Support deployment of Community Health Workers (CHWs)
Given the important role CHWs play in reaching underserved, high-risk
populations, how can coverage for these services be expanded?
The populations most affected by disparities in diabetes
face many hurdles to improved health outcomes, including distrust of medical
care providers, lack of health literacy and lack of diabetes self-management
education, among others. The ACA recognizes CHWs as important members of the
healthcare workforce that can help to achieve the goals of
health reform, especially in poor and underserved communities.xii
However, the new law does not include any specific financing or reimbursement
mechanism for these workers. CHWs (also known as health promoters or
promotores, community health advisors, patient navigators, outreach workers,
lay health advisors, or village health workers) have been shown to improve
health outcomes by providing health information and helping patients to
navigate the health care system.xiii
Even though CHWs can play a vital role in connecting
underserved populations with health care resources, CHW services are not widely
covered by insurers. Federal rules do not recognize CHWs as a billable provider
under the Medicaid program and as a result, the large majority of states do not
include CHWs as part of their Medicaid programs. Nonetheless, a few state
Medicaid programs have started experimenting with creative ways to fund CHWs,
such as using capitated funds, federal funding for administrative costs or
applying for a special waiver (Section 1115 Waiver). Some Federally Qualified
Health Centers (FQHCs) have found ways to employ CHWs by utilizing other
funding sources such as community grants.
The Alliance Experience
Alliance’s grantees have discovered that current credentialing standards
sometimes present barriers to third-party payments for CHWs. Those barriers, in
part, prevent the creation of integrated health care teams that require greater
flexibility in composition and payment to ensure wrap-around support of patient
self-management efforts in community-based and home-care settings.
the Alliance’s sites have explored a variety of different ways to effectively
utilize CHWs to deliver diabetes support services. For example:
Alliance's Dallas site, the Diabetes Equity Project (DEP), has seen clear
improvement in diabetes outcomes for their patients following the use of CHWs.
DEP's CHW program, called CoDETM (Community Diabetes
Education), has established diabetes health promotion "community hubs" at
several of its clinics. Results of the CoDETM program
reported at the close of its first year showed annual direct medical
expenditures of $461 per participant and significant reduction in hemoglobin
A1C levels in patients who participated in the program for 12 months compared
with a control group.
of this success, the Dallas site has taken the next step to expand the role of
these workers, utilizing a new job type, the "Diabetes Health Promoter." This
medical assistant is state certified as a community health worker through a
160-hour program and participates in 50 hours of diabetes/clinical training
initially, with several hours of ongoing continuing education each month.
Frequent coordination with the patient's primary care provider and interaction
with leaders of community partnerships is crucial to this model.
Alliance’s Chicago site is working to determine the types of roles and
activities that patients prefer for CHWs to perform and has conducted four
focus groups to learn more. This information will be used in the following
years to explore possible CHW integration into health center quality
improvement initiatives. Chicago is currently exploring an approach where CHWs
are identified from the pool of patients who have completed diabetes education
through the Chicago site’s program. Additionally, the use of text messaging
through mobile phones is being explored as a way for CHWs and other care
managers to conduct patient follow-up and continue to bolster patients'
self-management confidence and skills.
Policy Questions Arising from the Alliance
could private insurance coverage for CHWs be expanded?
are the reimbursement options for CHWs through Medicaid? While about half of
the states have efforts underway to cover CHW services through their Medicaid
programs, how could these services be included as part of the essential health
benefits specified for Qualified Health Plans for all states under the ACA?
could Health Professional Opportunity grants through the ACA best be leveraged
to help train CHWs?
minimal training standards and credentials for CHWs can ensure qualifications
and at the same time, increase availability of these links to vulnerable
can barriers be eliminated in credentialing standards that require certain high
level individuals (e.g. registered dieticians) to oversee the certification
requirements of CHWs to account for situations where such specific supervision
is not available or affordable?
can services most appropriate to individual members of the health care team,
including CHWs, be identified and incentivized?
could a standard scope of practice determination for CHWs help persuade public
and private payers to provide direct reimbursement for their services?