Who are CHWs? 16 B What do CHWs do? 17 C How are CHWs distinguished from other health and human service providers? 20 D Development of an Emerging Profession 22 3 CHWS IN MASSACHUSETTS
The Massachusetts Department of Public Health (DPH) defines Community Health Workers (CHWs) as public health professionals who leverage their deep understanding of the experiences, language, and culture of the communities they serve to fulfill various essential roles.
1 Providing culturally appropriate health education, information, and outreach in community based settings, such as homes, schools, clinics, shelters, local businesses, and community centers;
2 Bridging and culturally mediating between individuals, communities and health and human services, including actively building individual and community capacity;
3 Assuring that people access the services they need;
4 Providing direct services, such as informal counseling, social support, care coordination, and health screenings; and
5 Advocating for individual and community needs.
CHWs are distinguished from other health professionals because they:
1 Are hired primarily for their understanding of the populations and communities they serve;
2 Conduct outreach a significant portion of the time in one or more of the categories above;
3 Have experience providing services in community settings.
The Department of Public Health (DPH) utilizes a standard definition for Community Health Workers (CHWs) in public health practice, policy development, and community contracts, aligning with the recommendation from the Bureau of Labor Statistics' Standard Occupational Classification Policy Committee This definition, submitted by the American Public Health Association CHW Special Primary Interest Group and endorsed by the American Association of CHWs, was officially published by the Office of Management and Budget in January 2009 The 2010 Standard Occupational Classification, listed in the Federal Register, includes a distinct classification for Community Health Workers under Standard Occupational Classification 21-1094.
A community health worker (CHW) is a vital frontline public health professional who possesses a deep understanding of the community they serve This strong trust allows CHWs to act as liaisons between health and social services, enhancing access to essential services and improving the quality and cultural relevance of care Additionally, CHWs empower individuals and communities by promoting health knowledge and self-sufficiency through various activities, including outreach, community education, informal counseling, social support, and advocacy.
A "community health worker" encompasses various job titles that fulfill one or more roles as defined by the Department of Public Health (DPH) According to a 2005 report, community health workers play a crucial role in enhancing public health by providing essential services and support to local populations.
In Massachusetts, the Department of Public Health (DPH) identifies approximately 50 job titles that align with the Community Health Worker (CHW) job description, highlighting the essential role of workers in enhancing public health Various organizations and agencies utilize diverse titles for CHW positions, reflecting the broad scope and importance of this profession in improving community health outcomes.
13 Promotor or Promotora de Salud
Community health workers are truly "community health warriors" due to their vital roles in the community Their responsibilities extend beyond merely delivering health information; they act as case managers, housing specialists, and nutrition educators These professionals must educate on various levels, as health encompasses a wide range of issues The diverse roles they fulfill highlight their essential contributions, solidifying their status as warriors in the fight for community health.
Said by a CHW in Boston
Community Health Workers (CHWs) play a vital role in enhancing healthcare and public health within their communities They assist clients in enrolling in health insurance programs like MassHealth and Commonwealth Care, offer essential information and referrals to health and human services, and help navigate complex care systems Additionally, CHWs conduct home visits for clients with multiple health conditions, provide language interpretation services, and identify barriers to care such as housing and employment They also advocate for clients to ensure they receive appropriate, culturally competent services.
Community Health Workers (CHWs) in Massachusetts participated in six regional focus groups, sharing their diverse experiences, which are highlighted throughout this section Additionally, data from the 2008 DPH CHW Workforce Survey and other relevant sources are incorporated to provide further insights into the work of CHWs in the state.
Being a community health worker requires a blend of willingness, courage, and creativity to persist in challenging situations When individuals feel overwhelmed and unable to continue, the community health worker steps in with support, suggesting they take it one hour at a time This approach fosters resilience and encourages connection, often over a simple cup of coffee, to explore the next steps together.
The 2008 DPH CHW Workforce Survey highlights the importance of having a vision that extends beyond immediate challenges This perspective often stems from personal experiences, enabling individuals not only to act as a bridge for others but also to confidently assert that they have successfully navigated similar obstacles, ensuring a sense of safety for those they support.
Said by a CHW from Springfield, MA
The final report of the National Community Health Advisor Study categorized CHW functions into the following seven core areas:
1 Cultural mediation between communities and the health and social services system, how to use these systems, increase use of preventive care and decrease urgent or emergency care;
2 Providing culturally appropriate health education and information, prevention related information, managing and controlling illnesses such as diabetes and asthma;
3 Assuring that people get the services they need, case finding, motivating and accompanying patients to appointments and follow up care, making referrals and promoting continuity of care;
4 Providing informal counseling and social support, individuals and groups, to improve mental and physical health;
5 Advocating for individual and community needs, serve as intermediaries between clients and bureaucratic entities;
6 Providing direct services, basic first aid, administering some health screening tests;
7 Building individual and community capacity, facilitate health behavior change, act as community leaders to bring about community wide change Footnote 15
Community Health Workers (CHWs) utilize four key strategies in their service delivery: client advocacy, health education, outreach, and health system navigation These strategies are essential, as they represent the most commonly reported activities performed by CHWs in their efforts to support and improve community health outcomes.
