Alliance to Reduce Disparities in Diabetes

Support deployment of Community Health Workers (CHWs)

Policy Consideration:
Given the important role CHWs play in reaching underserved, high-risk populations, how can coverage for these services be expanded?

 The Problem

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

The 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.

Still, the Alliance’s sites have explored a variety of different ways to effectively utilize CHWs to deliver diabetes support services. For example:

  • The 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.
  • Because 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.
  • The 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 Experience:

  • How could private insurance coverage for CHWs be expanded?
  • What 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?
  • How could Health Professional Opportunity grants through the ACA best be leveraged to help train CHWs?
  • What minimal training standards and credentials for CHWs can ensure qualifications and at the same time, increase availability of these links to vulnerable populations?
  • How 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?
  • How can services most appropriate to individual members of the health care team, including CHWs, be identified and incentivized?
  • How could a standard scope of practice determination for CHWs help persuade public and private payers to provide direct reimbursement for their services?