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Sustainability Strategies

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 financing.

  • 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. Some states 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. Families USA provides a chart that describes different pathways for 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 through Community Health Teams, part of the state's healthcare delivery reform initiative (Vermont Blueprint for Health). 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' longstanding Community Health Representative (CHR) Program funds CHWs to provide health promotion and disease prevention services to their tribal communities.

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
Document
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
Date: 2010

Community Health Worker Resources from Families USA
Website
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
Date: 2020

Community Health Workers: Financing and Administration
Document
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
Date: 8/2011

Funding Community Health Workers: Best Practices and the Way Forward
Document
Identifies initiatives and progress made by various states around the U.S. related to funding mechanisms for CHW positions.
Author(s): Alvisurez, J., Clopper, B., Felix, C. , et al.
Organization(s): Yale School of Public Health, Southwestern Area Health Education Center (SWAHEC), Inc.
Date: 2013

Sustainable Financing Models for Community Health Worker Services in Connecticut: Translating Science into Practice
Document
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 and Economics
Date: 6/2017

Community Health Worker Forum: Summary Report
Document
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
Date: 5/2018

Advancing the Profession and Sustainability of Community Health Workers
Website
Describes key challenges and potential solutions to sustainability and replication of CHW programs.
Organization(s): Center for Health and Research Transformation, University of Michigan
Date: 3/2018

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