States Continue Efforts to Build and Strengthen Community Health Workforce

April 06, 2022 | Shelby Rowell

As the COVID-19 pandemic highlighted workforce challenges and longstanding health inequities within the healthcare and public health systems, interest in developing the community health worker (CHW) workforce has intensified across the country. A CHW is a frontline public health professional who shares life experience, trust, compassion, culture, and value alignment with the communities they serve. CHWs can work in a variety of settings and health issue areas including but not limited to disease control and prevention, maternal and infant health, oral health, social determinants of health, and racial and ethnic disparities.

The federal government passed the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and American Rescue Plan Act of 2021, both of which provided a variety of funding channels to support CHW programs and the direct hiring of CHWs. This includes CDC’s National Initiative to Address COVID-19 Health Disparities, which is funding state, local, territorial, and freely associated state health departments, and HRSA’s Community-Based Workforce for COVID-19 Vaccine Outreach program. These opportunities could allow states to create CHW positions, develop standardized or specialized CHW training programs, or support statewide or local CHW coalitions, among other activities.

Investments in the CHW workforce can provide impactful improvements in health outcomes and equity. Large-scale investments are being made in CHW trainings and direct hiring but states also can play an important role. By supporting policies that create a shared professional identify and build a broader system, CHWs can more effectively meet the health and social needs of marginalized communities. State policymakers should also look to ensure CHWs are included in decision-making processes so policies do not create unintentional barriers into the workforce.

This blog post will explore state legislation across several categories:

• Definitions, certification, and training
• Financing CHWs through Medicaid
• Expanding CHW-delivered services

Definitions, Certification, and Training for CHWs

Two strategies that can help create a professional identify and raise awareness of the CHW workforce are a formal, statewide definition for CHWs set in legislation and a certification process. Several states have previously passed legislation that served as an impetus to create a state CHW certification program, such as Arizona, Maryland, New Mexico, and Texas. Other state governments and CHW associations have also pursued certification without legislative action.

In April 2021, Illinois enacted HB 158 to adopt a formal definition and eleven core competencies for CHWs, drawing upon the definition adopted by the American Public Health Association and competencies adopted in the CHW Core Consensus (C3) Project. The legislation also gives the Illinois Department of Public Health authority to certify community-based certification training and create a CHW Certification Board, working closely with state education departments and statewide CHW associations. This bill also explicitly states that, while certification would be required for future Medicaid reimbursement, certification is voluntary and will not be required for the employment of CHWs.

Utah’s SB 104, which passed both the Senate and the House in February 2022, would create a voluntary CHW Certification Process administered by the Utah Department of Health. The bill sets a definition for CHWs, allows for the creation of a CHW Certification Advisory Board, and sets certain parameters for the certification programs, such as operating on a two-year renewal cycle and allowing CHWs with more than 4,000 hours to be exempt from training requirements.

HB 525 passed the Kentucky House of Representatives and Senate in March 2022. If approved by the Governor, this bill would give the Kentucky Department for Public Health the authority to develop core competencies for CHWs and establish a certification program through rules and regulations, reinforcing and providing legislative backing to a state CHW certification program launched in 2019.

Financing CHWs through Medicaid

States are also exploring opportunities to use Medicaid to finance CHW-delivered services. For example, in Illinois, HB 158 established that certain services delivered by certified CHWs working under the supervision of a Medicaid-enrolled provider will be covered under Illinois’s Medicaid program, following CMS approval (though state certification is still under development).

This bill also requires the state Medicaid agency to amend its contracts with managed care organizations (MCOs) to allow MCOs to employ CHWs directly using administrative funds or to subcontract with community-based organizations (CBOs) that employ CHWs. The bill further allows for CHWs employed through MCO administrative funds or subcontracts with CBOs to operate without certification (depending on the discretion of the MCO once state certification is finalized) and without requiring supervision of a Medicaid-enrolled provider.

In California, AB 2697 was introduced to the legislature in February 2022. If adopted, this legislation would state the intent of the legislature to create standards and requirements for CHW certification, establish payment and reimbursement standards, and create an advisory structure for a CHW benefit within the state Medicaid program. This bill also would state the intent of the legislature to establish policy focused on ensuring that CHWs, the State Department of Health Care Services, and the State Department of Public Health have the support needed in their workforce infrastructure to support the community they serve.

In addition, to its provisions on CHW certification, HB 525 would require the Kentucky Department for Medicaid Services to seek approval from CMS for a state plan amendment, waiver, or alternative payment model that would reimburse for services delivered by CHWs. In addition, the bill also identifies the services provided by CHWs that would qualify for reimbursement. These include direct preventative services, health promotion education, beneficiary/provider facilitation, diagnosis-based patient education, and any other service approved by the Department for Medicaid Services.

In Nevada, AB 191 and SB 420 both passed the Assembly and Senate and were enacted by the Governor in 2021. Under these bills, the Department of Health and Human Services is required to include reimbursement for CHW services delivered to Medicaid beneficiaries when the CHW is under the supervision of a physician, physician assistant, or advanced practice registered nurse enrolled in the Medicaid program.

Expanding CHW-Delivered Services

CHWs play an important role in improving health outcomes, providing interventions for chronic disease management, and increasing access to care among underserved populations. Several states introduced bills to establish pilot and grant programs that would hire CHWs. For example, the California Senate has introduced SB 861 in January 2022, which would establish the Dementia Care Navigator Grant Program within the Department of Aging and in partnership with CHW organizations.

In addition, the California Assembly has introduced AB 2548 in February 2022, which, if enacted, would authorize the California Department of Aging to establish a Healthier Homes/Age in Place Pilot Program. The program would provide grant funding for non-profit organizations to hire one full-time CHW to work at three aging housing developments in several counties through 2028.

A 7454 and S 322 are mirror bills introduced to the New York legislature in 2021 and are currently being considered in the 2022 legislative session. Under these bills, the New York State Department of Health is directed to develop and administer community-led and operated hubs in Kings and Bronx County using CBOs and CHWs to specifically address the maternal health crisis. Additionally, the Department of Health is authorized to hire and train qualified CHWs and doulas to identify and address SDOH-related health risks.

Looking Ahead: Continued Efforts to Build the CHW Workforce

It is critical for policymakers to work alongside CHW state associations and individual CHWs to ensure policies and practices meet the needs of CHWs without inadvertently creating barriers to employment or entry into the workforce. The National Association of Community Health Workers (NACHW) identified three overarching principles to create successful CHW programs and policies during the pandemic and beyond, including respecting CHW self-determination and incorporating CHWs into the design, development, and implementation of CHW policies and programs.

These principles are reinforced by the American Public Health Association recommendation that state governments ensure that working groups pursuing CHW-related policies be comprised of at least 50% self-identified CHWs (as seen in Illinois, Maryland, and Oregon, among others). In addition, policymakers can implement CHW policies that do not exclude practicing CHWs from the workforce. For example, this can look like Illinois’s policy, in which both certified and non-certified CHWs can be employed under the title “CHW,” even as the planned Medicaid reimbursement policy encourages certification.

As developments in CHW legislation and policy continue, ASTHO will provide updates and technical assistance to our members.