If You Want to Go Far, Go Together: State-Level Efforts to Expand - - PowerPoint PPT Presentation

If You Want to Go Far, Go Together: State-Level Efforts to Expand Integration of the Community Health Worker Workforce into Health Service Delivery

ARM 2018 areas of focus addressed

q Characteristics and outcomes of interprofessional and team- based models of care q [Licensed and] unlicensed health professional career trajectories q Impacts of emerging care delivery and payment models on the workforce q Workforce implications of health care and social service integration q Impacts of health professions’ regulatory and practice environments on effective use of the health workforce q Strategies that support practice in high need areas (e.g., medically underserved, rural, primary care)

Presentations

u Aunima Bhuiya, CDC: How Are State Public Health

Agencies and Their Partners Supporting CHW Workforce Development?

u Deborah Fournier, ASTHO: CHW Policy Tracking and State

Learning Collaboratives

u Ashley Wennerstrom, Tulane University School of Medicine:

Preliminary Results from the CDC CHW Certification Study

u Rep. June Robinson, Washington State Legislature:

Washington State Approach to CHW Workforce Development and Financing

Why CHWs are important – and different

u Evolution of health care includes

u Greater accountability and shared responsibility for population health u Greater focus on social determinants of health u Greater attention to health equity and persistent disparities

u CHW practice is relationship-based rather than transactional u Characteristics of high-performing CHWs are unconventional and

challenging to incorporate into policy

u Standards and definitions for the profession are coming into focus

HOW ARE STATE PUBLIC HEALTH AGENCIES AND THEIR PARTNERS SUPPORTING COMMUNITY HEALTH WORKER WORKFORCE DEVELOPMENT?

Presented By Aunima Bhuiya AcademyHealth Annual Research Meeting Policy Roundtable June 25, 2018

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION DIVISION FOR HEART DISEASE AND STROKE PREVENTION | DIVISION OF DIABETES TRANSLATION

AGENDA

• 1. Background on the CDC CHW Workforce Development Study
• 2. Recent CHW workforce development activities reported by states

implementing CDC chronic disease programs

• 3. Examples within specific states at different points in the process
• 4. Insights from state health departments

BACKGROUND

• CDC NCCDPHP-funded programs (known as

1305 and 1422) from 2013-2018

• all 50 states, 4 large city health departments

and territories

• CHW-related strategies to promote:
• community-clinical linkages, provision of self-

management programs; and

• n-going support for adults with high blood

pressure diabetes

• 30 of the funded states chose to work on

increasing CHW engagement in health systems and programs

https://www.cdc.gov/chronicdisease /about/state-public-health- actions.htm

PURPOSE OF THE CDC CHW WORKFORCE DEVELOPMENT STUDY

• Better understand how state public health agencies and their

partners including CHWs collaborate to advance CHW workforce development

• ARM themes addressed: career trajectories, impact of payment

models, implications of health care and community and social service integration, and impact of regulatory and practice environments

6 CATEGORIES OF STATE-LEVEL CHW WORKFORCE DEVELOPMENT ACTIVITIES

• 1. Including CHWs in state-

level health systems transformations

• 2. Supporting the self-

determination and

• rganization of the state

CHW workforce

• 3. Generating local

evidence on CHW contributions

• 4. Convening stakeholders

to develop statewide CHW workforce definitions and standards

• 5. Conducting outreach and

providing training and technical assistance to employers

• 6. Preparing and

recognizing CHWs through standardized training and/or certification

• 1. INCLUDING CHWS IN STATE-LEVEL HEALTH SYSTEMS

TRANSFORMATIONS

§ Including CHWs in new value- based care models (e.g., ACOs and PCMHs) § Adding CHWs to the state’s public health, health care, and workforce plans

