Community Health Workers: Workforce Trends and Developments. Carl H. Rush, MRP Community Resources, LLC San Antonio, Texas

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1 Community Health Workers: Workforce Trends and Developments Carl H. Rush, MRP Community Resources, LLC San Antonio, Texas 1

2 Today s topics Standards and credentialing: what s happening with certification at state and national levels? Boundaries with other professions Getting on the same page: the C3 Project Progress on financing Other new developments in evidence and policy 2

3 Change is accelerating in the states - and nationally 3

4 State Policy Development on CHWs Standards and credentialing? Financing/ payment? Workforce development? 4

5 Deciding on certification policy: process CHWs in leadership roles Stakeholders agree on purpose and objectives: why consider it? Stakeholders agree on meaning/definition of certification (includes sharing preconceptions) If you decide to have certification, commit to create responsive certification policies and procedures that respect the nature of CHW practice 5

6 Key Trends in CHW Certification 10 states have implemented certification: AZ, FL, IN, MA, MI, NM, TX, OH, OR, RI Close to implementing: PA, CT, MD, IL; AK and MN do not have it Some states opting not to pursue certification All states so far are choosing voluntary, not mandatory, certification; no licensing Difficult issues include administrative cost and fairness of application fees background checks verification of past work experience methods to assess community membership as a qualification 6

7 Newer Certification Models Independent certification boards (FL, RI, maybe PA, VA) Certification administered by CHW Association (AZ, MI) Certification awarded by accredited training programs (IN, SC) Licensing of CHW pools (NV) 7

8 Boundaries with other professions 8

9 Boundaries are being tested Patient Navigators American Cancer Society National Navigation Roundtable Peer Support Specialists Community Paramedics Alaska Community Health Aides Indian Health Service initiative Community Dental Health Coordinators (ADA) 9

10 CHWs offer what health care needs today! Establishing close relationships with patients Building trust: overcoming power distinctions and mistrust of institutions Fostering candid and continuous communication (continued) 10

11 Distinctive capabilities of the CHW (cont d) Working with Social Determinants of Health Affect people s health directly Affect their ability to access and utilize care, and follow provider recommendations How? Helping clinical staff understand people s lives Helping address individual situations (coaching, support) Mobilizing communities to address bigger issues 11

12 The CHW Core Consensus (C3) Project 12

13 C3 Project Purpose Develop contemporary consensus descriptions of: CHW Core Roles (Scope of Practice) CHW Core Skills and affirm existing knowledge about CHW Core Qualities (including being from the community ) Promote common language on CHWs for stakeholder education and as starting point for policy development 13

14 C3 Benchmark Documents STATE Roles /Scope of Practice Skills California Massachusetts California Health Workforce Alliance State Board of Certification SoP Definition City College of San Francisco CHW Curriculum State Board of Certification Core Competencies New York New York State CHW Initiative New York State CHW Initiative Oregon Minnesota Indian Health Service CHR Program Scope of Practice Committee, State Traditional Health Worker Commission MN Community Health Worker Alliance National SoP Definition Scope of Practice Committee, State Traditional Health Worker Commission Official State Curriculum NA/Revisit date TBD Texas State Definition of CHWs State Curriculum Standards (Coastal AHEC certified curriculum ) 14

15 C3 Findings: Recommendations on CHW Roles and Skills CHW Roles CHW Skills 1. Cultural Mediation Cross Cultural Communication 1. Communication Skills 2. Culturally Appropriate Health Education 2. Interpersonal & relationship Building Skills 3. Care Coordination, Case Management, System Navigation 3. Service Coordination and Navigation Skills 4. Providing Coaching and Social Support 4. Capacity Building Skills 5. Advocating for Individuals and Communities 5. Advocacy Skills 6. Building Individual and Community Capacity 6. Education and Facilitation Skills 7. Providing Direct Service 7. Individual and Community Assessment Skills 8. Implementing Individual & Community Assessments 8. Outreach Skills 9. Conducting Outreach 9. Professional Skills and Conduct 10. Participating in Evaluation and Research 10.Evaluation and Research Skills 11.Knowledge Base 15

