Community health workers (CHWs) are frontline public health employees who come from or have deep roots in the communities they serve. Many home-based care agencies leverage CHWs to build trusting client relationships and supplement workforce gaps.
While a caregiver is responsible for helping a client in their home with personal care and activities of daily living, a CHW is a member of the client’s community who acts as an advocate and liaison to health and community services.
The integration of CHWs increased during the COVID-19 pandemic, during which states relied on CHWs to supplement workforce shortages and build a more equitable care delivery system. In September 2022, the Biden-Harris administration announced $225 million in funds to train over 13,000 CHWs to support COVID-19 vaccination efforts and ensure that trusted messengers in health care were deployed to communities in need. This trend has continued nationwide in Medicaid programs, with at least 15 states reimbursing CHWs for services provided to Medicaid members.
“Home care agencies who desire to address the social determinant of health needs of their clients – to provide their clients with prevention, education, capacity building, advocacy skills to engage and navigate complex health care and health systems – may find that partnering with or integrating the roles, skills and services of CHWs to be highly advantageous,” Denise Smith, founding executive director of the National Association of Community Health Workers (NACHW), told Home Health Care News.
NACHW is a Boston-based nonprofit organization that supports communities in achieving health, equity and social justice.
CHWs provide cultural alignment based on ethnicity, language and other life experiences that have been found effective in addressing the corresponding barriers to accessing health and other services and systems, according to Smith. CHWs can screen for the social determinants of health, make closed-loop referrals, and build the capacity of patients and their families to eliminate barriers to health care, including enrollment into health insurance, prevention, education programs and determining other eligibilities.
“CHWs advocate for client capacity and work with the client to increase their health literacy and self-management skills,” Marianne Longo, chief clinical officer at Help at Home, told HHCN. “They have a unique capability to connect with the individuals they serve that imbues trust and leads to engagement. They know how to navigate health and human services and show clients how to do the same.”
Chicago-based Help at Home provides home- and community-based services (HCBS) through over 200 locations in 11 states.
For example, a home care agency may send a CHW to visit individuals with uncontrolled diabetes. During the visit, the CHW will collect health information, monitor behaviors, address medication compliance and dietary habits, and explore other needs, such as obtaining diabetic supplies. Additionally, CHWs can review medical literature and guidelines to ensure they effectively meet the needs of that specific population.
“Home care agencies can leverage CHWs to help their clients identify and address their health-related social needs such as financial and food insecurity or housing quality,” Longo said. “Agencies can also leverage CWHs to help clients navigate health care services and better understand their treatment plans. By supplementing home care staffing with CHWs, agencies can broaden their impact on their client’s quality of life and health outcomes.”
State requirements and Medicaid authority
There are national standards for CHW core competencies, according to Longo. Some states have enacted CHW certification programs based on these competencies.
“Certification overwhelmingly occurs at the level of the state, health department or through legislation,” Smith said. “Certification is not a requirement or even a pathway of every state.”
Some states, such as Washington, integrate CHWs into their home care programs to provide members support services, outreach and engagement.
States usually choose between using their Medicaid managed care contracts or preventative services state plan amendments (SPAs) to authorize CHW services in their Medicaid programs. States can leverage Medicaid managed care contracts to require health plans to deploy CHWs, set reimbursement policies and establish other program design elements, such as encouraging the broad use of CHWs by establishing targets and financial penalties or a required CHW-to-enrollee ratio, according to the National Academy for State Health Policy (NASHP).
“Typically, individuals receiving managed long-term services and supports have needs beyond personal care,” Longo said. “There is a substantial opportunity to assist with health-related social needs, health care navigation and health literacy. This support enhances the client’s life and supports the caregiver and the client’s family. Home care agencies are uniquely positioned to learn more about client needs and reduce health disparities.”
Preventative services SPAs can be pursued with or without Medicaid managed care contract authorization, using a reimbursement model typically tied to an established Medicaid fee schedule. Under these SPAs, CHWs provide services under the supervision of a licensed provider.
When identifying the preferred Medicaid authority, states should also consider how they will provide a sustainable, ongoing funding source for CHW initiatives to promote the stability of the CHW strategy, according to the NASHP. Funding considerations can help determine staffing arrangements for CHWs, whether based on the percentage of Medicaid members served, a staffing ratio or a caseload ratio for each CHW. The funding allocated to the CHW program can also influence the scope and numbers of CHWs deployed to serve Medicaid members.
Other considerations include whether CHWs need to become Medicaid providers to participate in the state’s CHW initiative or can be employed directly by health plans, providers or other entities in the Medicaid delivery system and what types of supervision will be required of CHWs to deliver services to Medicaid members.
“To successfully employ CHWs, the home care agency should have a strong understanding of the role and the barriers and facilitators to deploying a formal program,” Longo told HHCN. “They should have a cohesive population health management strategy and a strong digital infrastructure to support the delivery of CHW services. They should be familiar with the core competencies and be able to support the workforce’s onboarding and continuing education needs. Finally, they should consider their knowledge of, and relationship with, community resources and their ability to extend capacity to do more for the population they serve.”
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