• 2. SUPPORTING SELF-DETERMINATION AND

ORGANIZATION OF THE STATE CHW WORKFORCE

§ Convening CHWs to discuss workforce development § Surveying CHWs and employers § Assessing CHW training needs § Developing a CHW website § Promoting CHWs leadership positions in planning groups

• 3. GENERATING LOCAL EVIDENCE ON CHW CONTRIBUTIONS

§ Conducting local CHW effectiveness studies § Developing a business case or value proposition for CHW contributions in the state § Evaluating the impact of statewide certification § Disseminating evidence to stakeholders

• 4. CONVENING STAKEHOLDERS TO DEVELOP

STATEWIDE CHW WORKFORCE DEFINITIONS AND STANDARDS

§ Learning from CHWs, experts, and

• ther states

§ Building consensus among stakeholders about general approach § Setting specific occupation and training standards § Pursuing coverage through the state Medicaid program § Engaging health care champions

• 5. CONDUCTING OUTREACH AND PROVIDING

TRAINING AND TECHNICAL ASSISTANCE TO CHW EMPLOYERS

§ Undertaking educational campaigns about CHWs in health care § Assessing employer capacity for CHW integration § Holding employer trainings on including CHWs in health care teams § Providing technical assistance and evaluation support to clinical sites

• 6. PREPARING AND RECOGNIZING CHWS THROUGH TRAINING

AND/OR CERTIFICATION

§ Training CHWs on chronic disease management § Developing core competencies and statewide training programs § Recruiting CHWs for training/certification § Creating registries of trained/certified CHWs § Developing internships and continuing education

NUMBER OF STATES (OUT OF 30) REPORTING ACTIVITY IN EACH CATEGORY

• 1. State health

system s transform ations

13

• 2. W orkforce

self- determ ination and

• rganization

20

• 3. Local evidence

11

• 4. Convening

stakeholders to develop definitions and standards

23

• 5. Providing

training and technical assistance to em ployers

23

• 6. CH W training and/or

certification

22

TWO STATES STARTING THE PROCESS: UTAH AND KENTUCKY

§ Helped to organize the state CHW workforce by holding events and supporting the new statewide CHW association § Worked with partners to advance workforce development policy § Developed a business case for CHW contributions using local evidence

A STATE A LITTLE FURTHER ALONG IN THE PROCESS: MASSACHUSETTS

§ Developed a method for evaluating the impact of certification § Promoted upcoming CHW certification and continued to standardize and improve the quality of training programs § Provided technical assistance to clinical sites working to include CHWs in health care teams

INSIGHTS

§ Facilitators and barriers § In general, states reported that CHW integration sites need:

• clinic leadership support;
• CHW role definition, workflow, and feedback mechanisms;
• partner resources and protocol for sharing data; and
• CHW and supervisor training.

§ In general, states reported needing:

• identification of CHWs;
• CHWs to address social determinants of health;
• a defined CHW continuing education process;
• buy-in from all stakeholders; and
• a statewide workforce infrastructure.

CONCLUSION

• A wide array of CHW workforce development activities across the states participating in the

1305 and 1422 programs; extent of implementation varied

• Most states are thinking about certification, training, and financing
• Early stage in the process

ACKNOWLEDGEMENTS

Colleen Barbero, PhD, MPPA Erika Fulmer, MHA Bina Jayapaul-Philip, PhD Sharada Shantharam, MPH Refilwe Moeti, MA Centers for Disease Control and Prevention. State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (1305) Centers for Disease Control and Prevention. State and Local Public Health Actions to Prevent Obesity, Diabetes, and Heart Disease and Stroke (1422) The preliminary findings and conclusions of this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

ABHUIYA@CDC.GOV

NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION Division for Heart Disease and Stroke Prevention | Division for Diabetes Translation The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

THANKS!