Health screening Support for medication adherence
Care coordination Health care system navigation
Outreach Health education Client advocacy
Percent of CHWs employers in the 2008 DPH CHW Workforce Survey CHWs agree that these activities are essential components of their work.
Community Health Workers (CHWs) play a vital role in advocating for their clients by serving as intermediaries with healthcare bureaucracies, assisting clients in navigating barriers, and educating them about their rights within the healthcare system Beyond advocating on behalf of clients, CHWs empower individuals to become self-advocates within health and human services.
Empowering the community we serve with knowledge about their rights and entitlements is crucial for fostering equitable treatment By educating individuals on what to expect in various situations, they can confidently advocate for themselves While we cannot directly monitor the treatment of every client, we can ensure that they understand the standards of care they deserve This approach is essential in our efforts to eliminate disparities and promote fairness in healthcare.
Said by a CHW from Cape Cod
Community Health Workers (CHWs) play a vital role in educating individuals and communities about health issues, promoting health, and preventing and controlling diseases They deliver health education in various settings, such as clinics, schools, community organizations, and clients' homes The primary objective of their efforts is to empower clients to make informed health decisions and take charge of their well-being.
I actively engage in comprehensive education on topics such as anatomy, sexuality, and reproductive health Many individuals share with me their lack of awareness regarding essential information, including the transmission of bodily fluids It is concerning to realize that some people have been living with infections for years without understanding these critical aspects.
Said by a CHW from Boston
Demographics 25 B Where and with whom CHWs work 26 C Training and Certification 28 D Funding for CHWs 33 4 THE CRITICAL ROLES OF CHWs
In 2008, the Department of Public Health (DPH) conducted an investigation that identified 2,932 Community Health Workers (CHWs) in Massachusetts, a figure that slightly exceeds the 2,441 CHWs reported in the 2007 Health Resources and Services Administration National Workforce Study This number may actually be conservative due to the limitations in the sampling methodology used in the DPH CHW employer survey.
According to the 2005 DPH workforce survey, 76.2 percent of Community Health Workers (CHWs) are women, with a median age between 36 and 40 years Additionally, 60 percent of these workers possess a degree beyond high school, reflecting a higher educational attainment compared to the national average reported by the Health Resources and Services Administration.
The Community Health Worker (CHW) workforce exemplifies the increasing racial and ethnic diversity within the Commonwealth, with over 50% identifying as people of color This includes 23.7% African American, 20.6% Hispanic, 4.9% Asian or Pacific Islander, and smaller percentages of Native American and individuals from multiple ethnic backgrounds CHWs represent a wide array of ethnicities such as African, Cambodian, Chinese, Dominican, Haitian, Puerto Rican, Russian, and Vietnamese In Massachusetts, 19% of the population consists of people of color, with 14% being foreign-born and 20% speaking a language other than English at home, marking a 4% increase in the diversity of the state's population.
2000 census, 15 percent of state population was people of color, and a 7 percent increase from
1990, 12 percent of the state population was people of color Footnote 23 Over half, 58.6 percent, of CHWs in Massachusetts are bi or multi lingual, speaking the preferred language of their clients.
Source: 2008 DPH CHW Workforce Survey.
Race and Ethnicity of CHW Workforce In Massachuestts
P e rc e n t o f th e W o rk fo rc e
B Where and with whom CHWs work
Community Health Workers (CHWs) are employed across various agencies, such as community health centers, hospitals, and faith-based organizations Research indicates that 41% of CHWs work in Boston, with 21.6% in the Metro region, 14.4% in Central Massachusetts, 9.1% in the Southeast (including Cape Cod), 8.6% in Western Massachusetts, and 5.3% in the Northeast Additionally, 30% of CHWs serve rural clients through their respective agencies.
Source: 2008 DPH CHW Workforce Survey.
Source: 2008 DPH CHW Workforce Survey.
Community Health Workers (CHWs) play a vital role in supporting various at-risk populations, including individuals with substance abuse disorders, the homeless, immigrants, refugees, and those affected by HIV or AIDS, particularly adolescents A significant portion of the clients served by CHWs are either receiving or eligible for publicly funded health insurance According to a 2008 DPH workforce survey, 62.8 percent of CHWs are employed at agencies where 76 to 100 percent of clients qualify for publicly funded insurance.
Rural residents Infants/Children Adolescents Pregnant Women Persons at risk for or living w ith HIV/AIDS
Older Adults Immigrants/Refugees Persons w ith disabilities Homeless Persons Persons w ith substance abuse disorders
Regional Distribution of CHW Workforce in Massachusetts
Total CHW workforce in MA: 2932
Source: 2008 DPH CHW Workforce Survey.
Source: 2008 DPH CHW Workforce Survey.
CHWs who serve Clients with Publicly-funded
76-100% of clients 51-75% of clients < 50% of clients
Percent of Clients with Public Insurance
Community Health Workers (CHWs) often receive varying levels of training, with some participating in formal programs tailored to essential competencies, while others are trained on-site by their employers or in specific health topics relevant to their roles Many CHWs are employed in programs targeting particular health issues, such as asthma, HIV/AIDS, or diabetes, yet they frequently lack comprehensive training in the broader competencies required for their positions Alarmingly, a considerable number of CHWs do not receive any training whatsoever.
