Community Health Workers Policy Update: Highlights of opportunities and strategies

1. Montana Healthcare Workforce Advisory Committee April 7, 2014 Community Health WorkersPolicy Update:Highlights of opportunities and strategies Carl H. Rush, MRP Project on CHW Policy & Practice University of Texas – Houston School of Public Health

3. Unity 2014 Registration and Sponsorship • www.populationhealthcenter.org/chwln • www.usm.edu/csho

4. What’s your definition of CHW?

5. Community Health Worker Definition American Public Health Association (1) • The CHW is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. • This trusting relationship enables the 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.

6. Community Health Worker Definition - APHA (2) • The CHW also builds 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. • APHA Policy Statement 2009-1, November 2009

7. What Is Distinctive About CHWs? (1) • Do not provide clinical care • Generally do not hold another professional license • Expertise is based on shared life experience (and often culture)with people served

8. What Is Distinctive About CHWs? (2) • Rely on relationships and trust more than on clinical expertise • Relate to community members as peers rather than purely as clients • Can achieve certain results thatother professionals can’t

10. Link to CDC E-learning Series http://www.cdc.gov/dhdsp/pubs/chw_elearning.htm

11. Structural/System Challenges • CHWs are neither clinical nor administrative • Hierarchy and power based on clinical knowledge • System is used to narrowly defined interventions • System requires reporting of concrete results • System has its own culture… AND may be culturally diverse

12. Important National Trends • Integration of CHWs into patient care teams • Potential special roles in behavioral health • Credentialing – not an easy path • Standardization of skill development

13. The Pitfalls of CHW Integration: Example of the Mass. Case Management / CHW (Patient Navigator) Survey Case Managers • Unclear about PN role • Unclear about PN skills • Uncertain of how to incorporate PN into team CHWs • Unclear about PN role and role boundaries • Skills were not always used to their full potential • Did not feel respected • Part of the team • Culture

14. Integrating CHWs Into Healthcare Organizations and Patient Care Teams (1) • Relevance: healthcare reform, PCMHs, ACOs • How much of a change will this be? Weighing benefits against the cost of change • Assessing readiness to change • Assessing current organization and personnel – what intervention is needed by supervisor

15. Integrating CHWs into Healthcare Organizations and Patient Care Teams • Relevance: healthcare reform, PCMHs, ACOs • More complex than working in “outreach department” • Creates new challenges in scope of practice boundaries • Change is always hard!

19. Integrating CHWs into Teams – Organizational Assessment • How much of a change will this be? Weighing benefits against the cost of change • Assessing readiness to change • Assessing current organization and personnel – what intervention is needed by supervisor? • How well are CHW’s responsibilities defined/understood?

20. Integrating CHWs Into Teams - Planning • How will Patient spend time? relative to each team member (Pt flow); billable clinical hours? Systems issues to be addressed? • Creating clear guidelines for the CHW on when to refer and/or communicate with team members from other disciplines • Creating a safe environment (preventing/dealing with intimidating behavior) • Role of ethnicity, discrimination within teamProducing an action plan: familiarization, communication (how does CHW introduce herself? what to put on a nametag?)

21. Integrating CHWs Into Teams – Working With Other Team Members • Overlap with others’ roles; encouraging open discussion of perceived threats to their roles/job security • Advocacy by Supervisor with Organizational Leadership • Role of the Team Meeting - incrementally assessing the level of readiness and coaching • Using supervisor shadowing experience for coaching other team members • Team building exercises

22. Integrating CHWs Into Teams – Working With CHWs • Familiarization, communication (how does CHW introduce herself? what to put on a nametag?) • What level of clinical info will CHWs handle? What additional skill development is need for this responsibility? • Case presentation skills and focus on the “Essential Facts” - capturing the attention of the provider

23. Current national CHW initiatives (1) • HHS interagency working group on CHWs • OWH CHW leadership training • Amending DOL occupational definition • DOL “apprenticeable trade” • OMH Promotora/CHW initiative

24. Current national CHW initiatives (2) • NAO-APHA-UT curriculum guidelines project • HUD CHW Initiatives • CMS Center for Innovation • Grantee learning collaborative on CHWs • Rockefeller Foundation/Urban Institute study

25. Medicaid Breakthru: Preventive Services • 78 FR 135 p. 42306: 7/15/13–(effective Jan. 2014)§ 440.130 Diagnostic, screening, preventive, and rehabilitative service • “Preventive services means services recommended by a physician or other licensed practitioner…” (previously read “provided by”) • Brings rules into conformance with ACA • Commentary clearly reflects interest in funding services by CHWs and other “non-licensed” providers • Payment for CHW services will no longer need to be treated as admin costs

26. Requirements to Take Advantage of Medicaid Rule Change • Requires State Plan Amendment (in a few states this requires legislative authorization) • Must specify what non-licensed occupations are covered and qualifications (skill requirements) – not necessarily certification • Must specify what services will be paid for (CPT codes) and which Medicaid recipients are eligible • Must specify rates of payment and payment mechanism (FFS, MCO, bundled payment etc.)

27. Surge in state-level interest in CHWs In addition to established initiatives in AK, FL, IN, MA, MN, NJ, NY, OH, TX: • New movements in AZ, CO, IL, MD, MS, NE, NM, OR, RI, SC, VA, WI • 2014 legislation introduced in FL, IL, MD, NM, UT • Recent State investigations in AR, CA, DE, GA, IA, LA, MO, ND, PA, UT, WA, WV

29. Common Elements In State Initiatives • Gathering CHW workforce data • Convening leadership and “champions” • General education/awareness • CHW professional association/network • Agreement on standards and credentialing • Strategies for sustainable CHW roles

30. Recent state/local innovations with CHWs • Seattle-King County CHW study • Medicaid 1115 waiver in Texas • Oregon “CCO” legislation • South Carolina Medicaid pilot • Akron OH “Accountable Care Community” • Nevada pooled funds pilot

31. Discussion

33. Contact Info Carl H. Rush, MRP Project on CHW Policy and Practice U. of Texas Institute for Health Policy PO Box 5533 San Antonio, TX 78201-0533 (210) 775-2709 (210) 241-3983 mobile carl.h.rush@uth.tmc.edu