Deborah Fournier, JD Senior Director, Clinical to Community Connections Association of State and Territorial Health Officials

Op Opportunities for State Public Health Agencies to Su Support an and Integrate the CHW Workf kforce: CH CHW Policy Trac acking ng and and Stat ate Lear arni ning ng Co Communi unities

Who

St State Public Heal alth an and CHWs: Opportunity to im improve communit ity to clin linic ical l connectio ions

Downstream Clinical and patient-focused healthcare services Upstream Public health and place-based services

Improved Population Health

CHW Policy Tracking 2018

2018 2018 State CHW-re related legislation

AZ * CA CT HI* MD* MA MN* MO NC NJ OH OR SC* VA WA* CHW workforce definition

SB 1004 HB 5290 OH SB 301 H 4494 HB 2436

CHW certification/

• versight

HB 2324 HB 5290 SB 16 SR 6 SR 59 HB 490 SB 163 A 3511 S 61 SB1534 HB 1389 SB 417 SB 6498

CHW pilots/study/ initiative

HB 5290 SB16 HB 716 SB 266 HB 879 SB 544 HB 2011 H 1062

Labor protections

HB 5044

Inclusion of CHWs on advisory boards

SB 304 SB 975 HB 2480 HB 2820 HB 4363 HB 4470 SB 643 SB 2211 HB 1522

CHW training

AB 2804 SB 2374 SB 2475 HB 1638 HB 4454 SB 142 SB1534

CHW reimbursement

HB 610 HF 1269 HF 2919 SF 2765 *adjourned

Se Select 2018 state legislative ac activity on CHW ce certification

State/bill Description Arizona H.B. 2324 – Governor signed into law May 16, 2018 (https://bit.ly/2xPrUZM) Voluntary CHW certification (support from the Arizona Community Health Worker Association and the Arizona Community Health Worker Workforce Coalition) Connecticut H.B. 5290 – Governor signed May 14, 2018 (https://bit.ly/2HI2Pj6) Required a feasibility study on CHW certification, conducted in consultation with the CHW Advisory Committee. Maryland H.B. 490 – Governor approved May 8, 2018 (https://bit.ly/2HonA3l) Established a CHW Advisory Committee (which includes nine CHWs) to advise the Maryland Department of Health on matters related to CHW certification and training

Se Select 2018 state legislative ac activity on CHW in init itia iativ ives/pilo ilots/studie ies

State/bill Description Missouri H.B. 2011 – sent to the Governor May 30, 2018. (http://www.cqstatetrack.com/texis/re dir?id=5a83d7b94399 ) Appropriated $13.1M for funding community health worker initiative focuses on high utilizers in MO HealthNet (MO Medicaid) North Carolina H.B. 1062 (http://www.cqstatetrack.com/texis/re dir?id=5b109e2312a ) Proposed a pilot to recruit and train veterans as community health workers in order to implement an initiative to increase veterans’ access to health care. Maryland H.B. 716 – Governor approved April 10, 2018 (https://bit.ly/2HonA3l) Established a study that includes recommendations on ways to use community health workers to assist pregnant women

Se Select 2018 state legislative ac activity on CHW re reimbursement

State/bill Description Minnesota H.B. 2919 http://www.cqstatetrack.com/texis/red ir?id=5a8cd9f1202d CHWs can be reimbursed for telemedicine services as a licensed health provider so long as CHW meets state requirements in statute Minnesota H.B. 1269 http://www.cqstatetrack.com/texis/red ir?id=58a527622559 CHW costs are a component of FQHC allowable costs eligible for reimbursement

State-operated program

(NY for MCH navigators only)

Privately-operated program Program under consideration

Updated June 4, 2018

Program under development

Ev Ever-ch changing pict cture: State approach ches to CH CHW certification

St Strategies ar around defining certification

• Define objective first
• Air preconceptions around what certification looks like and fears of

negative consequences (and take deliberate steps to avoid these)

• Protect the diverse and community-based nature of the workforce
• Ensure pathway to certification is available to existing workforce
• Flexibility around structure and oversight
• Direct CHW input

