussion about the risk of driving a proliferation of academic or commercial training programs that could essentially redefine the field. We don’t want to see ourselves in 20 years needing to promote a CHW-like workforce because today’s CHWs got unintentionally crowded out by our regulatory mistakes.
GH: That is THE question. How do you 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!
CHWs are a two way bridge: they not only deal with patient outcomes, but improve the quality of care other providers and the system provide. In the back of our minds is the knowledge that they have the potential to transform the system, and we need to support that.
What are some of the requirements that should be considered in the decision to certify CHW training programs?
GW: We’ve defined four domains for training certification standards, each of which will require applicants to provide detailed information to help us understand their experience, values, training methods, staff qualifications, curricula, finances, sites, support services, and the like. The complexity arises in setting threshold requirements and specific rubrics for assessing training program applicants, especially new entities that we expect may seek to enter the field. As a general matter, we think it’s essential for training programs to use adult learning theory and methods and to employ experienced CHWs as trainers, along with other faculty or professionals. We’ve given a lot of thought to different training models and are willing to certify mixed online and in-person training programs, but we don’t expect to certify on-line-only programs, at least not initially. We think “the human touch” is too important, too fundamental to the CHW role. We are not going to define or require a standard curriculum. Training programs will have flexibility in that regard. Instead, we will be most interested in how effectively programs prepare their training participants to gain proficiency in the ten core competencies the Massachusetts Board of Certification of CHWs defines as the core practice and knowledge base for the profession. That will be the foundation of training program certification.
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.
GW: CHWs have to be involved in the process. If states develop policy or programs without CHWs, they are sure to encounter problems. The same is true for other sectors. 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. The relationship building involved in that process has all sorts of side benefits. As we “get under the hood” of health finance, for instance, looking at the opportunity CMS has provided by allowing Medicaid State Plan Amendments to allow non-licensed providers to deliver preventive services recommended by licensed providers, we are apparently ahead of the curve in thinking about how that might look. It’s based on the relationships and mutual respect that have been built through this process. So much is uncertain now in this changing environment. The more closely we’re working with one another, the better the results are likely to be. But that takes time.
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. For example, CDC continues to promote CHW state policy development through both its funded projects and leadership on consistent messaging. The federal government can also be a major convener of states working on CHW activities, which it is doing through the CMS Innovation Center that grew out of health reform.
GW: It would be helpful for the federal government to promote and accelerate development of a professional infrastructure for CHW utilization and workforce utilization in partnership with national foundations, public health organizations, state government, health quality and health finance experts, academics, and—importantly—CHW leadership. There’s no national accreditation for CHW training, for instance. We’re still working without a consensus definition of core competencies and scope of practice. Funding is scattered, at best. 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: I’m particularly concerned about sustaining the “CHW voice” in CHW policy development. As I mentioned before, none of this would have happened in Massachusetts without CHW leadership. We operate by the CHW principle, “Nothing about us without us.” In other words, CHWs have to be at the table, participating in every step of policy development and implementation. Our board of certification contracted with MACHW to run CHW focus groups while we were defining core competencies, for instance. But it’s challenging to engage CHWs, because they’re typically in work roles that don’t allow time “off” to engage in policy development. And 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!
Resource Topic: Accreditation/Certification, CHW Role, Community Health Workers/Volunteers, Country Ownership, Human Resources Management/Workforce Development
Resource Type: Best practices, Case studies, Evaluation, Issue papers
Year: 2014
Region:
Country: United States of America
Publisher May Restrict Access: No