In September 2022, the Biden Administration awarded $225 million in American Rescue Plan funding to train over 13,000 Community Health Workers (CHWs), the largest ever one-time federal investment in the CHW workforce. The Consolidated Appropriations Act of 2023 also reauthorized a CDC program through 2027 that supports the use of CHWs to improve health outcomes in medically underserved communities. These investments represent growing interest in supporting CHWs to strengthen population health.

CHWs are not defined by licensure or a single title, but rather who they are and what they do.

Who Are CHWs?

CHWs are trusted frontline public health workers who have a unique understanding of the communities they serve.

CHWs can act as liaisons between health/social services and the community to facilitate access to, and improve the quality and cultural competency, of service delivery.

CHWs are identified by many titles: Public health worker, community health advisor, representative, educator, advocate, promotora, outreach worker, liaison, navigator.

CHWs build individual and community capacity through various activities such as outreach, community education and advocacy, and provide social support and informal counseling when needed. The roles and activities of CHWs are tailored to meet the needs of the communities they serve.

What Do CHWs Do?

CHW’s roles vary widely and can support many outcomes based on the settings in which they work.

• Serve as intermediaries to link clinical services to community-based services and organization
• Develop and maintain constructive relationships with health system workers.
• Support the healthcare workforce by increasing communities’ health knowledge and self-sufficiency through outreach and education.
• Provide culturally sensitive and appropriate care and information to communities, and health and social service systems.
• Possess intimate knowledge of the culture, strengths, and challenges of the people they serve.
• Establish relationships and rapport to build the trust critical to improving access to care and health outcomes.

More information about the critical roles that CHWs can play in the health system and communities can be found here.

Benefits Of Supporting CHWs

Integrating CHWs in the health care team can reduce Medicaid spending and increase ambulatory care use. By diverting healthcare from emergency departments to preventative care units, CHWs can result in a savings of almost $100,000 per year.

A cost analysis of an evidence-based CHW program reported a return of $2.47 for every dollar invested for Medicaid payers, realized through fewer and lower cost admissions.

Patients who received help from CHWs were less likely to be re-admitted to the hospital.

Individuals with depression who received help and guidance from CHWs were charged a lower average total for treatment services while experiencing fewer high-cost encounters.

Overall, CHWs can:

• Enhance communication between communities and providers.
• Increase access and use of health services (including preventative screenings).
• Improve adherence to health recommendations.
• Reduce the need for emergency and specialty services.

Training CHWs

• Effective CHWs need excellent communication and interpersonal skills to facilitate relationship-building with the communities they serve, the cornerstone of their work. CWH roles can be agile and tailored to varied contexts; however, their needs for equipment, resources, and training are also context specific.
• There is no nationally standardized certification training for CHWs in the U.S. Certification and oversight varies state-to-state. Most CHWs receive on-the-job training focused on company-specific tasks or projects, which limits the generalizability of their training.
• Though ongoing training and professional development are beneficial—and especially salient when using CHWs in specialized or role-specific settings (e.g., substance use)—these opportunities are currently limited.
• Establishing formal certification programs, training guidelines, and curricula could benefit this field of practice by delineating CHW roles to successfully integrate CHWs into the existing healthcare workforce.

Funding CHWs

Despite the many valuable roles that CHWs can play to improve health care access and outcomes, sustainable funding streams are rarely allocated, posing a barrier to the widespread adoption and continued development of the CHW workforce.

• CHWs have historically been funded through time- and resource-limited grants, which can create unsustainable programs that disappear when grants end
• Many healthcare providers and health plans, particularly Medicaid managed care organizations, have expressed interest in CHWs for their potential to improve care quality, patient health and satisfaction, and to reduce costs.

Policy Strategies to Build & Sustain the CHW Workforce

COVERAGE: States can take a variety of approaches to authorize payment for, and encourage use of, CHW services. Specifically, states can:

• Authorize Medicaid payment for CHW services under different state plan benefits including preventive or outpatient services benefits. This map highlights state-level approaches for Medicaid reimbursement.
• Use State Plan Amendments (SPAs) to shape Medicaid benefits to address enrollee needs and reimburse for CHW services. With a SPA, benefits must be offered statewide and without targeting populations. Examples of state SPAs are outlined in this chart.
• Obtain Section 1115 demonstration waivers and Medicaid Managed care organization (MCO) contracts.

TRAINING: States can define CHW certification and training requirements.

• This table summarizes CHW training standards in 18 states.
• CHW certification in Indiana, for example, is open to anyone aged >18 years with a high school diploma or equivalent, creating a promising employment pathway, including for those without higher education.
• To promote the unification of CHWs, the Indiana Community Health Worker Association (INCHWA) has developed a framework through which Indiana CHWs may become certified.

Working with the Indiana Department of Health, INCHWA approves training vendors to train and produce Medicaid reimbursable certified CHWs.

CHW PARTNERSHIP: CHW associations can be valuable partners to better understand community needs and the policy priorities of the CHW workforce.

CHW professional organizations and associations exist in many states or regions (e.g., Ohio Community Health Worker Association), and at the national level (e.g., Ohio Community Health Worker Association), and at the national level (e.g., National Association for Community Health Workers).