Currently, there is a lack of statewide infrastructure for standardized Community Health Worker (CHW) training in the state Formal training opportunities are limited to just three locations, provided by two community-based programs: the Community Health Education Center in Boston and Lowell, and the Outreach Worker Training Institute in Worcester Upon completing their training, participants receive a certificate of completion However, only about 1,300 CHWs, representing less than half of the total workforce, have undergone formal core training.
The DPH CHW 2008 Workforce Survey reveals a significant disparity in formal training among Community Health Workers (CHWs) Only 7.4 percent of the workforce is employed by agencies where 76 to 100 percent of CHWs are formally trained, while nearly 30 percent work in agencies reporting no formal training for their CHWs Although 12.6 percent of employers indicate that a majority of their CHWs are formally trained, a staggering 42.6 percent of agencies report that none of their CHWs have received any formal training.
2008 Workforce Survey data suggest a relationship between training availability and the number of CHWs who work at agencies that report high levels of training among their CHW workforce
In Central Massachusetts, 82.4% of Community Health Workers (CHWs) are employed by agencies where over 50% have received formal training, while in the Northeast, this figure is 40.6% However, in the Metro, Southeast, and Western regions, the majority of CHWs work at agencies that report no formal training for their workforce Notably, in Boston, 63% of CHWs are at agencies with less than 50% formally trained staff, indicating a significant gap between the demand for training and the availability of CHW services in the area.
Massachusetts has been highlighted nationally for its leadership in innovative CHW training programs; Footnote, 24 however, barriers exist to CHWs’ access to these training programs In the
A 2008 DPH survey revealed several barriers to formal training for Community Health Workers (CHWs) identified by employers Key obstacles include inconvenient training times (29.9%), CHWs' busy schedules (27.3%), high training costs (24.1%), and the lack of training availability across various regions (19.3%) Additionally, some employers were unaware of existing training opportunities, noted insufficient backup staff during training sessions, and cited limited transportation options to training locations.
Barriers to Training as Reported by CHW Employers
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% there are no barriers CHWs not given release time
Formal training is not necessary
Not available in our region cost prohibitive CHWs too busy Not offered at convenient times
B ar ri er s to C H W t ra in in g
While only a small percentage of Community Health Workers (CHWs) have undergone formal training, many have acquired specialized training from their employers and have pursued post-secondary degrees or college courses to enhance their knowledge and skills This was highlighted in discussions among CHWs at the DPH regional focus groups and the Massachusetts Association of Community Health.
Workers regional meetings on credentialing indicated that training and opportunities for higher education are important to their effectiveness in their work and advancement in the field.
The Community Health Education Center and the Outreach Worker Training Institute have formed partnerships with state and community colleges to ensure that core training is recognized as college credit In Boston, the Community Health Worker Initiative has enhanced educational opportunities for Community Health Workers (CHWs) by establishing Certificate and Associate degree programs in Community Health in collaboration with local colleges and universities Bunker Hill Community College and MassBay Community College award up to 6 college credits for prior learning to students who complete 109 hours of training at the Community Health Education Center, specifically for those who earn both the Comprehensive Outreach Educator Certificate and the Advanced Comprehensive Outreach Educator Certificate.
Upon completing the Comprehensive Outreach Educator Certificate and Advanced Comprehensive Outreach Educator Certificate, students can earn 6 credits from Bunker Hill or MassBay The training emphasizes core competencies for community health workers (CHWs), enhancing their skills to effectively engage with their communities Students must submit a Prior Learning Portfolio to the college, detailing their learning experiences at the Community Health Education Center To assist with this requirement, the center offers guidance on completing the portfolio and provides a class audit of all attended trainings The Community Health Worker Initiative of Boston supports this program through facilitation and financial resources.
Bunker Hill and MassBay are partnering to establish a credit-granting relationship, offering personalized support through their Career Coaching Program for students looking to develop a Prior Learning Portfolio This initiative allows students to potentially transfer their Certificate and Associate degrees towards a Bachelor's degree in human services, focusing on community health.
The DPH investigation highlights the consensus among community health workers (CHWs), employers, funders, and payers on the importance of certifying CHWs to enhance workforce professionalism There is a strong demand for standardized training programs aimed at certifying CHWs in core competencies Several states, including Texas and Ohio, have enacted legislation requiring completion of approved training for certification, though they lack direct skill assessments Indiana and Alaska have established certification programs focused on specific health services, while Minnesota mandates credentialing for CHWs eligible for Medicaid reimbursement under registered providers Despite these initiatives, most states with certification processes have not adopted third-party reimbursement for CHW services, indicating a need for further research on the effectiveness of current certification programs.
Massachusetts lacks a systematic commitment to or infrastructure for supporting CHW training
CHWs Increase Access to Care 36
Access to care is defined by the Institute of Medicine as the timely utilization of personal health services to achieve optimal health outcomes Achieving timely access and optimal health relies on having health insurance to cover service costs, establishing a relationship with a regular primary care physician, and receiving preventive education and services.
Community Health Workers (CHWs) significantly enhance access to healthcare for individuals who previously faced barriers They excel in enrolling people in health insurance, connecting them with primary care providers, and promoting preventive care By leveraging their community ties and shared cultural or experiential backgrounds, CHWs effectively engage marginalized families and individuals who may be unaware of available services.
