Community Health Workers a Rural Treasure for Reducing Healthcare Divide

With a mission to improve rural healthcare access and outcomes for underserved populations through innovation and promising practices, the role of community health workers (CHWs) is rapidly evolving across rural areas, having been recognized by the U.S. Department of Labor as an essential part of the cost-effective delivery of healthcare. 

Back in 2009, the U.S. Bureau of Labor Statistics identified the unique standard occupational classification code 21-1094 for CHWs. Then, in 2010, the Patient Protection and Affordable Care ACT (PPACA) recognized CHWs as members of the healthcare workforce to promote healthy behaviors and outcomes, increasing access to preventive services under Medicaid and also implementing regulations allowing non-licensed healthcare workers (such as CHWs) to provide these services.  In addition, Medicaid programs were developed that utilize CHWs in their staffing.  Health homes were created to assist patients living with chronic diseases, and state innovation models were developed to drive healthy outcomes and quality of care. Additionally, CHWs have been incorporated in their work plans.

Purpose-Driven

In 2011, the National Rural Health Association (NRHA) established a commitment to train at least 60 CHWs along the U.S.-Mexico border to address access to care in this region of the country. More than five years later, this dedicated team has evolved into an official rural community health worker training Network that spans the entire border, along with growing collaborations in the Appalachian region. Today there are more than 500 trained rural CHWs across the nation. 

The American Public Health Association defines a CHW as a “front-line public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” They are critically important in rural areas, where health systems are limited, particularly in the area of culturally competent care provided by those who speak the same language, have the same socio-economic status, and have the same ethnicity as the rural clients they represent. 

Over the last few years, CHWs are becoming more widely used in healthcare models, even being included in Accountable Care Organizations (ACOs). The ACO model provides financial incentives to organizations that effectively and efficiently manage patient care populations to improve health outcomes while reducing the cost of care, especially high-utilization patients. Additionally, they participate in community-based participatory research, such as studies related to diabetes self-management education.

There are many advantages to using CHWs in a rural setting, and their impact can be greatly increased when they are fully integrated into the primary care team, working alongside physicians, nurses, and other clinicians. These advantages include but are not limited to: providing culturally appropriate health and prevention education regarding chronic diseases, physical exercise, and nutrition information; offering assistance in navigating the health services in coordinating care; advocating for individuals and communities within the health services systems; providing translation and/or interpreting services; delivering basic health screening tests, diabetes self-management education, and referrals for a wide range of health and social services; building capacity to address health issues; providing information counseling; creating connections between consumers and healthcare systems; ensuring cultural competence among healthcare professionals; and determining insurance eligibility and enrolling individuals into health insurance. Core services include outreach, education, clinical services, and advocacy.

Training Modules

There are several training modules used for CHWs within online toolkits. These include eight modules to support business and program framework and guidance:

• Module 1: Introduction of Health Workers – Insight of a CHW and an explanation of their roles.
• Module 2: Program Models – An explanation of different CHW models.
• Module 3: Training Approaches – Training Materials and procedures for CHWs.
• Module 4: Program Implementation – Building a program from bottom up.
• Module 5: Planning for Sustainability – Ensuring the CHW program functions properly.
• Module 6: Measuring Program Impacts – Methods for CHW program effectiveness.
• Module 7: Disseminating Best Practices – Sharing best practices of CHW program.
• Module 8: Program Clearing House – Examples of and contacts for successful CHW programs.

Stage Usage

There are several successful CHW programs implemented across the nation. Texas was the first state to develop such legislation, in 1999. Ohio followed in 2003, but Alaska impressively has had a certified program since the 1950s, including a CHW certification program to conduct specific activities like home visits and clinical service delivery. Oregon, Nevada, and Washington have state-level standards. Arizona, Southern California, Colorado, and Virginia offer programs at community colleges. Illinois has developed an advisory board to develop CHW training. Massachusetts has established a Board of Certification of Community Health Workers to assist with education standards, training, and certification requirements. Indiana is working on a scope-of-CHW practice to integrate into health systems. New York and Wisconsin are working on developing statewide alliances and networks for CHWs, and Hawaii, Minnesota, Mississippi, Kentucky, and New Mexico are working toward a non-state-mandated certification program and expanded utilization and certification of CHWs.

Some examples of program opportunities:

• Certification at the state level, which recognizes the work of CHWs, opening up the need for reimbursement opportunities for CHW services within plans and payer systems.
• Formal opportunities: Community college-based training for academic credit and career advancement opportunities.
• Training led by a physician assistant or nurse.

More Funding Needed

Currently, most healthcare facilities and agencies hire CHWs who are paid through grants or state or federal funds. There are some cases in which CHWs receive compensation on an hourly basis or serve as full-time employees with benefits, with their salaries based on local wages for similar work. In some other rare circumstances, CHWs are compensated through participation in incentives – gift certificates, programs, and reimbursement for travel.

Curriculum Studies/Training

Some states require CHWs to have state-level certification through an approved training program, but the CHW program varies state to state. There are many challenges to developing a streamlined training curriculum for community health workers, primarily due to different community needs. The result is that training continues to be vastly different from program to program. Standardization may never be achieved among states’ training programs, academic institutions, and direct service agencies, but the CHW role continues to grow. 

Within rural CHW programs there is a strong emphasis on role-playing before CHWs interact with patients, but a broad range of training and curriculum is available. Such activities include educating social service providers on population health needs, working with clinicians, delivering services as part of a medical home team, gathering information on medical clinicians, translating, interpreting, and facilitating client provider communications, and more.

Custom Designs

There are several CHW models currently in place:

1. Community Organizer and Capacity Builder Model: Promotes community action and builds community support for new activities.
2. Health Educator Model: CHWs deliver education to a specific population.
3. Outreach and Enrollment Agent Model: Similar to the Health Educator Model, only with greater outreach and enrollment responsibilities.
4. Care Coordinator/Manager Model: CHWs help people with complex health conditions navigate healthcare systems.
5. Member of Care Delivery Team Model: CHWs provide direct health services, collaborating with medical professionals.
6. Promotora De Salud – Lay Health Worker Model: CHWs are members of a specific population sharing social, cultural, and economic characteristics.

Keep Expanding 

The bottom line is that CHWs can be a rural treasure for recruitment and workforce retention, closing healthcare service gaps and providing customized service needs. They have proven to be an integral element of underserved communities, but to truly keep advancing and expanding they need financial sustainability provided by budgets at the state, federal, systems, and individual levels. Indeed, Alaska got started more than 50 years ago. It is time to blaze a new trail.