Sustainability Strategies for Community Health Care Worker Programs

Rural communities may explore multiple sustainability strategies for community health worker (CHW) programs. Achieving sustainability may involve implementing sustainable payment models, identifying and combining multiple private and public funding sources, leveraging community resources, working with payers and policymakers, and addressing CHW retention.

For additional information and considerations for sustainability, including information about funding, see:

Sustainable Payment Models

Both public and private payers may support CHW programs through traditional payment models or alternative payment models. In traditional payment models, like fee-for-service, CHWs are billable providers, and organizations receive reimbursement for eligible services provided by CHWs. Alternative payment models, like pay-for-performance, incentivize providers to deliver high-quality care and achieve improved outcomes. Funding from alternative payment models, such as global budgets or shared savings, can be used to invest in CHW services that help achieve target quality and outcome measures.

The National Academy for State Health Policy tracks state policies and laws related to CHW financing.

The following payers may support CHW programs:

Medicaid. Many state Medicaid programs provide reimbursement for CHW services. Some states, such as Minnesota, use fee-for-service payments to reimburse eligible CHW services, including health education and chronic disease management. Others use capitated models in which Medicaid pays a pre-specified amount to entities that employ CHWs. For example, New Mexico's Medicaid program required managed care organizations to establish contracts with CHWs in 2014 and to increase CHW hiring each year after 2016. States may need to apply for State Plan Amendments to authorize payment for CHW services or Section 1115 Demonstration waivers to test payment systems that involve CHWs.
Medicare and Private Insurers. While Medicaid programs more frequently invest in CHW services, Medicare and private insurers also provide some support. For example, as part of the state's healthcare delivery reform initiative, Vermont Blueprint for Health, Vermont employs CHWs through Community Health Teams. Multiple payers fund the Blueprint for Health, including Medicare and private insurers such as Blue Cross and Blue Shield of Vermont.
Indian Health Service (IHS). The IHS funds CHWs through its longstanding Community Health Representative (CHR) Program so that CHWs can provide health promotion and disease prevention services to their tribal communities.

Using State or County Funds

Some states or localities include a line item for CHW programs in their annual budgets. For example, the state of Kentucky provides annual funding for the rural Kentucky Homeplace CHW initiative. Some counties also use tax dollars, such as a percentage of mill levies, to fund CHW services. A mill levy is a property tax applied to the assessed value of a property. The Pathways to a Healthy Bernalillo County in urban New Mexico is a prominent example of this funding model. Rural communities may also explore similar tax-based funding opportunities for CHW services. While state or county funding can be relatively stable from year to year, they are also susceptible to reductions based on shifting administrations and economic outlooks.

Leveraging Community Resources

Many rural CHW programs have established strategic alliances between community organizations and public and private agencies to support sustainability. For example, some programs have established a Board of Directors or Strategic Advisory Council to guide CHW programs, fostering ownership for the program among community stakeholders while also identifying new opportunities for program sustainability. Community-based organizations also play an important role in the collaborative implementation and sustainability of CHW programs. Community-based organizations may:

Hire and train CHWs within their organization
Provide CHW training facilities
Contribute financial resources
Arrange or provide transportation services
Facilitate CHW program sustainability through formal agreements
Support evaluation and other strategies that build a business case for the CHW program

Developing strong partnerships in the business community, including placement of local business leaders on their Board of Directors, has helped some CHW programs to increase awareness of program benefits, identify new funding sources, and secure direct funding for aspects of the program.

Working with Payers and Policymakers

Working with state payers and policymakers is critical to successfully integrating CHWs into care teams. The Importance of Sustainability Planning page emphasizes the need to demonstrate the value of CHWs. Rural communities should consider issues related to the scope of CHW practice, return on investment, training and credentialing, and funding sources when working with payers and policymakers.

Addressing Common Challenges to Retention

Lack of CHW retention can negatively affect operations and relationships between patients and the program, which can present additional challenges to sustainability. Strategies to promote retention and sustainability include providing CHWs with opportunities for professional development, promoting collaboration among members of the care team, and preventing burnout.

In an effort to support sustainability within the CHW workforce, some states, including Iowa, Montana, and Alaska, are exploring apprenticeship models to provide initial training to CHWs. Apprentices receive structured training while earning a living wage and working toward a CHW credential or certificate. Apprenticeship program sponsors may receive state tax credits or funding from agencies that focus on promoting a skilled workforce such as state Departments of Labor, Workforce Development Offices, and Economic Development Authorities. In order to implement a CHW apprenticeship program, states may need to seek approval from the U.S. Department of Labor for their program curriculum.

Resources to Learn More

Community Health Worker (CHW) Financing Webinar
Video
Discusses potential payment mechanisms to support CHW programs, including lessons learned and best practices from community programs.
Organization(s): Centers for Disease Control and Prevention
Date: 2/2019

Community Health Worker Forum: Summary Report
Document
Describes key findings from a meeting of CHWs and supporters that aimed to identify barriers and gaps, promising practices, and lessons learned in developing a statewide infrastructure to maximize the impact of CHWs on diabetic outcomes of their patients, and foster sustainability, reimbursement, and retention of CHWs.
Organization(s): Centers for Disease Control and Prevention, Division of Diabetes Translation
Date: 5/2018