Community Health Workers (CHWs) have been instrumental in the success of health reform in Massachusetts, particularly through their contributions to Outreach and Enrollment grantee organizations funded by health reform legislation Their primary role has involved identifying and assisting uninsured residents in enrolling in publicly or privately funded insurance plans As a result, a significantly higher number of uninsured individuals than previously estimated have been enrolled in MassHealth, the Massachusetts Medicaid program, and Commonwealth Care plans This achievement has notably decreased the reliance on the Health Safety Net Trust Fund to cover costs for uninsured or underinsured residents in Massachusetts.
Many organizations funded by Outreach and Enrollment Grants from MassHealth utilize community health workers (CHWs) to identify, assess, and enroll residents in suitable health plans MassHealth prioritized funding for organizations with staff who possess deep community knowledge, cultural and linguistic sensitivity, and the technical skills necessary for enrollment assistance These essential skills are typically provided by community health workers, who play a crucial role in this process.
1 Since the inception of health care reform in 2006, Outreach and Enrollment grantee organizations have enrolled over 164,600 individuals in subsidized health insurance plans, namely MassHealth and Commonwealth Care Footnote 36
2 Outreach and Enrollment grantee organizations have also assisted 45,900 individuals to retain their insurance coverage through the annual renewal process Footnote 37
3 During 2007, seven CHWs at Project H.O.P.E in Hyannis, MA, an Outreach and
Enrollment grantee program, enrolled 4,000 people in MassHealth and 2,200 in subsidized Commonwealth Care plans Footnote 38
Linking to Primary Care Providers
Having a regular primary care provider is crucial for accessing healthcare, as they coordinate patient care and provide a medical home Community Health Workers (CHWs) play a vital role in connecting individuals and families to primary care providers, particularly after helping them enroll in health insurance Research indicates that CHWs engaged in case management activities are more effective in fostering and maintaining patients' relationships with their providers compared to those who only make a single contact.
In 2007, the Community Health Workers (CHWs) at Project H.O.P.E in Hyannis, MA, successfully assisted 4,990 individuals in choosing a primary care physician, while also providing essential education on available health services and guidance on navigating the healthcare system.
A randomized controlled trial conducted in Massachusetts found that community health workers (CHWs) significantly enhance the likelihood of newly insured individuals both enrolling in and retaining their health coverage over time, outperforming traditional enrollment methods.
Enrollment specialists emphasize that the initial enrollment process is just the beginning of ensuring that previously uninsured individuals maintain their coverage The ongoing challenge lies in addressing barriers to regular re-enrollment and facilitating effective engagement with the health system, a role that Community Health Workers (CHWs) are particularly equipped to handle.
A randomized controlled trial in Massachusetts demonstrates that Community Health Workers (CHWs) significantly enhance the enrollment of uninsured Latino children in health insurance compared to standard Medicaid and SCHIP outreach methods The CHWs, sharing ethnic and cultural backgrounds with the families they assist, are trained to navigate complex enrollment processes and advocate for families, leading to a remarkable 78% continuous insurance coverage in the CHW group versus only 30% in the control group Furthermore, children in the CHW intervention group secured insurance more quickly, averaging 87.5 days compared to 134.8 days for the control group, while their parents reported higher satisfaction with the insurance acquisition process.
Ensuring Use of Preventive Care
Community Health Workers (CHWs) play a crucial role in facilitating behavior change to enhance health outcomes They assist individuals in accessing a range of preventive health services, which encompass general health education, referrals for both chronic and acute conditions, comprehensive perinatal care, preventive screenings, and immunizations.
Kentucky Homeplace employs and trains 40 community health workers (CHWs) in rural, medically underserved areas to enhance healthcare access for their peers Approximately 75% of the residents served by these CHWs are at significant risk for diabetes In response, the CHWs distributed 3,000 diabetes self-tests and engaged with over 1,200 clients to educate them about colorectal cancer risks and available medical resources Through targeted teaching interventions, CHWs successfully improved screening rates for diabetes and colorectal cancer by raising awareness about the importance of early detection.
Published studies demonstrate the effectiveness of Community Health Workers (CHWs) in enhancing maternal and child health outcomes A review of 14 studies focused on CHW programs aimed at improving pregnancy outcomes revealed that eight studies reported positive effects on prenatal care, three indicated improvements in low birth weight deliveries, and one highlighted a reduction in preterm deliveries.
1 The low birth weight rate in two targeted Ohio counties fell significantly after the
The Community Health Access Program (CHAP), which relies significantly on Community Health Workers (CHWs), has demonstrated remarkable success in reducing low birth weight rates Data collected from over 300 clients indicate that the low birth weight rate in a previously impoverished area has decreased to less than 5 percent, down from over 23 percent.
An evaluation of the Massachusetts DPH Early Intervention Partnership Program, designed for high-risk pregnant women, revealed that participants significantly reduced the likelihood of having infants with abnormal conditions on their birth certificates Additionally, these participants were more likely to breastfeed at the time of hospital discharge compared to those not involved in the program.
