History of Community Health Workers
In recent years, efforts have evolved to professionalize the occupation by defining standardized core competencies, skills, and performance qualities. The U.S. Department of Labor (DoL) formally recognized CHWs as a distinct occupation by creating a standard occupational classification for the field in 2009.(1) Other national and state level efforts have also emerged to professionalize the occupation. The American Public Health Association defines CHWs as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables CHWs to serve as a liaison or intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.” The Community Health Worker Core Consensus (C3) project released a set of CHW roles and competency recommendations meant to provide those working in the field and those outside the field with a set of evidence-based standards to evaluate CHWs’ work across employment settings. Some states have adopted the recommendations, however, there remains wide variation in state’s approaches toward regulating the occupation.
In order to understand the adoption and evolution of CHW’s and the occupation’s professionalization, we sought to understand whether employers in states with and without regulation of the occupation were more likely to adopt C3 recommended roles, skills, and qualities in job ads for CHWs. The purpose of this study was to determine whether there is a relationship between state occupational regulation (i.e., certifications) and roles, skills, and qualities required by employers of community health workers.
Growth of the CHW Workforce
The Bureau of Labor Statistics projects the number of CHWs to grow 13 percent nationally from 2019 to 2029.(3) As of May 2020, the DoL reported that there were about 59,000 CHWs in the United States.(4) This number is likely under-reported due to the range of titles CHWs go by. Other sources estimate the number of CHWs in the United States to be closer to 100,000.(5)
Several key policy changes have contributed to the growth in the CHW workforce. In 2010, the Affordable Care Act specifically listed CHWs as health professionals who function as members of health care teams and mandated additional navigation and coordination support, increasing the opportunity for CHWs. In addition, changes to federal Medicaid rules in 2013 opened the door for potential reimbursement for preventive services offered by CHWs.(1) Some examples of funding programs that states have implemented include Medicaid 1115 waivers, state Managed Care Contracts (MCOs), and/or State Plan Amendments (SPAs) to financially support the work of CHWs. These funding mechanisms have allowed state Medicaid offices to change how they organize, pay for, and incentivize health plans and providers that serve low-income or vulnerable patient populations.(6) In recent years, the CDC supported CHW programs through the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health grant (7) and more recently through COVID-19 Prevention and Control funding.(8)
National leaders have called for increased involvement of CHWs in the healthcare system, both as part of the COVID response and as a longer-term strategy to build a strong public health foundation.(9) Health plans are employing CHWs to address high costs from frequent-flyers or super-utilizers, and self-insured employers are employing CHWs for their health promotion and prevention programs to keep people healthy and on the job. Hospitals and health systems are using CHWs for proactive community engagement and post-acute care coordination to reduce 30-day readmissions and uncompensated care costs. Clinics and other outpatient offices are using CHWs to manage high-need chronic care patients and improve physician and nursing productivity.(10)
Across these settings, employers report integrating CHWs into multidisciplinary teams as a means to address pressing public health and healthcare needs, including improving service access and quality while reducing cost due to unnecessary utilization of services. Current literature is repleat with articles citing the value and/or impact of CHWs’ on improving chronic disease outcomes,(11–15) increasing access to health care services,(16,17) reducing unnecessary hospitalizations.(18–22), and overall add value to healthcare systems.(23,24) According to a Biden campaign analysis of studies on CHW programs, such roles may produce an annual return of $2.47 for every dollar invested from the perspective of a Medicaid payer.(25)
Their knowledge, shared life experiences, trust-based relationships built on trust enable CHWs to address root causes of health issues in ways traditional systems often fall short (due to lack of time, cultural competence, and/or community linkages).(26) Continued growth in demand for CHWs will be driven by business models demonstrating success, policies that influence the evolution and expansion of CHW roles, standardization of the skills needed, and improved quality of jobs and career paths available to CHWs.
CHW Regulation
There has been a shift towards increased state regulation, specifically certification, of the CHW occupation to ensure standardization and quality of the role, due to growth in employment and new/different types of organizations employing CHWs.(1) As of 2020, 19 U.S. states have implemented voluntary statewide CHW certification programs. Certification is seen as a mechanism to build a workforce with a common set of core skills, abilities, knowledge base, and training, signaling competency to employers, payers, and other members of health care teams.(27)
CHW certification is a specific form of credentialing related to recognizing an agreed-upon set of occupational standards, with certification itself often being voluntary. Broader occupational credentialing options also include licensure, registration, and permitting. To our knowledge, no states are exploring licensure for CHWs because CHWs do not perform clinical duties requiring a license and CHW practice does not pose a significant risk of harm to the public.(28,29)
Key benefits of certification include legitimizing the role of CHWs and ensuring consistency in the quality of care provided, conferring opportunities for educational and career advancement, improving employment stability, assuring that CHWs have a standard skillset and knowledge base, and increasing funding for services.(30,31) Key factors many states cite as rationale for instituting a CHW certification process include establishing a reliable indicator or definition of CHW qualifications, gaining recognition for CHWs as an occupation or profession, and/or meeting reimbursement requirements.(28) CHW certification may provide the necessary support context to enable successful CHW programs within the larger healthcare system,(27) although there is lacking evidence regarding the relationship between certification and quality of care or patient outcomes.(32)
Although certification has several benefits, there are risks that certification and increased regulation may lead to narrow or rigid scopes of practice and over-medicalization of the field, undermining the community-centric orientation that often make CHWs so successful. In addition, there is a risk that certification processes could exclude people who may naturally be very effective CHWs but are turned away by regulatory criteria serving as barriers to entry and due to cost.
State Differences in CHW Certification
Although there are no national certification standards, C3 offers a single set of roles, skills, and qualities that are endorsed by major national stakeholder groups and is meant to be used by states as they develop the requirements for CHW certification. In spite of the C3 standards, there is variation in how state regulation and certification programs are carried out.(33) Key differences in CHW programs across states include the maturity of the program, type of certifying organization (i.e., public or private), entity certified, and cost of certification. The requirements for CHW certification include specific competencies (e.g., roles, skills, and qualities) that must be met. Some differences in select state CHW programs are displayed in Table 1.
Table 1 Differences in CHW Regulation Across Select States
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Mature CHW certification programs
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New CHW certification programs
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No CHW certification program
|
|
Texas
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Rhode Island
|
Virginia
|
Pennsylvania
|
Tennessee
|
Alabama
|
Wyoming
|
Statewide CHW certification program exists
|
Yes
|
Yes
|
Yes
|
Yes
|
No
|
No
|
No
|
Start dates for CHW certification program
|
2002 (34)
|
2016 (35)
|
2018 (36)
|
2019 (37)
|
n/a
|
n/a
|
n/a
|
Certifying organization
|
TX Dept of State Health Services (public)
|
RI Certification Board (private)
|
VA Certification Board (private)
|
PA Certification Board (private)
|
n/a
|
n/a
|
n/a
|
Entity certified
|
Individuals, training programs, and/or instructors
|
Individuals only
|
Individuals only
|
Individuals only
|
n/a
|
n/a
|
n/a
|
Certification cost
|
No cost
|
$125
|
$100
|
$50
|
n/a
|
n/a
|
n/a
|
In states that have been certifying CHWs for a longer period of time and have more mature regulatory programs, we expect to see increased standardization in job competencies. The results of adoption of such standardization are expected to be seen in in the job ads from employers as they recruit for a consistent workforce that meets established competencies and quality standards.