Featured Articles: Workforce

Community Health Worker Financing

Friday, January 16, 2015   (0 Comments)
Share |

by Alyssa Panning, Member Services Coordinator

 

The Western Forum for Migrant and Community Health, taking place in San Diego February 23-25, 2015, will offer multiple sessions on Community Health Workers (CHWs).  Over the past 50 years of the community health center movement, CHWs have proved to be an invaluable piece of the primary health care foundation, providing effective, culturally-sensitive care to millions of people.  CHWs have also been effective in improving population health in developing countries around the world, and they are identified as a key strategy in helping to achieve the United Nations’ Millennium Development Goals. 

 

The American Public Health Association defines CHWs as follows: “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served.  This trusting relationship enables a CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. CHWs also build individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy.”  CHWs are known by numerous titles. Within the community health center world they are commonly referred to as outreach workers, promotores, patient navigators, or peer educators.

 

Many studies have demonstrated improved health outcomes and patient satisfaction using CHWs, and others show enormous cost savings for programs that employ CHWs.  One study of a CHW outreach program for underserved men in Denver found a return on investment ratio of more than $2 for each dollar invested[1].  A study in Maryland found that patients served by CHWs cost around $2200 less per year than those not served by CHWs[2].  Arkansas had a 24% reduction in Medicaid spending by employing CHWs[3], and in Texas, Christus Health earned $16 for every $1 spent on CHWs[4].  A study in New Mexico, including FQHC Hidalgo Medical Services, compared resource commitment and cost savings of 448 patients who received CHW intervention and 448 who did not over a six month period.  It found that those who had care from CHWs cost a total of $2,044,465 less than those who did not receive CHW services. The program has now been expanded to more counties in New Mexico[5].

 

Most healthcare programs use a variety of public and private funding streams to pay CHWs, and some CHWs are volunteers.  Funding can come from private foundations, national public programs like HRSA, CMS, the CDC, or from local public health departments.  When funding ends, CHW programs are often disrupted.  CHWs are most effective when they have a lasting relationship with patients; being able to build trust within the community is critical for the success of the program.  Therefore a lack of consistent funding means that some CHW programs are unstable, and the program cannot create a solid foundation of trust and communication in the community[6].  In addition, disrupted programs can cause CHWs to lose trust in the healthcare system, and they may choose to work elsewhere.

 

In the last few decades, more funds have been set aside for CHW programs because of the valuable services they provide and the cost savings they demonstrate.  In 1999, the Centers for Disease Control and Prevention (CDC) started the Racial and Ethnic Approaches to Community Health (REACH) program, which was designed to reduce racial and ethnic disparities in health, and has been continually funded since that time.  REACH grantees have included community health centers and have focused on community-oriented participatory approaches to health, which have included CHWs[7].  In 2005, the Patient Navigator Outreach and Chronic Disease Prevention Act authorized HRSA $25 million in administered grants for patient navigator services.  In 2010, HRSA funded ten new patient navigation programs[8].  In 2009, HRSA Service Expansion Grants focusing on enabling services for special populations totaled $5 million for patient navigation, and many of the awardees used the funds for CHWs[9].  In 2011, the CDC, gave $103 million to governments, tribes, and nonprofits in 36 states to promote healthy communities, reduce chronic disease, and create partnerships.  Many of the grantees used the funds to train and employ CHWs[10]. 

 

Under the ACA, the Patient Navigator Outreach and Chronic Disease Prevention Act was reauthorized until 2015.  While within the rest of the ACA there are no funding sources specifically for CHWs, they are identified in numerous sections of the ACA where funding has been authorized, such as Area Health Education Centers grants, Hospital Readmission Reduction grants, Hospital Community Benefits grants, and Maternal, Infant, and Early Childhood Home Visiting Programs[11].  Most relevant to community health centers, the ACA authorizes Patient-Centered Medical Homes (PCMH) and Community Health Teams (CHT), as well as Grants to Promote the Community Health Workforce.  Both of these programs emphasize the importance of multi-disciplinary healthcare teams, which can include CHWs.  However, funds for Grants to Promote the Community Health Workforce have not yet been appropriated.  Nevertheless, it is momentous that the largest piece of healthcare legislation in many years authorizes and encourages the use of CHWs in a variety of preventive care fields.

 

Under the ACA, access to preventive health services under Medicaid has improved, and non-licensed providers can provide certain preventive healthcare services.  In order to opt in, states must file a State Plan Amendment that describes what services will be covered and who will be providing them[12].  So far, no states have done this, but it is an opportunity for states to make use of CHWs.  The ACA also provides for Medicaid “health homes” to coordinate care for Medicaid beneficiaries with chronic conditions, and some states are using CHWs to achieve this.  Around 15 states have filed State Plan Amendments to add Medicaid health homes, and a few states, including Maine, New York, Oregon, South Dakota, Washington, and Wisconsin, have designed programs that specifically include CHWs[13].  The ACA has also created funding for State Innovation Models, which test innovative ways to transform healthcare delivery and payment.  Six states were given awards, and four states have included CHWs in their plans, including Arkansas, Maine, Minnesota, and Oregon[14]. 

