Supporting and Integrating Community Health Workers: Leadership Opportunities for State Public Health Agencies

January 26, 2018 | Anna Bartels

Improved population health lies at the intersection of clinical healthcare delivery and community-focused public health. Community health workers (CHWs) have a unique ability to bridge these two fields and address both individual and community health.

The American Public Health Association defines CHWs as “trusted, knowledgeable frontline health personnel who typically come from the communities they serve.” Their value lies in their unique ability to build trusting relationships between patients and providers, as well as their deep understanding of the community through lived experience. CHWs are valuable assets in improving health literacy and self-sufficiency through community outreach, education, informal counseling, social support, and advocacy.

CHWs are on the cutting edge of what we know healthcare needs to do, which is address the full spectrum of patient needs and social determinants of health. As healthcare systems face increasing pressure and incentives to reduce cost and improve outcomes at a population level, CHWs offer a way to build clinic to community linkages and connect vulnerable populations to health and human services. State health agencies (S/THAs), in turn, are well-positioned to build the infrastructure necessary for scaling up the use of CHWs by defining their core competencies and building opportunities for CHW training, financing, and employment.

ASTHO hosted a learning community in 2017 to position S/THAs as CHW leaders and drive multi-sector action around CHW workforce development. With support from the Health Resources and Services Administration (HRSA), ASTHO offered seven months of technical assistance in Louisiana, Nebraska, Nevada, North Carolina, and Oklahoma. Topics centered on CHW coalition building, core competencies, certification programs, and financing options. Common strategies emerged across the learning community members, which can be considered in other states working across sectors to develop the CHW workforce.

Who should be at the table?

CHW certification and financing are interconnected decisions, so S/THAs may benefit from first building strong foundational relationships with stakeholders:

• Support from agency leadership is needed to drive change and commit resources to solving workforce challenges. High-level support, such as from the state health official or senior deputy, can initiate cross-agency collaboration, buffer against staff-turnover, and encourage alignment with broader state health or economic goals. S/THA program managers should also be at the table to drive action and implement change.
• Direct CHW participation is critical to understanding the on-the-ground realities and impact. For example, the Nevada Department of Health and Human Services has helped create and provide initial funding for a state CHW association to give CHWs voice and network with peers.
• Healthcare providers should be present to discuss CHW integration into primary care teams, and how to bridge potential cultural divides.

How can the S/THA get internal and external partners on the same page?

The S/THA must align with partners and speak a common language. However, the agency first needs to develop successful internal coordination mechanisms before external coordination can be achieved:

• S/THA staff can develop internal workgroups and communications strategies to ensure there is common language across agency divisions. Staff may wish to use a standard CHW definition across the agency’s programs and use consistent language in requests for proposals.
• To achieve external coordination, partners must ensure there is consensus and “buy-in” around the need for ongoing communication and engagement. External coalition meetings also offer an opportunity for the S/THA to understand the goals and motivations of their partners.

How can the agency lead efforts to develop a CHW certification program?

CHW certification is a potential mechanism to standardize the CHW workforce and encourage employment in the health system by declaring that a CHW has certain qualifications. There is a wide array of policy and administrative options around certification, so S/THAs may benefit from exploring how others have approached certification:

• Break down stakeholder objectives and preconceptions around certification early in the process. This includes beliefs about what certification would achieve and fears about potential negative consequences.
• Protect the diversity and community-based nature of the workforce. Certification programs should offer a pathway for existing CHWs to achieve certification, typically based on experience instead of education requirements.
• Create opportunities for CHW input. Actively seek feedback on how proposed certification programs will play out on the ground. For example, North Carolina held eight regional listening sessions across the state to hear recommendations on training and certification processes.

Ultimately, CHWs can help stakeholders achieve key objective they are already pursuing, such as improved chronic disease outcomes, health equity, and strengthened linkages between clinical and community services. CHWs also complement structures like medical homes and accountable care organizations, and the S/THA can support these models with a robust CHW workforce. Because CHWs work at the crossroads of public health and healthcare, they have a unique ability to affect change at the individual, family, and community levels and achieve public health goals.