Community Health Workers (CHWs) have the potential to reduce health care costs and improve health care access, particularly for people with complex human service needs.1 As trusted members of the communities they serve, they help create bridges between patients and health systems to better meet patients’ needs. CHWs have been studied since the 1960s, and their effectiveness in diverse settings is well documented.2 However, until the Affordable Care Act (ACA) was passed in 2010, CHW roles within health care systems were limited.3 The ACA promoted the broader use of CHWs through a number of initiatives designed to reward health outcomes and value rather than paying providers by volume.4 One prominent ACA initiative under the Center for Medicare and Medicaid Innovation (CMMI) was the State Innovation Model (SIM) grants to states to design and test new payment and care delivery models.5 While the political future of the ACA remains uncertain, states continue to use their previously awarded SIM grants to experiment with how CHWs can improve health care outcomes and lower the cost of care.
This brief, developed with support from the Commonwealth Fund, highlights the ways that states are using SIM grants to integrate CHWs into value-based health care systems. States can use their SIM experience and momentum from aligning multiple stakeholders to overcome the challenges to diffusing CHWs throughout the health care system.
CHRT staff conducted 19 interviews with key informants from 14 states. Key informants included state health department and Medicaid officials, leaders from state CHW associations, leaders in health systems and other organizations employing CHWs, and CHWs themselves. Twelve of the 14 states had received SIM test awards (described below). CHRT staff supplemented the interviews with a systematic literature review, including academic and non-academic publications and state policy reviews.
The CMMI created SIM grants to help states transform their health care systems in ways that improve access and quality while reducing costs.6 The grants allowed states to design plans and test models that meet state-specific needs. SIM provided two types of funding:
- “Pre-testing/design awards” that allowed states to plan their strategies for transformation
- “Testing awards” that allowed states to implement strategies to transform their health care systems
SIM grant funding was awarded in two rounds, the first in 2013 and the second in 2014. Thirty-eight states received SIM awards totaling $960 million. Many states that received design awards in the first round received testing awards in the second round to implement the plans they developed with their design award. Fifteen states that received SIM testing awards included CHWs in their strategies for health care system transformation. See Figure 1 for a summary of SIM-related CHW activity.
The goals of the SIM grants are to improve health care while reducing costs. CHWs can play a key part in achieving those goals. Over four decades of research has shown that CHWs play important roles in addressing social determinants of health and improving health outcomes.7 The ACA described CHWs as key members of community-based health care teams who have the potential to lower costs and improve health care outcomes.8 CHWs increase access and quality of health care9 while also reducing the overall cost of care,10 especially for people with chronic conditions.11
CHWs are distinct from other health care professionals because they are chosen specifically for their knowledge and experience with the cultural and socioeconomic context of the communities in which they work.12 This knowledge and experience allows them to build trust with patients in ways that other providers often cannot. CHWs working with or within health care systems may be in unique positions to act as liaisons between health care providers and patients, and to help patients access medical and social resources.13 Importantly, CHWs are uniquely able to increase patient understanding of their health condition and provider recommendations. Providers working with CHWs often are better able to understand patient needs.14
Figure 1: SIM-Related Community Health Work Activity for States that Received SIM Test Awards
States used SIM funding to promote the integration of CHWs in two broad categories: 1) CHW workforce development, and 2) demonstrations to integrate CHWs into healthcare systems. Underlying each state’s efforts is the challenge of creating sustainable funding for CHW services. These approaches reflect three CHW integration challenges that interviewees identified:
- Diverse functions lead to lack of a standard understanding of the role of CHWs. Despite a long history of CHW programs in other countries,15 and in the United States since the 1960s, the CHW profession is not formalized in the United States. CHWs lack a common definition, standardized training and a certification process.16
- CHW roles are not well-known to the medical community, making integration into care teams a potentially daunting process.
- CHW funding almost universally comes from grants and therefore is unsustainable. The lack of a sustained funding stream creates barriers to stable, long-term CHW employment and integrated CHW programs.
States kept these challenges in mind while designing their SIM grant CHW models. Each state designed its CHW models by convening multi-stakeholder task forces, including state and local health departments, health plans, health systems, community health centers, foundations, non-profit organizations, and educational institutions.17 Four examples of these efforts are highlighted below.
