Community Health Workers and the Heart of Public Health

February 11, 2021|12:13 p.m.| Marcus Plescia MD, MPH | ASTHO Chief Medical Officer

Marcus PlesciaAs we recognize American Heart Month and the significant role of heart disease in COVID-19 related health outcomes, it is sobering to realize that Black adults continue to have the highest mortality rate for heart disease and are more likely to have hypertension than whites, Asians, and Hispanics. There are also important lessons and insights from our efforts to address heart disease disparities that can inform the COVID-19 response and the decisions we will make about the future of public health. All of this got me thinking about work I did earlier in my career working with community health workers (CHWs) to address disparities in cardiovascular disease as part of a CDC REACH 2010 grant I helped lead. I was impressed with the emerging science on the effectiveness of CHW-led interventions in improving cardiovascular disease outcomes, particularly in communities of color. I was even more impressed at the perspective and insight our CHW team provided on how to work with and engage the communities we were trying to reach. I anticipated an increasing role for CHWs in the public health workforce in the years to come.

Over the years evidence has expanded on CHWs improving outcomes and even reducing disparities in heart disease and many other public health priority areas. However, their presence in state and local public health workforce is still modest. A number of efforts have sought to expand the role of CHWs in medical care settings by developing reimbursement through third party payers, along with including them in managed care contracts and incorporating them in state Medicaid plans. Increasing CHWs in medical care settings is valuable, but there is an important role for CHWs in population-based work to engage communities in changing social norms, and addressing policy, environmental change, and ultimately addressing social determinants of health. The experience and lessons of the COVID-19 pandemic could substantially change the way we practice public health in the future, and provides opportunities to expand the role and presence of CHWs in the state and local public health workforce.

  • Build with recent expansion funding.
    New funding streams are emerging for public health through testing and contact tracing that provide resources for agency expansion by hiring CHWs. We must insist that this expansion of the public health workforce is appropriate, long overdue, and must be sustained. Once the pandemic is controlled, contact tracers—who were hired because of their acceptance and trust in the community—should stay in the workforce and expand public health capacity to control core infectious diseases like HIV and other STIs. But their focus could also be expanded to creatively engage in other issues like better control of chronic disease risk factors including diabetes, hypertension, and tobacco use. A new CDC funding opportunity from the National Center for Chronic Disease Prevention and Control could also help states support this work "through training and deployment of community health workers (CHWs) so they are prepared to successfully engage with existing state and/or local public health-led actions to build and strengthen community resilience."
  • Create a supportive hiring environment.
    Public health leaders can help create opportunities and a career ladder for CHWs by working with state human resources systems (which often also apply to local government) to establish positions at different levels of experience and define a clear scope of CHW practice. Considerable work has been done in a number of states to develop training programs and define certification programs for CHWs that include flexibility for current CHWs to become certified while continuing to serve as a diverse and trusted source for the communities they represent.
  • Sustain CHW Financing.
    States have other methods to sustain funding for CHWs and the option to hire CHWs directly. CHWs can be funded through grants, managed care contracts, the Medicaid fee schedule, and state plan amendments. States do not require a waiver or plan amendment approval from CMS if Medicaid managed care contracts are changed to require or encourage specified CHW services. States can also develop and hire CHWs through attrition in other positions that are no longer as relevant to emerging public health workforce roles and needs in population health.
  • Contribute to Evidence Demonstrating the Value of CHWs.
    State health departments can support efforts to strengthen evidence of the effectiveness of CHWs. This includes sharing the health department’s innovative approach to supporting CHWs through infrastructure changes and supporting CHW workforce studies.
  • Support Peer Networks.
    The National Association of CHWs (NACHW) started in 2019 and had its first annual meeting in 2020. ASTHO, NACCHO, and other professional associations can work collaboratively to engage, support and mentor the staff and board of NACHW as it works to develop its strategic organizational development plan and infrastructure. Professional organizations can prioritize including NACHW in funding opportunities to address health disparities and members can attend and support their events and activities.

Community health workers are trusted community members emerging as frontline public health workers. Our society now looks to public health to address extraordinary disparities that have become abundantly clear as black, brown and low income families have borne the brunt of suffering and death in the COVID pandemic. CHWs have a strong understanding of the communities they serve, can provide a bridge to build trust and understanding between the community and the public health system, and serve as a credible voice to policymakers. In many ways, they represent the ‘heart’ of public health. They should be a major priority in our plans to build and support the public health workforce post pandemic.

Marcus Plescia, MD, MPH, is the chief medical officer at ASTHO