Rural communities may explore multiple sustainability strategies to support community health worker (CHW)
programs. Achieving sustainability often requires combining multiple private and public funding sources. To
review additional considerations for sustainability, see Sustainability Strategies and Sustainability Strategies for Specific Issues
in the Rural Community Health Toolkit.
Additional information about funding can be found in the Community
Health Workers in Rural Settings topic guide. For information about time-limited grants, see Grant
Funding for Community Health Worker Programs.
Implementing Sustainable Payment Models
Public and private payers may support CHW programs using traditional payment models (such as fee-for-service) or
alternative payment models. In traditional payment models, CHWs are billable providers and organizations receive
reimbursement from payers for eligible services provided by CHWs. Alternative
payment models offer providers incentives for high-quality care and improved outcomes. Providers may use
funding from alternative payment models, such as global budgets or shared savings, to invest in CHW services
that may help achieve target quality and outcome measures. The National Academy for State Health Policy tracks state policies and laws related to CHW
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
management. Some states use capitated models in which Medicaid pays a pre-specified amount to entities that
employ CHWs. For example, New Mexico's Medicaid
managed care organizations to establish contracts with CHWs in 2014 and to increase CHW hiring each
after 2016. States may need to apply for State Plan
to authorize payment for CHW services or Section
1115 Demonstration waivers to test payment systems that involve CHWs. Families USA provides a chart
describes different pathways
funding CHWs in Medicaid.
Medicare and Private Insurers – While Medicaid programs more frequently invest in CHW
services, Medicare and private insurers also provide some support. For example, Vermont employs CHWs
Health Teams, part of the state's healthcare delivery reform initiative (Vermont Blueprint for
Multiple payers fund the Blueprint for Health, including Medicare and private insurers such as Blue Cross
Blue Shield of Vermont.
Indian Health Service (IHS) – The IHS' longstanding Community Health Representative (CHR)
Program funds CHWs to provide health promotion and disease prevention services to their tribal
Using State or County Funds
Some states or counties include a line item for CHW programs in their annual budgets. For example, the state of
Kentucky provides funding for the rural Kentucky Homeplace CHW initiative
each year. 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 financial arrangement,
but rural communities may also explore opportunities to fund CHW services through tax dollars. While state or
county funding may be relatively stable from year to year, funds may also be vulnerable to reductions based on
shifting administrations and economic outlooks.
Exploring Opportunities for Apprenticeships
Some states, including Iowa
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 state Departments of Labor,
Workforce Development Offices, Economic Development Authorities, or other agencies that focus on promoting a
skilled workforce. States may need to seek approval from the U.S. Department of Labor for their CHW
apprenticeship program curriculum.
Leveraging Community Resources
Many rural CHW programs have created strategic alliances between community organizations and public
and private agencies to support sustainability efforts. Some have formed a Board of Directors or Strategic
Advisory Council to guide programs. Creating a sense of ownership for the CHW program among community
stakeholders has helped to build trust and to identify new opportunities to sustain activities. Community
stakeholders may also help build a strong business case for the CHW program.
Community-based organizations may also support collaborative implementation and sustainability of CHW programs.
They often hire and train CHWs. They may also offer key resources and fulfill functions to bolster the success
of a CHW program such as:
- Providing CHW training facilities
- Contributing financial resources
- Arranging or providing transportation services
- Facilitating CHW program sustainability through formal agreements
Some rural CHW programs have developed strong partnerships in the business community, including placement of
local business leaders on their Board of Directors. Buy-in from and collaboration with the business community
has helped some CHW programs to:
- Increase awareness of program benefits
- Identify new funding sources
- Secure direct funding from local businesses for parts of the program
Working with Payers and Policymakers
Working with state payers and policymakers can be critical to ensuring full integration of CHWs into care teams.
The Importance of Sustainability
Planning page describes the need of demonstrating the value of CHWs.
There are several considerations around the
scope of CHW practice, return on investment, training and credentialing, and funding sources. Rural communities
may need to consider these issues when working with payers and policy makers.
The Centers for Disease Control and Prevention (CDC) provides Policy Evidence Assessment Reports that describe
the documented benefits of CHW interventions and may help rural communities make the business case for investing
in CHW programs. CDC also offers a free 6-session course on Promoting Policy and Systems Change to Expand
Employment of CHWs. Local, regional, or state CHW associations may provide helpful suggestions or
resources for advocating for change.
Addressing Common Challenges to Retention
Lack of retention can negatively affect operations and
relationships between patients and the CHW 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.
Resources to Learn More
Handbook for Enhancing CHW Programs:
Management and Maintenance
Presents the fifth component of the handbook focused on management and maintenance of CHW programs. Highlights
the contributions of CHWs along with team-building, two-way communication, recordkeeping, quality assurance,
skills development, and recognition and incentives that should be addressed by managers.
Organization(s): Centers for Disease Control and Prevention
Community Health Worker
Resources from Families USA
Lists briefs, reports and webinars related to CHW program sustainability. Includes a discussion on Impact
Estimator Tools that are useful for determining the positive financial and quality impact of CHWs. Information
is provided about new delivery and payment models, and the use of CHWs to decrease costs, promote health equity,
and reduce disparities.
Organization(s): Families USA
Community Health Workers: Financing
Summarizes the variety of funding opportunities available for CHW programs, and how these funding sources can be
used by a variety of healthcare programs and organizations.
Organization(s): National Health Care Council for the Homeless
Community Health Workers: Best Practices and the Way Forward
Identifies initiatives and progress made by various states around the U.S. related to funding mechanisms for CHW
Author(s): Alvisurez, J., Clopper, B., Felix, C. , et al.
Organization(s): Yale School of Public Health, Southwestern Area Health Education Center (SWAHEC), Inc.
Models for Community Health Worker Services in Connecticut: Translating Science into Practice
Demonstrates how research on CHW interventions can be applied to produce cost-effective programs that will
improve health outcomes and achieve a positive financial return on investment. Four proposed sustainable CHW
models were developed by researchers and aligned with Connecticut's State Innovation Model (SIM) to provide
individuals with complex healthcare needs including diabetes, hypertension, and asthma.
Author(s): Katharine London, Kelly Love, Roosa Tikkanen
Organizations: Connecticut Health Foundation, University of Massachusetts Medical School Center for Health Law
Worker Forum: Summary Report
Describes key findings from a forum 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
the Profession and Sustainability of Community Health Workers
Describes key challenges and potential solutions to sustainability and replication of CHW programs.
Organization(s): Center for Health and Research Transformation, University of Michigan
Community Health Worker (CHW) Financing Webinar
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