CDC Community Health Worker Forum May 2018

Summary of Discussions

  •  Identify existing barriers and gaps to developing a statewide infrastructure to promote longterm sustainability and reimbursement for CHWs as a means to establish or expand their engagement in: (a)  CDC-recognized lifestyle change programs for type 2 diabetes prevention through the National Diabetes Prevention Program. (b) American Diabetes Association (ADA)- recognized/American Association of Diabetes Educators (AADE)-accredited diabetes self-management education and support (DSMES) services.


  • Identify promising practices and lessons learned in CHW reimbursement and sustainability that may inform and guide the future efforts of states, CHWs, and others to develop a statewide infrastructure to promote long-term sustainability and reimbursement for CHWs. 


  • Identify promising practices and lessons learned about the roles CHWs can play in increasing enrollment and improving retention in CDCrecognized lifestyle change programs for type 2 diabetes prevention and/or ADA-recognized/ AADE-accredited DSMES services for diabetes management. 


  • Gather “pearls of wisdom” from the perspective of CHWs that would be important to share with states, CHWs, and others engaged in this work. 

 Within the broad framework of those objectives, participant discussions centered on several themes and concepts. This report summarizes the insights and opinions of the participants around those themes.


 This report is not a consensus document— that is, the forum discussion was not intended to achieve agreement among all participants— nor does it represent official recommendations  endorsed by CDC. Rather, it offers the perspective of diverse CHWs, allies, supporters, and states on what they believe is needed to build an infrastructure for CHW sustainability and financing. 


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 PARTICIPANT INSIGHTS 

Defining CHWs’ Roles and Developing the Workforce


  • CHWs follow the adage “Nothing about us without us.” The same should apply to efforts to develop a statewide CHW infrastructure. 


  • A consistent definition of what constitutes CHWs’ roles is needed, along with a greater understanding among decision makers of those roles and the value CHWs bring. It is critical that the CHW definition capture the full  array of their skills, roles, and responsibilities; the range of places in which they work; and the variety of job titles that encompass similar tasks—and to communicate their core competencies and value. 


  • Workforce development is essential. Better systems are needed to attract and prepare the next generation of CHWs and ensure retention and promotion of current CHWs. There is a general lack of funding and time for professional development and peer learning among CHWs. Additionally, managers and supervisors of CHWs, and top executives in their organizations, may not fully grasp the realities of the CHW job; advocacy and fostering professional development for CHWs could be included in training and TA for individuals who supervise CHWs. 


  • There is disagreement about the need for and value of CHW certification. Some people believe standardized training and certification  are necessary, while others believe CHWs can perform their roles effectively with less formal training coupled with experience in the field. Some states have opted for voluntary  certification of CHWs and others have not. 


  • Support for networks should be a priority. This includes launching and maintaining the National Association of CHWs—which is intended to elevate the CHW profession and provide a forum for communicating about and within the workforce—as well as statewide alliances and networks. Current funding to support such groups and CHWs’ participation in them is lacking.


 Increasing Integration of CHWs in Health Care Systems and Community-Based Organizations 


  • CHWs have not become part of the fabric of health care. Despite the evidence of CHWs’ contributions, buy-in from the health care and public health communities is not universal. CHWs should be integrated from the start in strategies and budgets. It is also essential that CHWs have access to electronic health records to facilitate their ability to serve clients effectively. 


  • A single interaction between a CHW and client may address multiple clinical needs and help ameliorate the impact of social determinants of health. Given the relational nature of their work, CHWs often perform activities beyond the “official” scope of their job  to meet client needs. 


  • CHWs desire, and should have, a voice at the table with decision makers at all levels (federal, state, health system, organization, etc.). They can help educate policy makers and administrators about CHWs’ roles and inspire them to support and advocate for this workforce. In such conversations, CHWs must convey not only the compassionate side of their work but also the financial benefits.  


  • Expanding integration of CHWs within both medical and public health systems and community-based organizations requires identification and dissemination of effective methods for doing so and addressing challenges in payment options for CHWs. Such efforts should draw on existing examples and guidelines and seek to strengthen partnerships between health care and CBOs. 


  • Enhancing financing strategies to build the CHW infrastructure and facilitate CHW engagement is essential and will require an openness to identify and consider novel approaches. Current funding mechanisms— which often flow from federal sources to states  for specific health purposes—can limit the types  of health issues CHWs address. There may be ways to leverage the increasing focus on population health to advance the infrastructure for CHWs.


  • It is important to foster CHW connections across federal agencies, including in the Department of Transportation, Federal Interagency Health Equity Team, Health Resources and Services Administration, Office of Minority Health, and all the Department  of Health and Human Services. 


 Improving CHW Compensation and Documentation of CHWs’ Contributions 


  • Compensation for CHWs should be commensurate with the professional services they provide. Institutionalizing CHWs as a public health career path would be an important first step to ensure compensation  similar to other public health professionals. Compensation is often complicated by shortterm funding (e.g., grants) and Medicaid policy limitations and budgetary pressures. 


  • Inadequate documentation of CHWs’ contributions results in an incomplete understanding of CHWs’ program impact and can have financing ramifications. Efforts to show impact should build on existing evidence and provide compelling local data; the National Association of CHWs could help gather and disseminate this information.  