Community Health Workers (CHWs) play a crucial role in enhancing screening rates for various health conditions, particularly cancers A comprehensive analysis of 15 studies demonstrated that CHW interventions significantly improve individuals' utilization of preventive services, including breast cancer screenings.
CHWs Improve Health Care Quality 38
Timely preventive screenings and primary care are crucial for enhancing the quality of care and achieving better health outcomes, as acknowledged by health and social service providers According to the Institute of Medicine, health care quality is defined as the extent to which services enhance the likelihood of desired health outcomes while aligning with current professional knowledge Recently, health care professionals have emphasized the importance of patient-centered care, which prioritizes the preferences, needs, and values of patients, as a vital element in improving health care quality High-quality, patient-centered care encompasses these fundamental principles.
1 open communication between patients and providers,
2 delivery of culturally competent services,
3 high levels of patient satisfaction with the care and services they receive, and
4 ongoing chronic disease self management
CHWs play an important role in improving all four of these aspects of health care quality
Examples of research findings include:
Improving Communication between Patients and Providers
A home visiting program in Chicago achieved significant reductions in infant mortality and increased immunization rates among low-income African American and Hispanic families by integrating Community Health Workers (CHWs) into its service delivery model The success of the program can be attributed to the CHWs' effectiveness in improving communication and fostering connections between these families and the healthcare system As a result, the program reported fewer infant deaths than both citywide and community averages, higher immunization rates than local and national figures, and overall normal health and development in infants.
The Southeast Asian Birthing and Infancy Project in Lowell, Massachusetts, significantly improved prenatal care for ethnic and linguistic minorities by employing culturally matched bilingual and bicultural staff This initiative focused on health advocacy and education for pregnant and parenting women, leading to a remarkable increase in early prenatal care enrollment Within two years, the percentage of young pregnant women who delayed registering for prenatal care until their third trimester dropped from 40% to just 5%.
A randomized study involving 309 African American men with hypertension revealed that those receiving intensive care from a nurse practitioner and community health worker (CHW) team were more than twice as likely to express extreme satisfaction with their treatment and management of high blood pressure compared to those who only received one-time education and referrals.
Improving Self management of Chronic Diseases
The rise of chronic illnesses like cardiovascular disease, diabetes, and asthma is transforming primary care practices in the United States The Institute of Medicine emphasizes that enhancing care quality should focus on chronic conditions Additionally, the Centers for Disease Control and Prevention (CDC) advocate for the use of Community Health Workers (CHWs) as an effective strategy to lower cardiovascular disease risk and enhance cardiovascular health, as well as to prevent, treat, and manage diabetes, particularly among high-risk minority populations.
Chronic care management focuses on two key strategies: empowering patients to actively manage their health conditions and connecting them with supportive community resources Community Health Workers (CHWs) play a vital role in facilitating these processes, ensuring that patients receive the education and support they need for effective self-management.
Prevention and Management of Heart Disease
A review of six studies related to heart disease and stroke concluded that CHW interventions were associated with “significant improvements in participants’ blood pressure care and control.” Footnote 61
In a randomized controlled trial conducted in Baltimore, community health workers (CHWs) significantly enhanced hypertension management among African American men By conducting home visits, CHWs educated and motivated clients and their families to adhere to hypertension management strategies while also referring them to necessary services.
A study conducted in Baltimore revealed that Community Health Workers (CHWs) play a crucial role in multidisciplinary teams, enhancing hypertension management among low-income African American men Patients who received care from teams that included CHWs experienced notable improvements in blood pressure and a decrease in heart disease rates, in contrast to those who only received standard education and referrals.
Prevention and Management of Diabetes
A study conducted in East Harlem found that 80 percent of Hispanic women with diabetes who received assistance from Community Health Workers (CHWs) successfully completed a diabetes management program, in contrast to only 47 percent of those who did not have CHW support.
In Massachusetts, community health centers, CHCs, collectively care for nearly 30,000 African American and Latino patients living with diabetes Footnote 65
Data from the Holyoke Health Center’s diabetes self-management program highlights the positive impact of Community Health Workers (CHWs) on patient engagement and health outcomes Participation in this program has been linked to improved health measures and a reduced risk of diabetes-related complications The research emphasizes that the success of patient engagement is largely attributed to CHWs, who foster personal relationships, model healthy behaviors, promote self-management, and connect patients' home situations with their clinical care.
Massachusetts CHW diabetes intervention research: Evidence for CHW effectiveness in
In Massachusetts, two initiatives are underway to assess the effectiveness of Community Health Workers (CHWs) in enhancing diabetes self-care and blood sugar control among patients The Massachusetts League of Community Health Centers and the University of Massachusetts Medical School are conducting research on the impact of integrating CHWs trained in chronic care and diabetes management into existing health center teams aimed at reducing health disparities Additionally, the PACT program, in collaboration with Codman Square Health Center, Joslin Diabetes Center, and Harvard’s Medical and Public Health Schools, is investigating how CHW interventions can improve care for vulnerable diabetes patients struggling with treatment and self-care.
CHWs Reduce Health Disparities 41
The Institute of Medicine recommends CHWs as part of a “comprehensive, multin level strategy to address racial and ethnic disparities in health care.” Footnote 68 In addition, the Pew
Community Health Workers (CHWs) provide unique opportunities to enhance preventive and primary care access for diverse communities in America The Massachusetts Commission to End Racial and Ethnic Health Disparities highlighted that CHWs serve as effective resources, helping minority populations navigate and utilize primary care and preventive services more efficiently.