Connecticut’s state SIM office established a CHW Advisory Committee to complete work in two phases. The first phase culminated in a May 2017 report that recommended a policy framework for defining CHWs and their scopes of practice and outlined sustainable funding options. Parallel to this work, the Connecticut Legislature recently passed a bill defining CHWs and designing a feasibility study for CHW certification. The second phase of this work involves coordination with the Connecticut’s SIM care delivery reform activities, which include the use of patient-centered medical homes (PCMHs) and “Advanced Networks” (i.e., Accountable Care Organizations, or ACOs). The state requires Advanced Networks participating in its Medicaid Shared Savings Program to use CHWs and participate in a technical assistance program that the CHW Advisory Committee will draft. The program will cover CHW care delivery models and CHW integration best practices. It also will develop a toolkit for integrating CHWs into primary care practices.
The Michigan Community Health Worker Alliance (MiCHWA) used the SIM grant to supplement funding from foundations and the Michigan Department of Health and Human Services to expand the reach of its core competency-based CHW training and certificate program. Through recruiting and training new instructors and working within the existing education system, CHW training has expanded to a growing number of community colleges and community organization sites throughout the state. The state SIM office recommends that SIM-selected PCMHs employ CHWs for care coordination and participate in standardized training and webinars. CHWs are addressing emergency department utilization and social determinants of health in Michigan’s SIM Community Health Innovation Regions—a demonstration that is still in its early stages.
Minnesota used SIM funds to test novel models for integrating CHWs into Accountable Communities of Health (i.e., ACOs). The state funded CHWs to work in several settings, including a mental health community center, a county jail system with those who are recently released, a public health department with refugees, and a rural federally qualified health center where CHWs helped patients follow through with specific elements of their care plans. By addressing patients’ social and personal needs (such as applications for food assistance), CHWs freed up other care team members to focus on patients’ clinical needs—an outcome that interviewees noted leads to more effective and cost-effective care. Minnesota also produced a CHW Toolkit designed to offer practical guidance to employers seeking to use CHWs. The toolkit describes various CHWs models; hiring, training and supervising practices; and sustainable financing models.
In the Vermont SIM (which has concluded its funding), CHWs were employed as part of a nurse-led community health team, providing outreach to individuals and creating institutional connections among primary care offices and social service organizations. Those interviewed noted that many health care practices struggle to make connections to social services, even though more practices are starting to pay attention to the effect of social determinants of health on their patients. The social service sector is decentralized and has opaque eligibility requirements, and referrals are much more complex than simply giving someone a phone number. It is often difficult for medical providers to know if their patients received necessary social services to which they were referred. CHWs in Vermont addressed this need. They extended the reach of providers and helped to close the loop between medical and social service organizations. ACOs received a per member per month payment for their community health teams funded through a tax assessment on health plans. Though the Vermont SIM has ended, the community health teams continue as part of the Vermont Blueprint for Health.
The SIM funding provides an important learning laboratory to demonstrate ways to effectively develop and deploy CHWs; yet sustainably financing CHWs remains a challenge. Although six states used SIM funds to develop the CHW workforce through expanding trainings, and many others are working toward state certification programs, interviewees noted that without additional efforts to integrate CHWs at a provider level18 and to obtain sustainable funding sources,19 these activities alone are unlikely to lead to permanent integration of CHWs into health care systems.
The SIM funding gave states and localities the ability to experiment with different CHW roles and team models, giving health care providers more experience working with CHWs. This ability to experiment at a local level allows CHW models to adapt and respond to local needs, taking advantage of CHWs’ knowledge of their own communities and building upon local programs and partnerships. Interviewees, particularly those from CHW associations, suggested that as healthcare providers get more experience with CHWs through the SIM and other efforts, they can begin to understand the value that CHWs add to health systems and the importance of clarifying CHW roles. A few states have funded CHWs through per member per month payments to individual practices or ACOs, though it is unclear if these funding streams will continue after SIM grants end. In an example of one state’s strategy to fund CHWs beyond the SIM, Washington used its SIM experience to obtain a Medicaid waiver in which ACOs covering the entire state employ CHWs.
Though six states have finished with their SIM testing award funding, many states are still in the process of implementation. There are likely to be additional lessons learned on CHW workforce development, CHW integration demonstrations and CHW funding models. States will, hopefully, build on their SIM experiences to further expand and integrate CHWs when SIM funding ceases. With the multitude of stakeholders involved, the SIM work across the U.S. is advancing the engagement and recognition of the value of CHWs. As the U.S. healthcare system shifts to reward value over volume, states can continue the work of the SIM to align payments and service delivery models to overcome the barriers to the integration of CHWs into the healthcare system, including sustainable financing mechanisms.
Acknowledgments: The staff at the Center for Healthcare Research & Transformation would like to thank the Commonwealth Fund for its support of the development of this brief, as well as Kirsten Bondalapati, Neha Kumar, Ezinne Ndukwe, and all the state experts and community health workers interviewed for the brief.