Maine Community Health Workers Initiative

Compilation of Input from other states with CHW initiatives

November 26, 2013

Background: Phone interviews conducted with Michigan, Minnesota, Florida, Vermont, Connecticut, and Massachusetts and Oregon. These interviews were conducted by phone and ranged from 30 to 80 minutes in length. Interviewees were a mix of staff members from CHW associations, AHEC chapters, state health departments and/or CHW projects.

The same questions were asked of participants (see below for script). In the instance of Massachusetts and Oregon, most of the information flowed from presentations given at APHPA (delivered by Massachusetts CHWA, MA Department of Health and Oregon CHWA). In these instances I followed up with briefer or more focused phone conversations afterwards.

Interview Script:

Give background on Maine project- focus on SIM goals of payment reform and service delivery reform as well as our limited history and capacity as a state to working with CHWs in a systemic way. Provide background on me and MMHP.

1. Background/history of your state’s CHW efforts?

2.Lessons in developing programming in rural communities, outside of FW communities.

3.What model did you use to bring stakeholders together? Were there any unexpected allies?

4.Workforce Development considerations- how do we put our best foot forward?

5.Where/What type of entity owns the education & training piece in ___ state?

6.Much of payment reform focuses on the aligning CHWs w/PCMHs and/or as part of ACOs. In your opinion what states have succeeded in this realm?

7.Lessons learned in developing infrastructure in your state? If you had to do it over what would you do over?

8.If you were to develop a CHW pilot, what parameters would you look to define it? Any non-negotiable requirements of applicants?

Question #1: State Effort: Building CHW Capacity=Commitment for the Long Haul

  • Genesis of how when, and why states have convened around CHWs varies- there is no one path, and the development/evolution of capacity is a significant time commitment.
  • MA began its formal activities in 2003 and since 2010 has been working to build a CHW Board (seated in their Department of Health) as well as certification standards.
  • MI had tried twice before to organize on statewide basis but not until work was funded in 2011 did they succeed
  • Access to consistent/quality education and training was motivating force in MN/CT.
  • In 2003, CT through its AHEC connections began offering training developed at UCSF and then through the National Educational Collaborative at University of Arizona/
  • Funders compelled states to integrate CHWs or provide more consistent competency based training and/or adhere to specific program models (FL/MN/CT).
  • US-CDC/Office of Women’s Health funds flowing to Florida
  • Employers were key in jumpstarting process too (MN/CT/FL)- again pushing for competency based . consistent training and education.
  • Legislative mandate & policy development also influences direction and level of activity (MN/MA/VT/OR).

#2 Rurality impacts training/organizing/developing a shared identity

  • Distance learning is key to make education and training accessible- education can NOT be place based;
  • Face to Face time is key even if it is just 1x/year to create and build relationships and a shared identity (Florida-Michigan-Minnesota-MA- Oregon);
  • Long-history in tribal and agricultural communities using CHWs-capacity and model already exists there(FL/MI);
  • Connectivity and creating ability to connect needs to be consistently provided to keep allies/CHWs/stakeholders connected to the process;
  • Oregon after various attempts to address distance decided on developing regional networks and decentralized the function of networking and support to the regions.
  • Types of allies may vary based on geography- i.e. FQHCs or Rural Health Centers may be more involved from rural communities as they have history of being part of community.
  • HC Reform in VT mandates that CHWs are available through all hospitals regardless of location- place should not determine availability of services
  • In VT the CHW office is a draw to patients- hospital outfitted space that clients love to visit.

#3 Stakeholder Process & Unexpected Allies

  • Open membership key to transparency, building broad base of support amongst any and all allies will likely be key to success later on. It is also important to distinguish between allies and CHWs for role clarity sake.
  • MN- early on engaged higher education and traditional HC leaders as it became clear that CHWs would be part of ACA and Triple Aim.
  • MA- education within health department was key to build partnerships for potential future relationships
  • MI- recruiting and keeping CHWs engaged in process instead of having others speak on their behalf which is a compromise;
  • Emphasis on early engagement to foster future success (CT, MN & MA). In CT the coalition wished they had engaged MH/SA/Social Services early on in process.
  • Cultivating organizations who will support of CHW involvement is key as it leads to a higher level of CHW participation (OR).
  • Common language, integrity of CHW model, coalescing around a shared purpose are key to grounding group members.
  • FL- Certificate developed in vacuum at University of Miami without involvement of any CHWs, model did not reflect scope of practice accurately.
  • Need to be mindful of not being unduly influenced by one sector or one voice, i.e. FL found that discussion was guided by folks interested in education and organizing of home health aides.
  • Iterative nature of organizing means that as new people join at different points along the way there needs to be constant education on the process as well as leadership development for CHWs;
  • Supporting and modeling participation, being decision makers in process.