Improving Health among Vulnerable Populations
Research indicates that community health workers (CHWs) engaged in patient navigation and case management can effectively address disparities in cancer screenings Patients of color frequently receive diagnoses at more advanced stages of illness than their white counterparts, leading to increased mortality rates within minority populations Therefore, enhancing cancer screening rates is essential for mitigating disparities in cancer-related deaths.
A recent randomized controlled trial in Atlanta revealed that African American women participating in a Community Health Worker (CHW) intervention were significantly more likely to attend follow-up appointments after their mammograms Specifically, 91.7% of the CHW group kept all of their scheduled appointments, in stark contrast to only 74.3% of the control group.
A study conducted in Santa Clara County, California, revealed that Vietnamese American women, who experience the highest rates of cervical cancer among racial and ethnic groups in the U.S., showed significantly improved pap smear rates when participating in a Community Health Worker (CHW) intervention Notably, 46% of women in the CHW group who had never been screened for cervical cancer received a pap smear, compared to just 27.1% in the control group that only received media education.
African American and Hispanic patients at a New York teaching hospital who received Community Health Worker (CHW) services achieved a colonoscopy completion rate of 66%, significantly higher than the citywide average of 47% This program also resulted in fewer screening cancellations and an impressive patient satisfaction rate of 98%, with 66% of participants indicating they would not have undergone the procedure without the support of CHW navigation services.
In 2007 and 2008, the Baltimore City Health Department launched a partnership with Baltimore County aimed at addressing health disparities among African Americans, specifically focusing on reducing rates of cardiovascular disease and diabetes A central element of this initiative is the employment of numerous community health workers to support these efforts.
Twenty community health workers (CHWs) will be stationed at local health centers, each managing a caseload of around 30 patients diagnosed with diabetes and/or hypertension These CHWs will implement an evidence-based protocol that includes conducting home visits, providing education, offering support, and referring patients to enhance their overall health and healthcare access.
Addressing Social Determinants of Health and Strengthening Communities
Health disparities arise not only from limited access to preventive and healthcare services but are also shaped by social, economic, and environmental factors The Healthy People 2010 initiative emphasized the importance of tackling social inequities that heighten health risks for entire communities Many public health professionals advocate for greater community engagement in problem-solving efforts to enhance 'social capital' and improve overall health outcomes.
Footnote 79 as effective public health approaches A number of projects around the country and in Massachusetts have involved community health workers as keys to such strategies.
A community-based participatory research program in Portland, Oregon, focused on low-income African American and Latino communities, aimed to enhance social capital Community Health Workers (CHWs) were integral to the initiative, effectively addressing social determinants of health such as education disparities and access to services They, alongside local church members, identified critical issues like lack of health insurance and employment opportunities In response, residents formed a cooperative to tackle these challenges Additionally, another neighborhood confronted youth violence and police brutality, leading to the establishment of a community coalition that included young police cadets and a Peace Campaign to foster safety and trust.
CHWs help increase access to care in Springfield
In the North End of Springfield, MA, a challenging landscape persists, with 10 percent of residents cycling through the jail annually, high rates of chronic illnesses like HIV, asthma, diabetes, and heart disease, and a disheartening high school graduation rate of only 35 to 40 percent The community faces economic hardships, reflected in one of the lowest median family incomes in Massachusetts Local activists and the North End Outreach Network (NEON) emphasize the importance of community collaboration to address these issues Community Health Workers (CHWs) have proactively engaged with residents, knocking on doors to foster relationships and encourage participation in community activities, such as after-school programs and English classes From 2003 to 2006, CHWs reached over half of North End households, uncovering significant health concerns, including asthma in nearly 30 percent of homes and diabetes in 20 percent Their efforts in assisting residents with health insurance led to a substantial reduction in the uninsured patient rate at Brightwood Health Center, decreasing from 16 percent to 8 percent.
CHWs Improve Service Delivery and Reduce Health Care Costs 42
CHW WORKFORCE DEVELOPMENT
All stakeholders in Massachusetts, including community health workers (CHWs), employers, educators, foundations, and payers, recognize the urgent need to enhance the CHW workforce through comprehensive strategies focused on training, higher education, certification, and career development To effectively meet the goals of healthcare reform and improve public health, the Commonwealth must expand CHW training programs and establish a standardized certification process While innovative public-private partnerships are already contributing to CHW workforce development, a modest investment in infrastructure is essential to ensure quality and encourage broader participation from both public and private payers in utilizing CHWs to strengthen primary care and community-based health systems.
The DPH investigation reveals both strengths and challenges in creating a standardized, accessible CHW training system across Massachusetts Notably, the state benefits from two well-established and successful core CHW training programs, specifically the Boston Public Health Commission’s Community Health Education Center and Central.
The Massachusetts Area Health Education Center’s Outreach Worker Training Institute offers a comprehensive curriculum grounded in interactive adult education principles, focusing on essential core competencies Spanning 45 to 55 hours, the program fosters connections to higher education and emphasizes culturally sensitive strategies that promote diversity Key strengths include flexible implementation, collaboration with Community Health Worker co-trainers, personalized support for participants to navigate systemic and organizational challenges, and encouragement for individual professional development.