CHW Value Proposition

Va Value proposition for CHWs

State/Study CHW Intervention Cost savings Nevada Division of Public and Behavioral Health CHW Pilot Program Initiative (https://bit.ly/2sBdtDu) CHWs embedded in managed care

• rganization to assist with patient education,

referrals, and insurance enrollment. The three CHWs worked with members for 30-60 days, leading to a 1.81 ROI stemming from reduced numbers of acute (re-)admissions and ED visits and reduced prescription costs per member per month New York: Bronx-Lebanon Hospital Center (https://bit.ly/2swo8zt) CHWs integrated into the PCMH to provide care management and supportive services (e.g. home visiting and service navigation) Pilot showed net 2:1 ROI from reduced hospitalizations and ED visits and increased primary care revenue Arkansas: Tri-County Rural Health Network Community Center (https://bit.ly/2swo8zt) CHWs provided navigation from nursing home care to home- and community-based care in three counties Arkansas Medicaid saved $2.6 million over three years. Washington: The Healthy Homes Project, Seattle and King County (https://bit.ly/2sMe1FU) CHWs visited homes of low-income children with asthma to provide education to children and their caregivers. CHW home visits led to 1.9:1 ROI and reduced hospitalizations compared to standard care. New Mexico: CHWs in Medicaid Managed Care (https://bit.ly/2swphaf) CHWs provided 6 months of advocacy, patient education, and social support to high-utilizing Medicaid enrollees 448 received intervention: total cost of care was $2,044,465 less post-intervention compared to pre- intervention, with a total program cost of $521,343.

Va Value proposition for CHWs

CMMI Health Care Innovation Awards Evaluation (https://bit.ly/2FDGK4N)

• "Of six types of innovation components that we evaluated (i.e., used health IT,

used community health workers, medical home intervention, focus on behavioral health, used telemedicine, workflow/process redesign intervention), only innovations using community health workers (CHWs) were found to lower total costs (by $138 per beneficiary per quarter).”

• Clinicians also reported spending between 30-50% less time arranging and

coordinating social services and referrals.

ASTHO’S CHW Technical Assistance

Te Technical Assistance (TA) Plan

• State-specific TA
• Opportunities for

cross-state learning

• Topic areas:
• Certification
• Strategic planning
• Coalition building
• Financing

Site visits Individual calls LC webinars Resources

AS ASTHO CHW Learning Community States

NJ CT RI DE MD ME IL IN MI OH WI AL KY MS TN NY PA AZ CO ID MT NM NV UT WY CA HI OR WA GA NC SC VA WV IA KS MN ND NE SD AR OK TX FL LA VT NH MO MA DC 2018-2019 cohort (H RSA support) 2017 cohort (H RSA support) 2016 cohort (CD C support) AK

St State-Id Identified T TA N Needs

• 1. CHW participation and broad coalition building
• 2. Standardized trainings and core competencies
• 3. CHW certification programs
• 4. Financing options

Ch Challenges

• Constantly shifting state landscape:
• Competing priorities
• Staffing and leadership changes
• Federal uncertainty
• Varied provider models
• Need for coordination and shared vision:
• Internal agency coordination
• External partner coordination
• High-level connections and support
• CHW engagement

Pr Progress in 2017 learning community

• Positioned state health agency as central convener
• Support for state CHW association/outreach
• Value proposition to engage state health agency leadership/divisions
• Legislative language around certification

Strategies for Coalition-Building and Partner Alignment

Ge General areas of state health agency support fo for CHW workfo force development

Research Partnerships Policy & Program Resources Leadership

Geoffrey Wilkinson, “State Health Department Support for Community Health Worker Workforce Development and Engagement,” available at http://www.astho.org/Health-Systems- Transformation/Documents/State-Health- Department-Support-for-CHWs-Toolkit- Version/

Co Coalition building - Wh Who should be at the ta table?

