Supporting Community Health Workers in Territories and Freely Associated States

March 24, 2025

The U.S. territories and freely associated states have made tremendous strides in creating and sustaining community health worker (CHW) programs to improve access to care and improve health outcomes. However, much of the recent funding for CHW programs comes from time-limited grants, which highlights a need for sustainable funding sources. This resource offers recommendations developed by the National Association of Community Health Workers to develop sustainable and culturally appropriate CHW capacity and infrastructure.

Methodology

NACHW sourced its recommendations for T/FAS to grow and sustain their CHW programs through resources housed in the NACHW Document Resource Center. NACHW’s selection criteria included identifying resources that were developed or implemented from the perspectives of T/FAS and Indian Health Services or have national level racial equity ‘norms’ of CHW processes, programs, and policies (defined as at least 25 states with implementation of a recommended process, program, or policy). NACHW then formulated and vetted recommendations with NACHW staff and board members for consideration of applicability and feasibility with specific expertise from local and national partners.

NACHW Recommendations

1. Strengthen and integrate the CHW workforce in healthcare, Medicaid, and public health to enable CHWs to prevent and treat health challenges in culturally adaptive ways.

CHWs are valuable contributors across a range of settings—including healthcare, public health, and community-based organizations—and evidence demonstrates that CHWs can support a reduction in healthcare costs and utilization. Therefore, T/FAS can encourage policies that allow CHWs to be funded and integrated across both healthcare and community settings.

The Northern Mariana Islands’ Commonwealth Healthcare Corporation runs a mobile primary care clinic that increases community access to preventive health services. Commonwealth Healthcare Corporation is exploring opportunities for CHWs to expand provider capacity and extend the reach of mobile clinic services.

Medicaid levers may be available to cover CHW services or providers, such as through a state plan amendment, an 1115 waiver, or managed care contracts (though Puerto Rico is the only T/FAS that operates under managed care). For example:

• The Early and Periodic Screening, Diagnostic, and Treatment benefit in Medicaid requires that all children under age 21 enrolled in Medicaid are entitled to this benefit. It requires states and territories to provide access to any Medicaid-coverable service in any amount that a jurisdiction deems medically necessary to discover and treat childhood health conditions before they become serious, regardless of whether these services are covered under the state plan. Although there are important differences in Medicaid reimbursement in T/FAS compared to states, islands are eligible for participation in the benefit.
• The Medicaid and State Children’s Health Insurance Program (CHIP) operates in all U.S. territories—Guam, Puerto Rico, American Samoa, the Commonwealth of the Northern Mariana Islands, and the U.S. Virgin Islands. The Medicaid and CHIP Payment and Access Commission summarizes federal requirements and design features for Medicaid and CHIP programs, including eligibility, enrollment, benefits, financing and spending, data and reporting, and quality and program integrity.

2. Develop a task force with CHW representation for each island jurisdiction to explore legislative policies related to CHW workforce standards.

NACHW recommends identifying CHWs and CHW employers jurisdiction-wide and convening a dialogue to understand their interests and goals for any CHW-focused policy development. This could include setting up advisory councils or workgroups in advance of pursuing legislation that defines the workforce, core competencies, certification, or any other workforce standards.

• The American Public Health Association’s CHW Section recommends that such task forces or workgroups be comprised of at least 50 percent self-identified CHWs to ensure that jurisdictions develop policies with CHW voices held central.
• U.S. states that have defined core competencies often reference the National Council on CHW Core Consensus Standards and may offer legislative models that could be adapted by other jurisdictions. For example, the Hawaii Senate Bill 858 directs the Hawaii State Department of Health to establish a certification process with at least two tiers of CHWs, an oversight body, a retroactive certification process for practicing CHWs, and multiple sources of payment to CHWs, all of which should be driven by a task force that ensures representation of CHWs from each county.

3. Create a full scope of practice and training opportunities for CHWs with local CHW leadership.

T/FAS can work with CHWs to establish jurisdiction-wide definitions, standards, and/or policies for the CHW workforce. This could include developing a standardized, widely accepted definition of the workforce, creating a scope of practice, and developing inclusive training and certification programs, all of which should respect the identity and role of all CHWs.

• Kentucky, New Mexico, and Nevada can provide examples of CHW scopes of practice. In addition, the U.S. Virgin Islands Department of Health worked with the U.S. Virgin Islands Division of Personnel to create a job classification for both a CHW and a Community Health Outreach Coordinator within the government of the Virgin Islands. The CHW classification codifies the wide variety of CHWs’ duties to engage, support, advocate, and educate community members in overall wellness.
• The Center for Community Health Alignment recommends CHW certification programs to honor a balance of training and experience. For example, the IL House Bill 158 and 159 outlines the creation of a CHW certification board, authorizing new CHWs to obtain certification and existing CHWs to be grandfathered in. In addition, the Republic of the Marshall Islands offers a certification for community health outreach workers that consists of both completing a training program based in the College of the Marshall Islands, as well as demonstrating at least two years’ experience.
• Training should be accessible to everyone, especially those with lived experience and who are members of vulnerable communities. For example, Guam Marianas Training Center offers a training for community healthcare workers, which in 2022 the center delivered at no-cost for trainees due to an education stabilization fund. California and New Jersey also serve as strong examples of best practices in CHW training.

4. Work with partnering organizations to implement CHW workforce studies and create baseline workforce data on where CHWs are leading within communities

CHW networks and health departments can work effectively together to get results. NACHW promotes unifying and recognizing CHWs by partnering with ally organizations and agencies. Partnerships can also support efforts to collect data and jointly advocate for CHW funding and sustainability. State examples below can be used as a template to spark ideas about the uses of a CHW workforce assessment in T/FAS jurisdictions:

• A workforce assessment creates a baseline to understand CHW training requirements, qualifications, compensation, roles (including the extent to which CHWs are integrated into care teams and work in supervisory positions), and activities. NACHW has identified principles and strategies to create an equitable CHW workforce study.
• The Massachusetts CHW association, state health department, and the University of Massachusetts created the first comprehensive statewide CHW workforce survey (PPT download) in the United States, which at least 26 states have implemented since then.
• The Rhode Island Department of Health and CHW Association of Rhode Island collaborated on a survey that confirmed community-based organizations are major employers of CHWs and that healthcare organizations hired more CHWs and diversified CHW roles. This report created state-specific data on key workforce sustainability issues.

5. Integrate CHWs into clinical care teams while ensuring CHWs can maintain their community connectedness.

As healthcare entities hire CHWs, it is important to ensure that CHWs are supported in the workplace. This includes ensuring that CHWs have clearly scoped roles that are understood by the entire care team. CHWs should also have the opportunity to receive training, pursue professional advancement, have supervision by CHWs or supervisors that have a background in community engagement, and have the time and autonomy to retain their community connections. In addition, training should be provided not only for CHWs but also for employers in providing assistance to CHWs and integrating CHWs into the team.

Conclusion

T/FAS can use the community health worker model, as well as models and practices from other states, to design effective CHW programs and training across diverse communities and geographic areas. It is also important to recognize that implementing CHW workforce development initiatives requires CHW leadership, and T/FAS should leverage investments jurisdiction-wide for these initiatives.