Massachusetts has robust training programs for Community Health Workers (CHWs), yet faces significant challenges, particularly in western and southeastern regions where training opportunities are scarce Key issues include insufficient funding for existing programs, the absence of a standardized core curriculum, lack of certification for trainers, limited recognition of CHWs in higher education, and inadequate capacity to create specialized health curricula Despite these challenges, there has been a notable rise in demand for specialized training, especially in chronic disease management Organizations like the Outreach Worker Training Institute and the Community Health Education Center have responded by developing tailored curricula for the Department of Public Health, the Massachusetts League of Community Health Centers, and the Robert Wood Johnson Foundation, focusing on conditions such as diabetes, asthma, cardiovascular diseases, and various cancers.
Community Health Workers (CHWs) require enhanced pathways to obtain college degrees that recognize their skills, alongside specialized training from programs like the Community Health Education Center and the Outreach Worker Training Institute The Community Health Worker Initiative of Boston is pioneering a model that offers a higher education certificate and an Associate's degree in Human Services focused on community health at the community college level Additionally, a Bachelor's degree program emphasizing prior learning and community service is being developed in collaboration with the College of Public and Community Service at the University of Massachusetts Boston By providing transferable college credits for successful completion of CHW training programs, such as those offered by the Community Health Education Center and the Outreach Worker Training Institute, CHWs can achieve their Associate's and Bachelor's degrees more easily.
Continuing education is essential for Community Health Workers (CHWs) to enhance their skills and meet re-certification requirements Additionally, CHWs require on-the-job supervision, employer-supported training, mentoring, and clear career advancement pathways to foster professional growth This holistic approach to workforce development benefits both CHWs and their employers by promoting better retention of experienced staff and enhancing the effectiveness of multidisciplinary health teams.
B CHW Certification: Developing a Massachusetts Blueprint
Community Health Workers (CHWs), along with their employers, funders, and health service providers, recognize the importance of certification to enhance the skills and competencies of CHWs, ultimately benefiting community health Implementing a state-sponsored certification process is essential for a comprehensive policy initiative aimed at recruiting, training, and maintaining a skilled and effective workforce in the health sector.
The CHW Advisory Council assessed certification efforts from states like Texas, Ohio, and Minnesota, focusing on their models' mechanics, wage impacts, career advancement opportunities, and the involvement of CHWs in the certification development process For Massachusetts, it's crucial to consider the state's healthcare reform experience and the specific needs of CHWs and their employers A thorough evaluation of the roles, responsibilities, benefits, and potential challenges for stakeholders in the certification process is essential To establish desired outcomes, it's important to explore how certification could influence CHW compensation, workforce stability, recruitment and retention, educational opportunities, and overall community health improvements.
To maintain the integrity and effectiveness of Community Health Workers (CHWs), it is crucial to prevent certification from limiting their practice The flexibility and holistic approach of CHWs are essential in defining their role and the significant contributions they make to healthcare and public health systems Additionally, certification should not act as a barrier for individuals aspiring to engage in community health work.
Council members recognize that a flawed certification process may lead to exclusivity By actively engaging Community Health Workers (CHWs) in the development and management of the certification process in Massachusetts, it is essential to preserve the attributes that contribute to the effectiveness of CHWs.
Massachusetts risks necessitating the development of a replacement workforce if it does not strengthen its primary care system Enhancing injury and disease prevention efforts will inherently depend on skilled professionals who can effectively engage with vulnerable community members.
Training and Education 45 B Certification: Developing a Massachusetts Blueprint 46 6 RECOMMENDATIONS FOR A SUSTAINABLE CHW PROGRAM
Conduct a Statewide Identity Campaign for the CHW Profession 47 2 Strengthen Workforce Development 49 3 Expand Financing Mechanisms 52 4 Establish an Infrastructure to Support CHW Work 64 CONCLUSION
4 Establish an Infrastructure to Ensure Implementation of Recommendations
Implementing the recommendations for developing a reliable and sustainable Community Health Worker (CHW) workforce faces various challenges, yet all are technically feasible The success of these initiatives hinges on the dedication and commitment of policymakers and institutional leaders to actively support and pursue these recommendations Additionally, many of the proposals come with estimated timeframes that rely on the willingness to implement them effectively.
1 Conduct a Statewide Identity Campaign for the CHW Profession
Recognizing and standardizing the term Community Health Worker (CHW) is crucial for the advancement of the CHW profession within the healthcare system The absence of a nationally accepted definition creates obstacles to acknowledging the valuable contributions of CHWs It is essential to understand and appreciate their unique skill sets and the diverse areas where they can positively impact healthcare, public health, and human services Increasing awareness of CHWs and their roles will enhance service delivery and may also lead to greater employment and career advancement opportunities for these professionals.
To ensure the successful implementation of the Advisory Council's recommendations for a sustainable community health worker (CHW) program in the Commonwealth, a statewide identity campaign is essential This comprehensive campaign aims to enhance awareness of CHWs among communities, clients, health and human service providers, employers, and the CHW workforce Increasing recognition of the CHW profession and its significant role in improving access to care and reducing disparities is crucial for the effective integration of CHWs into the health and human service delivery system.