• Direct CHW engagement
• High-level agency support
• State health agency managers
• Providers
• External (neutral) facilitation

helpful

St Strategies for securing high-le level l support

• Value Proposition:
• Advantages for state population health AND workforce development goals
• Outline costs, feasibility, and capacity for state health agency to convene

internally/externally and advance a CHW agenda

• Benefits to the agency
• Benefits to providers
• Generate a specific “ask”:
• E.g., State health official letter to providers/contractors re: CHW

education and training

St Strategies for internal al an and external al coordination

• Internal:
• Consistent language in requests for proposals; common CHW definition

across divisions

• Unified communications strategy and resource dissemination
• Internal workgroups; internal staff lead
• External:
• Build consensus around need for collaboration
• Ongoing stakeholder coalition meetings
• Force Field Analysis to review enabling and restraining forces

Th Than ank you!

Association of State and Territorial Health Officials (ASTHO) 2231 Crystal Drive, Ste. 450 Arlington, VA 22202 CHW resources: www.astho.org/community-health-workers/ Deborah H. Fournier, JD Senior Director, Clinical to Community Connections dfournier@astho.org

CHW Certification:

Preliminary results from the CHW Certification Study

Carl Rush, MRP Terry Mason, PhD Meredith Sugarman, MPH Ashley Wennerstrom, PhD, MPH

Disclaimer

This study is funded by the Centers for Disease Control and Prevention. The preliminary findings and conclusions of this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Background

u CHWs are effective u CHW certification growing u 10 states have implemented a CHW

certification process

u Many more may be actively considering

u Little known about processes of

developing and implementing certification

u May be important IF other states

• pt for certification

What is certification?

u Process to document skills/qualifications of an individual

to perform the roles/duties of a CHW

u May require

u Training u Assessment u Continuing education

u Could affect (positively or negatively)

u CHW titling u Practice u Compensation

Process for assessing applicant's proficiency in required skills Practice standards Scope of practice: boundaries with other professions Definition of CHW and core competencies

If CHW certification is developed, there are several considerations

Procedures to renew, revoke, expire, appeal Continuing education requirement Administrative home: how to finance the cost? Eligibility and application process

Models of certification

u Voluntary or mandatory u Individual vs employer vs training

programs/instructors

u Administered by the state, a private entity, or a CHW

• rganization

u Could be implemented through the use of legislation

Study methodology

u Examined state-level actions and organizing structures related to CHW certification u Reviewed documentation on legislative, administrative, and/or financing supports for CHWs in 50 states, Washington D.C., and Puerto Rico u Identified seven states at multiple stages of certification for study Considering Implementing Implemented

Methodology - continued

u Key informant interviews u CHWs u State health officials u Payers u Employers u Interviews u Audio-recorded u Transcribed u Coded and interpreted using applied thematic analysis

RESULTS

Interviewees

u40 interviews completed

Sector # of interviews State 11 Medicaid 2 CHW 12 Employer 15

Theme 1: CHWs must be involved in developing certification

u “I think including the voices of [CHWs] and

engaging them in the process has been really rewarding as well...”

u “The energy came from us. It’s just the way the work

happens…you don’t get to unite or you didn’t get to in the past and it was hard to feel you had a voice. So, this was an organization that helped us create our voice.”

Subtheme: Promoters of CHW involvement

u Deference to CHWs/CHW organizations and/or leadership

acknowledgement from the state

u

“I think that CHW influence has been present the whole way through…I think that this committee made sure that the coalition of [CHWs] was probably the primary voice.” u Convening opportunities (e.g. CHW workshops and summits)

u

“I…think creating a structure…is helpful in terms of the transparent opportunities for people to plug in, in terms of participating.” u Public hearings about certification rules

u

Allowed CHWs to shape policy and certification requirements

Subtheme: Barriers to CHW involvement

u Language access u Logistics

u

Time constraints

u

Geography (e.g. urban vs rural access)

u

Costs to participate u Employers

u

Did not provide time off of work to attend meetings u Perceptions of certification development process u Bureaucratic u Driven by state staff and academic institutions u CHW voices not heard u “I think I have said that the whole process we went through in order to set this up doesn't have CHW leadership, really. It didn't come from the CHWs. They were cherry picked, and then they could say they had [CHWs] involved.”

