Promoting Sustainable Financing of Community Health Worker Programs

July 26, 2024 | Logan Kelly

Community health workers (CHWs) develop trusted relationships with individuals based on community knowledge and shared life experiences, and provide services such as coaching, navigation of health and social services, and social support. Federal and state COVID-19 funding streams spurred the growth of the CHW workforce, as it supported hiring, training, and deploying CHWs across the country. As these funding streams come to an end, many CHW programs now face funding gaps—however, Medicaid and Medicare present new, promising funding opportunities. In a growing number of states, there are mechanisms for Medicaid to cover CHW services, and in January 2024, Medicare began reimbursing for a new set of services called Community Health Integration (CHI), marking the first time that Medicare services were designed to include specific roles for CHWs.

In this shifting funding landscape, state and territorial health agencies (S/THAs) can shape policy development and implementation to support sustainable financing of CHW services. They are critical in elevating CHW and community perspectives, and ensuring that the community organizations hiring CHWs can access relevant financing systems. Further, public health leadership can raise awareness of new funding streams, track their utilization, and see that these new policy options “stick.”

With CDC support, ASTHO partnered with the Center for Health Care Strategies (CHCS) to convene a series of calls for state public health agency staff around emerging CHW financing options. Drawing on the experience and insights of participating states, outlined are key strategies for S/THAs to support the CHW workforce.

Policy Development and Implementation

Support effective design and implementation of Medicaid and Medicare funding opportunities, including by engaging CHWs and community partners. Throughout the establishment of new funding opportunities, S/THAs can be key partners in supporting policy development and implementation by:

• Incorporating perspectives of CHW stakeholders, community organizations, and multiple agencies in program design decisions. Some states have established CHW advisory bodies to support policy design and implementation.
• Encouraging adequate Medicaid reimbursement rates. Medicaid rates for CHW services and overall CHW average wages vary widely across states. States such as South Dakota and Kansas have engaged CHW partners in developing rates that will support greater access to these services.
• Providing education and supporting infrastructure development for CHW employers to integrate with healthcare entities and receive new forms of reimbursement.
• Analyzing Medicaid claims data periodically to understand uptake of CHW services and support effective implementation in states with Medicaid reimbursement for CHW services.

Capacity-Building

Support capacity-building for braided and blended funding models. As new healthcare financing opportunities for CHW services become available, S/THAs can work with CHW employers to create funding models that braid or blend funding from different sources (e.g., public health, healthcare, and social services) to avoid overreliance on a single funding source. This involves:

• Supporting the development of community care hub infrastructure. Community-based organizations (CBOs) often lack the infrastructure to contract with healthcare entities. Community care hubs coordinate administrative functions and manage funding streams for a network of CBOs and are especially important for supporting the CBO-healthcare partnerships to contract for Medicare CHI services.
• Considering opportunities to align public health, Medicaid, and/or Medicare funding, including through initiatives that incorporate CHWs into broader strategies to address social determinants of health (SDOH). Some states are exploring how to align Medicaid coverage with CHI services in Medicare.
• Identifying non-traditional funding sources to support CHW activities. There is a range of HHS grants that have directly addressed CHW training and hiring, but other federal agencies such as the U.S. Department of Labor or Housing and Urban Development may have funding opportunities that can incorporate CHW services.

CHW Training and Certification

Design and refine CHW training and certification programs to align with financing opportunities. States vary in how they structure and administer CHW training and certification programs, though S/THAs serve as program administrators in many states. Although there is no federal requirement for CHWs to be certified for Medicaid reimbursement, it is common for states and CHWs to pursue certification and/or training requirements as part of authorizing new Medicaid coverage. The Medicare rule authorizing CHI services defers to relevant state rules on training and certification.

S/THAs can align CHW training and certification with these new funding streams, while also addressing the importance of accessible certification for practicing CHWs, by:

• Aligning CHW training program requirements with the knowledge, skills, and abilities that CHWs will need to deliver services reimbursable by healthcare payers. S/THAs can develop a crosswalk of existing training curriculum requirements against CHI and Medicaid competencies to identify any gaps.
• Offering dual certification or specialized certification/training pathways to maximize opportunities for CHW employment and reimbursement. For example, the New Mexico Office of CHWs offers both a state generalist CHW certification and three levels of specialist certifications, which have helped to support more CHWs to bill to Medicaid.
• Allowing certification reciprocity between states, which could ease the pathway to certification especially among CHWs who work near/across state borders or serve tribal populations.

Looking Ahead

The growing momentum for CHW services and new financing opportunities enable S/THAs to enhance the sustainability of CHW programs. S/THAs can support policy development that meaningfully engages CHWs, and affirms the full range of the CHW workforce’s strengths and capabilities. Learn more about how S/THAs can serve as CHW program funders, administrators, and policy design champions in ASTHO-CHCS report, “Opportunities for Public Health Agencies to Advance Sustainable Financing of Community Health Worker Programs.”