1.1: Encourage all state and local government agencies to adopt the “community health worker” term and DPH definition in rules, regulations, and program guidelines as per the DPH 2002 policy The adoption of the CHW term will provide ongoing opportunities for accurate data collection for the Commonwealth when tracking workforce size and contributions towards the elimination of health disparities.
Implementation timeframe: within 6 to12 months.
1.2: Develop an educational campaign about CHWs targeted at CHWs, employers of
Community Health Workers (CHWs), along with funders, policymakers, local health departments, and residents benefiting from CHW services, should collaborate on a campaign akin to existing public health awareness initiatives led by the Executive Office of Health and Human Services and the Department of Public Health (DPH).
Implementation timeframe: 12 to18 months to allow for the development of the educational campaign.
1.3: Encourage private and public funders of CHWs to use the term “community health worker” when releasing funding opportunities involving outreach, community based health education and promotion, and connecting community members to health care and social services The adoption of the CHW term by private and public funders will facilitate enhanced data collection for funders The implementation of the utilization of the CHW term by all funders of CHW services will set the stage for employers of CHWs to adopt the term as well.
Implementation timeframe: within 12 to 24 months to allot time to adopt the CHW term as potential funding is released during various funding cycles.
To enhance clarity regarding attendance, it is essential that all training and educational programs for Community Health Workers (CHWs) consistently use the term "CHW." This ensures that the intended audience for these programs is clearly defined.
1.4: Advise individuals, agencies and institutions which provide CHW training and education to adopt and utilize the CHW term when designing and implementing programs, including use in their curricula, promotional materials, and public presentations.
Implementation timeframe: 6 to 12 months and beyond.
1.5: Incorporate the role of CHWs in the content of training and education curricula for health care and human service professionals, particularly in the community and state college and university systems The inclusion of CHWs will assist healthcare and human service providers to integrate CHWs into care delivery teams and maximize the effectiveness of the health care and human service programs.
Implementation timeframe: 12 to 24 months and beyond to provide time for educational institutions to include CHWs in the curriculum.
2 Workforce Development: Create a Statewide CHW Training, Education, and Certification Infrastructure
To enhance the development of the Community Health Worker (CHW) workforce, the CHW Advisory Council has proposed essential recommendations These recommendations focus on providing sufficient infrastructural support, implementing comprehensive training and education programs, establishing a certification process for both CHWs and training entities, and creating a CHW Board of Certification.
2.1: Develop a statewide CHW training and education infrastructure, including multiple points of access and entry, based on the following models:
1 Expand and make affirmative recommendations for current, successful community based training models, community based CHW training models have proven to be effective for many CHWs and their employers The CHW Board should determine areas of the state where such community based models are needed, assess the feasibility of possible expansion into these areas, and recommend strategies for their development and oversight The CHW Board should consider multiple possible partners to serve as institutional training “homes,” such as community health centers, Area Health Education Centers, and other community based organizations.
2 Develop a consistent, high quality CHW training program that travels throughout the Commonwealth to offer trainings in any geographic location where a need is identified in partnership with a host organization
3 Partner with public institutions of higher education across the Commonwealth to develop and support the implementation of training and educational pathway models College credits should be awarded for completion of CHW training programs, and those credits should be “portable” among participating educational institutions.
2.2: Engage key public and private partners to develop financing strategies for a sustainable, consistent, high quality CHW training infrastructure
1 The first step in this process should be an investigation into financing strategies other states have used to support training and certification for CHWs
2 The Executive Office of Health and Human Services could seek line item funding from the General Treasury for CHW training programs.
2.3: Develop an approved CHW training curriculum, including defined core competencies, and a curriculum for CHW supervisors, for use by all certified CHW training programs.
1 The CHW Board of Certification should review existing curricula and literature in the field, including learning objectives, content, teaching methods, and evaluation techniques
2 CHW training programs should include a minimum of 45 contact hours
2.4: Encourage all CHW training programs to include training for supervisors of CHWs based on identified curricula
Supervisor training has been developed and is offered by the existing CHW training programs, and should serve as a model for future program development.
2.5: Enforce systematically across DPH the 2002 policy, see Appendix G, requiring contractors to develop internal agency plans for the training, supervision, and support of CHWs, including implementation of specified operational measures for training.
2.6: Establish a Community Health Worker Board of Certification
The Governor should establish a Community Health Worker Board of Certification (CHW Board) within the DPH Division of Health Professions Licensure, comprising at least seven members representing the CHW workforce, employers, training organizations, and other stakeholders Appointments should be made in consultation with the CHW Advisory Council as outlined in Recommendation 4.2 The CHW Board will oversee the regulation of training and certification for CHWs and their trainers, while also providing recommendations for career pathways to enhance the professional development of the CHW workforce.
The Commissioner of the Department of Public Health (DPH) or their designee will convene quarterly meetings to oversee the implementation of training and certification recommendations for the Community Health Worker (CHW) Board Board members will serve three-year terms or until their successors are appointed Additionally, a full-time professional will be designated to staff the CHW Board, with extra administrative support provided as necessary.
2.7: Develop and implement a certification process for CHW trainers and training entities.