16 More info on C3 Join mailing list: Download 2016 Report: 16

17 Financing/Payment Issues 17

18 Elephant in the Room: How Are FQHCs paid? New UDS data show less than 1,000 CHWs employed in over 9,000 clinical sites Prospective payment system may discourage employment of CHWs: independent patient contact by CHW is not an encounter What is current/potential impact of managed care? value-based payment??? 18

19 Favorable Trends Appearing in Medicaid DSRIP Waivers growing in popularity - (some create ACOs) State Plan Amendments Health Homes some include CHWs (ME, MI, MO, NY) Other (MN, ND) defining CHWs as a class of providers Trend toward value-based payment (not billing for CHWs) Requirements in health plan contracts under managed care 19

20 1115 DSRIP Waivers Map 20

21 Medicaid administrative expenditures States and MCOs already have flexibility to employ/pay for CHWs as Medicaid administrative expenditures many do but Pennsylvania Medicaid allows MCOs to treat spending for CHWs as part of cost of provision of care 21

22 Newer Medicaid CHW models CMS lists Pathways to Health CHW model as a recommended model for care coordination Oregon requires CHWs and similar workers be employed as part of their Coordinated Care Organizations (ACOs) Rhode Island Medicaid will cover asthma home visiting model as a part of required benefits - often CHW-led North Dakota SPA allows payment for CHRs performing Targeted Case Management 22

23 Quality improvement in managed care New regulations on Medicaid Medical Loss Ratio, effective 2017 Allows Medicaid MCOs to count certain expenditures on activities that improve health care quality along with actual medical expense (cost of care) when calculating MLR, rather than include them in admin expenditures Specifically cited by CMS staff as opportunity to encourage payment for CHW services Federal Register 2016, 81FR27522 (42 CFR 438.8) 23

24 Other national developments 24

25 Key national supporters 25

26 CDC Workforce Policy Studies on CHWs Study on State-Level Certification completed January 2018 Focus on interviews and existing documents in 7 states Review of national literature 50-state database of certification related documents Study on Social Return on Investment (SROI) from CHW Workforce Development to be completed by end of

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28 thecommunityguide.org 28

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30 February 2018 Health Care Innovation Awards (HCIA) Meta-Analysis and Evaluators Collaborative Annual Report Year 3 Prepared for Timothy Day Centers for Medicare & Medicaid Services Center for Medicare & Medicaid Innovation 7500 Security Boulevard Baltimore, MD

31 we found that the potential sources of bias weighting vs. matching methods, patient recruitment problems, and covariate imbalance (discrepancies between beneficiaries and comparison group members) had negligible impacts on the HCIA effects reported by FLEs. These results suggest that the difference-in-difference (DID) effects reported by FLEs are unlikely to have been systematically biased, either favorably or unfavorably, by the way comparison groups were constructed or by the way intervention groups were selected. We expanded our investigation of structural, innovation, and implementation features that affected TCOC effects sizes in the ambulatory care innovations. A set of meta-regression analyses found several features (e.g., awardee was a for-profit organization) associated with either cost savings or dissavings (e.g., innovations with a rural focus or for Medicare beneficiaries). 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). To obtain a more comprehensive understanding of the relationships between features of innovation implementation and outcomes, we created and estimated a path model that took selected features from the three meta-regression analyses and linked them to the two utilization measures and TCOC. Although several features were related to patient recruitment problems and turnover challenges, neither of these had a significant impact on the core outcomes. As in our last t f d th t h it l d i i h d h t i t TCOC ff t i th 31

32 Creating a National Association of CHWs National webinar series, 2015: technical assistance to local, state, regional organizations Strategic planning retreats, Atlanta, July 2017 and Chicago, Feb Planning launch in 2018 Will emphasize participation by, and support to, local and state networks: recent survey Possible regional structure, national conference 32

33 discussion (210)

Community Health Workers: Credentialing and New Opportunities

Community Health Workers: Credentialing and New Opportunities Carl H. Rush, MRP Project on CHW Policy & Practice, U. of Texas Institute for Health Policy ORHP Grantee Webinar March 13, 2014 Today s topics