Promising Practices and Lessons Learned about CHWs’ Roles in CDCrecognized lifestyle change programs for type 2 diabetes prevention and/or  ADArecognized/AADE-accredited DSMES services for diabetes management 


  •  Because CHWs understand the cultures that make up their community, they can help policy makers and programs better understand, reach, and serve target populations. CHWs should be engaged in tailoring and adapting diabetes management and type 2 diabetes prevention curricula and activities to ensure they are user-friendly and culturally and linguistically appropriate. 


  • Standardized training related to the National Diabetes Prevention Program and DSMES could help CHWs more effectively support those programs and services.


  • Because many of CHWs’ clients live complex, marginalized lives, getting commitment to attend DSMES services or lifestyle change programs can be difficult. Emphasizing how CHWs’ involvement in type 2 diabetes prevention and diabetes management programs can help individual clients as well as contribute to the overall well-being of the community may encourage CHWs to connect individuals to these programs and services. 


  •  Best practices for engaging CHWs in diabetes management and type 2 diabetes prevention activities at the grassroots level already exist. Systematically documenting and sharing such practices is necessary. 


  • CHWs work to address all of an individual’s health issues. Thus, it is important to explore ways for CHWs to address diabetes management and type 2 diabetes prevention alongside other health conditions and social determinants of health. 


NEXT STEPS 

This CHW forum provided many helpful insights that will inform future work. CDC will consider how to incorporate this information in a training and technical assistance guide for working with CHWs in this arena, which is currently under development, and explore development of other materials such as job aids to distill key information and foster communication with and support for state health departments.  








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CHW Common Core Competencies (C3) 2016

C3 Project progress Report 2016

 

Understanding Scope and Competencies: A Contemporary Look at the United States Community Health Worker Field Progress Report of the Community Health Worker (CHW) Core Consensus (C3) Project: BUILDING NATIONAL CONSENSUS ON CHW CORE ROLES, SKILLS, AND QUALITIES

Project Focus: to help advance consensus in the U.S. Community Health Worker (CHW) field by producing recommendations for consideration and adoption on common elements of CHW Scope of Practice and Core Competencies.  It is anticipated these recommendations, building on foundational work in the field, will be useful in various settings including in the design of training curricula and CHW practice guidelines for use at the local, state, and national levels.



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APHA Policy Statement 2009

Community Health Workers: Definition


APHA Policy Statement 2009-1    

defines CHWs as


“…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/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.”


CHWs, also known as Promotores de Saludoutreach workers, lay health advisors and other titles, have been contributing to public health for decades, but have come to greater prominence in recent years through a growing body of research attesting to their contributions, recognition as an occupation by the U.S. Department of Labor and prominent mention in the Patient Protection and Affordable Care Act.  State and federal policy, however, have not kept pace with the growing interest in this workforce.  At least a dozen states are seeing significant movement toward more supportive policies around CHWs.

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National Community Health Advisor Study 1998

National Health Advisory Study 1998

Community Health Advisors (CHA) help people take greater control over their health and their lives. They promote healthy living by educating about how to prevent disease and injury as well as how to access health and human service systems. The National Community Health Advisory Study identified steps to strengthen outreach services of CHAs across the country. The study was funded by the Annie E. Casey Foundation.


Table of Contents

1. Overview (pp. 1-7)

2. Methodology & Study Participants (pp. 8-10)

3. Core Roles and Competencies of Community Health Advisors (pp. 11-17)
Study Chapter written by Noel Wiggins, MSPH (Assisted by Angelina Borbon, PHN)

4. Evaluating CHA Services (pp. 18-24)
Study Chapter written by J. Nell Brownstein, PhD (Assisted by E. Lee Rosenthal, MPH)

5. Community Health Advisors - A Career in Development (pp. 25-33)
Study Chapter written by E. Lee Rosenthal, MPH
Study Youth Supplement written by Roberta Rael, et al.

6. Community Health Advisors in the Changing Health System (pp. 34-41)
Study Chapter written by Sarah Johnson, MSW, MPH

7. Conclusion (pp. 42-44)
Study Chapter written by E. Lee Rosenthal, MPH

Summary of Core Recommendations - Reference Page (pp. 45-46)


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References

Medtronic Foundation

Fairall L, Bateman E. Health workers are vital to sustainable development goals and universal health coverage BMJ (2017); 356


Johnson CJ, et al. Learning from the Brazilian Community Health Worker Model in North Wales.  Globalization and Health (2013) 9(1):25 ·32.


Lehmann U, Sanders D. Community health workers: What do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. WHO (2007).   http://www.who.int/hrh/documents/community_health_workers.pdf

 
Macinko J, Harris MJ. Brazil’s Family Health Strategy – Delivering Community-Based Primary Care in a Universal Health System. NEJM (2015) ;372: 2177-2181 


Novotny L. 3-minute case study: Health workers from the community. AthenaInsight, une 12, 2018 https://www.athenahealth.com/insight/3-minute-case-study-health-workers-community(opens new window)


Wadge H, et al. Brazil’s Family Health Strategy: Using Community Health Care Workers to Provide Primary Care. The Commonwealth Fund, Dec. 13, 2016. https://www.commonwealthfund.org/publications/case-study/2016/dec/brazils-family-health-strategy-using-community-health-care-workers



Zulliger R. The Community Health Agent Program of Brazil. CHW Central. 2018. http://www.chwcentral.org/blog/community-health-agent-program-brazil(opens new window)











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