 

In January 2014, CMS made an important change to Medicaid regulations, clarifying that states can reimburse for preventive services, “recommended by a physician or other licensed practitioner…within the scope of their practice under State law[15].”  This opened the door for reimbursement of CHWs and other health professionals.  Previously, states could cover only preventive services that were provided by a licensed practitioner.  States do need to file State Plan Amendments that describe who will provide services and any training they will receive, and no states have done this yet[16].  However, Minnesota and New Mexico were previously able to navigate around the hurdle: Minnesota allows CHWs to reimburse for services through its State Plan and New Mexico requires managed care plans to provide CHW services[17].  The New Mexico study mentioned above was in partnership with a managed care organization, Molina Healthcare of New Mexico.  In Vermont, insurance companies pay into a fund for CHWs[18].  Many states are realizing the need for CHWs and are navigating ways to include them in primary healthcare. 

 

As the landscape of healthcare continues to evolve and policy makers realize the need for effective preventive, community-based care, the value of CHWs will continue to increase.  Many states are recognizing their importance, and are working to create opportunities for healthcare organizations to employ CHWs.  However, it is likely that health centers and other healthcare organizations will continue to use a variety of funding streams to support the valuable work of CHWs until more consistent funding is appropriated.  Health centers should work with local and state policy makers to be part of the discussion around CHW policy and funding, because CHWs are an integral part of effective preventive care programs.  Learn more about CHWs and the unique roles they play within healthcare and public health at the Western Forum for Migrant and Community Health in February.  Stay tuned for more information about CHWs in future issues of QuickNotes. 



[1] Whitley, E., R. Everhart, and R. Wright. “Measuring Return on Investment of Outreach by Community Health Workers.” Journal of Health Care for the Poor and Underserved, 17.1 (1996): 6-15

[2] Fedder, D., R. Chang, S. Curry, and G. Nichols. “The Effectiveness of a Community Health Worker Outreach Program on Healthcare Utilization of West Baltimore City Medicaid Patients with Diabetes, with or without Hypertension.” Ethnicity and Disease. 13.1 (2003):22-7

[3] Felix, H., G. Mays, M. Stewart, N. Cottoms, and M. Olson. “The Care Span: Medicaid Savings Resulted when Community Health Workers Matched Those with Needs to Home and Community care.” Health Affairs. 30.7 (2011):1366-74

[4] Maricopa County Public Health. “Community Health Worker Opportunities and the Affordable Care Act (ACA).” (2013) http://coveraz.org/wp-content/uploads/2013/09/Community-Health-Workers.pdf

[5] Johnson , D. et al. “Communtiy Health Workers and Medicaid Managed Care in New Mexico.” Journal of Community Health. (2011)

[6] Alvisurez, J., B. Clopper., C. Felix, C. Gibson, and J. Harpe. “Funding Community Health Workers: Best Practices and the Way Forward.” (2013) http://www.healthreform.ct.gov/ohri/lib/ohri/sim/care_delivery_work_group/funding_chw_best_practices.pdf

[7] CDC. “Investments in Community Health.” http://www.cdc.gov/nccdphp/dch/programs/reach/pdf/2-reach_factsheet-for-web.pdf

[8]Health Resources and Services Administration. Patient Navigator Outreach and Chronic Disease Prevention Demonstration Programs.  http://bhpr.hrsa.gov/nursing/grants/patientnavigator.html

[9] HRSA “Service Expansion for Enabling Services for Special Populations.” 2009. https://grants3.hrsa.gov/2010/Web2External/Interface/FundingCycle/ExternalView.aspx?&fCycleID=0D37BB89-0E3A-4455-8451-979BE0C27F0B&txtAction=View+Details&submitAction=Go&ViewMode=EU

[10] CDC. “Community Transformation Grants.” 2014. http://www.cdc.gov/nccdphp/dch/programs/communitytransformation/

[11] Maricopa County Public Health. “Community Health Worker Opportunities and the Affordable Care Act (ACA).” (2013) http://coveraz.org/wp-content/uploads/2013/09/Community-Health-Workers.pdf

[12] Katzen, A. and M. Morgan. “Affordable Care Act Opportunities for Community Health Workers.”  (2014) http://www.chlpi.org/wp-content/uploads/2013/12/ACA-Opportunities-for-CHWsFINAL-8-12.pdf

[13] Ibid

[14] Ibid

[15] Trust for America’s Health and Nemours. “Medicaid Reimbursement for Community-Based Prevention.” (2013) http://www.astho.org/Community-Health-Workers/Medicaid-Reimbursement-for-Community-Based-Prevention/   

[16] Katzen, A. and M. Morgan. “Affordable Care Act Opportunities for Community Health Workers.”  (2014) http://www.chlpi.org/wp-content/uploads/2013/12/ACA-Opportunities-for-CHWsFINAL-8-12.pdf

[17] Burton, A., D. Chang, and D. Gratale. “Medicaid Funding of Community-Based Prevention.” (2013) http://www.nemours.org/content/dam/nemours/wwwv2/filebox/about/Medicaid_Funding_of_Community-Based_Prevention_Final.pdf

[18] Alvisurez, J., B. Clopper., C. Felix, C. Gibson, and J. Harpe. “Funding Community Health Workers: Best Practices and the Way Forward.” (2013) http://www.healthreform.ct.gov/ohri/lib/ohri/sim/care_delivery_work_group/funding_chw_best_practices.pdf

 


Membership Software Powered by YourMembership.com®  ::  Legal