Helping Community Health Workers Excel in the Public Health Workforce

July 23, 2024 | Andrea Lee, Kristian G. Myers, Tasha Catron

Community health workers (CHWs)—who work under various titles and across multiple settings—are vital to enhancing health outcomes and reducing health disparities for marginalized populations. According to CDC, CHWs are the first line of defense in public health and trusted members of the communities they serve. Studies have shown that CHWs are effective in improving access to primary care services, reducing the misuse of emergency room services, increasing health screening rates, and lowering the cost of healthcare. In addition, their support helps families adopt and maintain healthy behaviors and overcome barriers encountered in the healthcare system.

All of that said, community health workers often go unrecognized for their public health contributions. The CHW profession has been around for over 65 years, but in many ways, the visibility of CHWs has grown only in recent years. For example, in 2019, the National Association of CHWs was formed. In 2023, Congress passed a resolution declaring Aug. 28 to Sept. 1 as National Community Health Worker Awareness Week, and CHWs were added to the U.S. Bureau of Labor Statistics Occupational Outlook Handbook. Despite this, many people—specifically, those with the power and influence to hire CHWs—are still unaware of the work and impact of CHWs and how to integrate them into a patient's continuum of care.

Support and Recognition

CHWs are a unique component of the public health workforce because of their strong roots in the community, lived experiences, and trusted relationships. They see and understand the full community context and range of factors affecting health outcomes. Since they are already woven into the fabric of their communities, CHWs will inherently advocate for sustainable solutions rather than temporary fixes.

One way to recognize the work of CHWs is to ensure their voices are central in all policy and programmatic work related to their profession, truly modeling the “Nothing About Us Without Us” mantra. This can also include other public health professionals becoming allies with CHWs within health agencies and community organizations, as well as championing long-term sustainability and supporting a living wage for CHWs. Policymakers and public health professionals must listen to CHWs, understand their needs and challenges, and determine how to help them excel as vital members of the public health workforce.

Investment in Workforce Development

Many CHWs learn technical skills through professional development training to ensure they are well-equipped to serve the needs of their communities. While certification and training standards for CHWs vary by state, training typically aligns with a set of core competencies (as defined by the national CHW Core Consensus Project, considered the closest approach to a national benchmark). Examples of core competencies include:

• Communication skills.
• Advocacy.
• Knowledge of the community.
• Education for health behavior change.
• Capacity-building.
• Service coordination.

CHWs need clear pathways for growth, to continue advancing as CHWs or to move into supervisory positions. They are subject matter experts of their communities and their expertise should be regarded as highly as academic degrees when opportunities for advancement arise. Another critical component of CHW workforce development is supportive supervision, training, and mentorship. Unfortunately, some CHWs, especially those who work within a clinical setting, may be supervised by clinical staff or others who truly do not understand the role and significance of CHWs. However, with a clear job description, identified roles and responsibilities, an informed supervisor, and a strong mentor, CHWs can thrive within a clinical setting and serve as a critical community-clinical linkage. In states that have CHW certification, creating a tiered approach (such as the one developed by the South Carolina Community Health Worker Association) can support CHW career advancement by growing their skills in specialty tracks or earning a credential to demonstrate the depth of their expertise.

An effective CHW workforce cannot be built overnight. The public health system needs to help CHWs move “up” instead of “out” by investing in workforce development. Tasha Catron, former CHW and co-author of this blog, knows firsthand that CHWs need career ladders to remain in the field. Tasha originally sought a position as a CHW within the health department and made various lateral moves until eventually obtaining a position focused on diversity, equity, and inclusion. She credits her success in this new role to her experience as a CHW, which equipped her with the understanding of the impact that social determinants of health have on overall health. If CHWs do not have long-term job opportunities, a living wage, benefits, and growth potential, they will leave the workforce.

Sustainable Funding

CHW programs across the United States make quantifiable improvements in health outcomes among historically marginalized communities—with dozens of studies over the past six decades showing a documented return on investment of CHW interventions across populations, settings, focus areas, and geography, including Nevada, Maryland, Kentucky, New Mexico, Texas, and Colorado.

Despite the evidence of population health impacts and financial gains, fiscally sustaining CHWs long-term remains a challenge, as agencies typically rely on limited-term grants to fund CHW positions. Fortunately, California is one of several states paving the way toward sustainably financing CHW services through Medicaid. In 2022, the California Department of Health Care Services (DHCS) submitted a Medicaid State Plan Amendment to add CHWs as a preventive service, which was approved by the Centers for Medicare & Medicaid Services. These services may include resource navigation and referral, health education, screening and assessment, and individual support or advocacy. To meet eligibility for Medicaid reimbursement, CHWs must be supervised by a Medicaid-enrolled provider and receive a state-recognized certificate by demonstrating prior experience or participating in training.

Additionally, as of January 2024, non-profit community-based organizations (CBOs) and local health jurisdictions (LHJs) that provide CHW services in California can enroll as Medicaid providers to receive Medicaid reimbursements. However, setting up the associated billing processes often requires administrative investments that CBOs and LHJs may not have in place. Technical assistance and startup support from DHCS will be critical to tap into this sustainable funding opportunity.

Policy Change

As California’s Medicaid policies transform, legislators are also considering strengthening systems to support this new model. During the 2023-24 legislative season, California Assembly members introduced Assembly Bill 3149 to require DHCS to convene a Promotores Advisory and Oversight Workgroup to examine the implementation of the CHW benefit under the Medicaid program. If passed, the workgroup will consist of at least nine appointed individuals with at least 51% comprised of CHWs. The appointees must represent geographically diverse areas of California, which align with recommendations by the APHA CHW section. The workgroup will ensure CHW training and outreach materials are culturally and linguistically appropriate, advise DHCS to increase the accessibility of CHW services statewide, make recommendations on outreach strategies, and more.

Policy change is necessary to make sustainable actions on behalf of CHWs. While research has consistently demonstrated the effectiveness of CHWs in transforming communities and enhancing health outcomes, this has not been backed with proper investments proving their value in a community-based approach to public health. By shaping policy that aims to elevate these often-unrecognized heroes, the public health system can achieve equity, save lives, and reduce disparities.