Theme 2: Community membership is a key CHW qualification

u Stakeholders generally understand the value

u “… everyone understands the magic if you will of

[CHWs] isn't textbook based, it's life experience based.” u Can be challenging to integrate into

certification standards

Subtheme: Strategies for incorporating community membership into certification requirements

u Grandparenting u Applicant interviewing/ assessment during orientation u Required letters of recommendation from community/CBO u Documentation of languages spoken u Use of APHA definition language in legislation

“People who “fake” their way into this field, they don’t last very

• long. They don’t. I’ve seen it…People will know that you’re not

genuine and they might not even open up to you anymore if they know that you’re not really genuine at what you do.”

Theme 3: Facilitators of CHW Certification Development & Implementation

u Organized CHW groups u Pre-existing u Funding for convening CHW work groups/organizations u Technical assistance/resources u National groups u Academia u Other states u State staff/office to support CHWs u Buy in u Champions in state government/legislature/organizations u MCOs & health systems u Statewide education about CHW roles, including among CHWs

Theme 4: Barriers to Certification Development & Implementation

u Need for education about CHW roles and certification u Distrust of partners u Concerns over state-administered certification u Division among the workforce, i.e. among promotores, CHR, and

CHWs

u Lack of resources u Time constraints/turnover by state or CHW organization staff to

devote to certification

u Low level of support (funding and advocacy) at the state level u Difficulty identifying qualified/appropriate instructors for training

courses

u Lack of leadership/driver

Theme 5: Roles for state government

u Create/fund staff positions to support CHW workforce u Serve as a convener u Administer training and/or certification u Support greater employment of CHWs

Conclusions

uIF certification is to be implemented uCHWs to the front uCommunity membership is a key CHW

qualification

uEducation about CHWs is essential uA convener is necessary

Questions?

Carl Rush carl@chrllc.net T erry Mason tmason826@gmail.com Meredith Sugarman sugarman@tulane.edu Ashley Wennerstrom awenners@tulane.edu

Washington State Approach to CHW Workforce Development and Financing

• Rep. June Robinson

A Recent History

• 2012 Voluntary Statewide Training Program Launched by Department of

Health

• 2015 Community Health Worker Task Force Convened
• 2017 and 2018 Potential Legislation Introduced

Statewide Training

• Launched in 2012
• 30 hours core curriculum: roles and boundaries, communication skills,

cultural competency, organization skills, documentation skills, etc.

• Additional health specific modules: breast health and cancer

screening, cardiovascular health and hypertension, diabetes & pre- diabetes, behavioral health, health coaching & motivational interviewing, etc.

• Combination of in-person and online

CHW Task Force

• Formed and convened in 2015 by State Department of Health and Health

Care Authority (Medicaid Agency)

• 55 members, 1/3 of whom were CHWs
• Agreement on definition, roles, qualities and skills
• Recommendations for Training & Education and Finance & Sustainability
• Chose to not recommend certification

Nascent Statewide Network

• We are missing a strong organized CHW voice

Legislation Introduced

• Challenges include lack of understanding of role
• Not a priority for the busy calendar of healthcare committees
• Skeptical of “scope wars”

Future Opportunities

• Medicaid Transformation –Workforce efforts
• Regional organizations –Accountable Communities of Health –charged

with transformation projects are turning to CHWs

• Recognition of health disparities as a driver of cost

Contact Information

• Rep. June Robinson

P.O. Box 40600 Olympia, WA 98504-0600 june.robinson@leg.wa.gov 360-786-7864