#4 & #5 Workforce Development Considerations, Approaches and Entities

  • Unanimity that a certificate can be a stepping-stone to future educational attainment or better paid employment;
  • Developing clarity around core competencies is essential and must be first step to defining curriculum/learning needs.
  • CHWs MUST be part of dialogue from the start.
  • Employers can and may play a pivotal role in workforce development- determining and demanding training be available, covering costs/$$$ to support training. Conversely, employers can also be barrier- not paying for training or time away from direct service. Most frequently cited was lack of support for continuing education/networking of CHWs.
  • Careful consideration of where training and education “lives” is critical early step to assure access and potentially success.
  • Involvement of higher education (community colleges/university systems) is mixed:
  • In (MN) partnering with community colleges built sustainability on the workforce development side early in process.
  • Other states (Florida and Michigan) there is deep division between education and community members. Questions about profit motive driving decisions about who can grant the certificate and/offer the training have affected ability to organize a broad based network.
  • Formal education (i.e. credit bearing courses leading to certificate) requirements should be approached cautiously for a number of reasons:
  • Credit-based learning allows for you to measure what individual learned. Secondarily it promotes the opportunity for CHWs to walk in the two worlds of academia and community.
  • Potential to exclude individuals who have history of serving their community as CHW but are not prepared to succeed in the classroom.
  • Certificate does not necessarily equal job opportunity. Often individuals successfully complete the coursework but no employment is available.
  • Cost- who is responsible for covering it? In some instances it is a barrier for those individuals with community connections but not the financial resources to pay for training.

Payment Reform Models

  • MN and VT are seen as models for reimbursement (billing code approved & bundled payment);
  • MA and OR have legislative mandated process for developing certificate as necessary intermediary step to move towards reimbursement.
  • A few health insurers have integrated CHW model (specifically Molina) hiring directly or subcontracting for services.
  • OR/VT CHW model was part of system reform, not just payment reform. Oregon had CHWs integrated into ‘roadmap of HC reform”
  • Proceed cautiously as current focus on hot-spotters and highest utilizers originates from a ROI perspective and short-term gains(and not health equity/long-term health outcomes). This approach may sacrifice CHW model integrity/scope of work (VT/FL).

#7 Lessons Learned- Infrastructure for CHWs/ Do-Overs

  • Many states started with comprehensive studies/surveys to understand issues better- not only to characterize who CHWs were, scope of practice and training, but also to engage stakeholders/employers to share their insights for development of process and policy.
  • MA conducted study in 2006 (funded under HC Reform law) to develop recommendations.
  • CT surveyed employers to determine what training they saw as necessary.
  • Develop mutual agreements early in process to guide decision making along the way.
  • Adequate funding to pay for those pieces that support sustainability- curriculum and policy development, CHW participation in activities, evaluation, etc.
  • Focus on funding actual services often clouds need to resource key developmental activities (MA).
  • Common language and guiding principles/values developed at start of process can guide decisions and prevent misunderstandings and splintering along the way (FL/MN/VT/MI).
  • St Johnsbury’s Hospital (VT) initial grant for funding was approved with significant changes. They fought it to assure the integrity of CHW model was not compromised.
  • Front runner states have mandated certification/reimbursement/studies, etc.

#8 Design of Pilots- Requirements and Scope

  • Capacity will be key contributor to success of pilots, should be requirement to document:
  • Readiness measure- is applicant set up with policy and practices/culture/supervision model that will assure success? How will they recruit? How will they assess life experience?
  • Is there alignment of mission/vision/values with CHW model- not just applicant organization but proposed project?
  • Evaluation measure- what is capacity of applicant to conduct evaluation activities? Examples of how they have used evaluation results in the past? Outcomes to share?
  • Evidence of their connections to the community to be served?
  • Design of pilots should contribute to scaling-up/spread of model
  • Opportunity to show diversity of contributions of CHW to HC delivery system- not just about health education (i.e. care management, enrollment, interpretation, etc.). Conversely, need to be thoughtful about the scope given experience of CHW and host organization’s capacity to support CHW.
  • Not just about the outcomes but building strength-capacity to move beyond grant funding