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Community Health Workers in Rural Settings

The American Public Health Association defines a community health worker (CHW) as:

“...a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.”

They are critically important in rural areas where health services are limited, particularly services that offer culturally competent care. Often, CHWs speak the same language, share the same ethnicity and are of the same socio-economic status as the rural clients they serve. While CHWs have traditionally been used to work with minority populations, the use of CHWs has increased greatly in recent years so that they now serve a wide variety of rural and underserved populations.

CHWs, in rural settings, work to improve healthcare outcomes by facilitating healthcare access; adding value to the healthcare team; and enriching the quality of life for people who are poor, underserved and in diverse communities. CHWs act as a liaison between providers and consumers within rural communities. Some of the services CHWs provide include:

  • Culturally appropriate health and prevention education
  • Referrals for a wide range of health and social services
  • Assistance in navigating the health services system and in coordinating care
  • Advocating for the individuals and communities within the health service system
  • Translation and/or interpreting services
  • Basic health screening tests

For additional information about the roles and services of a CHW, see RHIhub's Community Health Workers Toolkit.

This topic guide provides resources that identify different community health worker models, demonstrate effective community health worker programs, and outline the issues and challenges to the development of community health worker programs.

Frequently Asked Questions

Are community health workers officially recognized members of the healthcare workforce?

Community health workers are recognized by the U.S. Department of Labor (DOL) as health professionals and as an essential part of cost-effective healthcare systems. In 2009, the Bureau of Labor Statistics identified the unique standard occupational classification code (SOC), 21-1094, for the community health worker. In 2010, the Affordable Care Act (ACA) recognized CHWs as members of the healthcare workforce to promote healthy behaviors and outcomes, by increasing access to preventive services under Medicaid and implementing regulations allowing non-licensed healthcare workers such as CHWs to provide these services. Also, other Medicaid programs were developed that utilize CHWs in their staffing. For example, “Health Homes” were created to help patients living with chronic illness, and State Innovation Models (SIMs) were developed to improve health outcomes and quality of care. Both of these programs have included CHWs in their work plans.

What are the various duties/roles of community health workers?

The DOL provides a definition of community health workers that identifies a broad spectrum of the basic duties or roles served by community health workers:

“Assist individuals and communities to adopt healthy behaviors. Conduct outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. May collect data to help identify community health needs.”

However, since its classification in 2009 by the DOL, the use of community health workers has grown, and the occupation has been evolving. Other roles may be developed over time in order to provide better care and education to community members, particularly as the provision of healthcare services in rural areas evolves. For additional duties and roles, see the Program Models section of the Rural Health Information Hub's Community Health Worker Toolkit. Also, The Evolution, Expansion, and Effectiveness of Community Health Workers provides a detailed table listing the roles of community health workers in prevention and community well-being.

Where can I find current information and data on the types of healthcare industries that employ CHWs and the wages paid for this occupation?

Occupational Employment and Wages: 21-1094 Community Health Worker, from the Bureau of Labor Statistics, provides current and comprehensive listings of national employment estimates and mean wage estimates for the community health worker occupation. Also, industries with the highest published employment and wages for this occupation are provided in a detailed table.

How can our healthcare organization start and sustain a community health worker program?

RHIhub's Community Health Worker Toolkit can help rural organizations learn about and evaluate opportunities for developing a CHW program and provide resources and best practices developed by successful CHW programs. This toolkit is made up of seven modules, each concentrating on different aspects of CHW programs including program models, training approaches, implementation, sustainability, and evaluation.

Showing the benefit of the program is an important step in sustaining a CHW program. The ROI Toolkit: A Guide for Conducting a Return on Investment Analysis of Your Community Health Worker Health Program (free registration required) helps organizations identify the key elements for conducting a return on investment analysis in order to prove the impact of the program.

Where can I find funding to help develop a community health worker program in our rural healthcare organization?

Often healthcare facilities and local agencies hire CHWs and pay them through grants or with state or federal funds. Although grant funders may not specifically say they support the development of a community health worker program, they may be clear on their mission to improve rural healthcare access and outcomes for underserved populations through innovation and promising practices. The development of a community health worker program may be the perfect solution to foster that mission. See the Rural Health Information Hub's Community Health Workers in Rural Settings funding section for a listing of funding opportunities. Also, the Program & Research Support section of RHIhub's Community Health Worker Toolkit includes a list of foundations, organizations, and federal agencies that have funded community health worker (CHW) programs and research and provides examples of what they have done.

How can CHW programs pay for themselves within an ACO model?

CHW programs can work well within Accountable Care Organizations (ACOs). The ACO model provides financial incentives to organizations who efficiently and effectively manage patient care. CHWs can be used by ACOs to improve health outcomes while reducing the cost of care, particularly for high-utilizer patients. For additional information on opportunities to financially support CHW programs see CHW Toolkit: Summary of Regulatory and Payment Processes and Affordable Care Act Opportunities for Community Health Workers.

Do community health workers need to be certified?

Currently, that depends on your state. Some states require community health workers to have state-level certification, through completion of an approved training program and acquisition of specific skills, while other states do not require certification at this time. If credentialing is required, it is often done by a local health department or a state level agency.

As the community health worker profession grows, more states have been developing a certification process. For additional information on the certification and qualifications of CHWs, see Community Health Worker: Academic Requirements. More information on the certification of CHWs can be found on the State Certification Programs module of the Community Health Worker Toolkit. Current information on state certification of CHWs and enacted CHW legislation is available from the National Academy for State Health Policy (NASHP) State Community Health Worker Models.

What kind of training do CHWs need and can a rural healthcare organization develop their own training program?

There are a number of academic programs throughout the country that train CHWs at various levels of instruction. Generally, the training of CHWs depends on the needs of the healthcare organization. At this time, most CHW training programs are local and employer driven. Organizations customize their curriculum to best fit their needs. Commonly found components within a CHW training curriculum are:

  • Cultural competence
  • Patient intake and assessment
  • Protocol delivery
  • Screening recommendations
  • Risk factors
  • Insurance eligibility and enrollment
  • Communication skills
  • Health promotion
  • Disease prevention and management

There has been growth in the number of available CHW training programs in recent years, with numerous programs currently available across the country. Some offer college credit while others are community-based to meet the needs of the local population.

The Training Approaches Module of RHIhub's Community Health Worker Toolkit contains more information on the development of a CHW training program. For information on the certification, credentialing, and qualifications of CHWs, see The Evolution, Expansion, and Effectiveness of Community Health Workers; and Community Health Worker: Academic Requirements.

Should CHW training programs be formally certified?

Certification of CHW training programs is not consistent throughout the nation. Some states require a specified amount of training from a certified trainer for an individual to work as a community health worker. The trend to standardize and certify community health worker training programs appears to be growing.

There are advantages to developing state-certified CHW training programs by promoting a common, transferable knowledge base that can be used in many settings. Also, by providing training that meets certain standards or certification, CHWs may receive the recognition of other healthcare professionals and of the communities where they serve.

Texas was a leader in early efforts to certify CHW training programs — see publications from the state's work in this area at 2017 Annual Report Promotor(a) or Community Health Worker (CHW) Training and Certification Advisory Committee and Promotor(a) or Community Health Worker (CHW) Training and Certification Program.

For additional information about the certification of CHW training programs see Community Health Workers: Roles and Opportunities in Health Care Delivery System Reform.

Last Reviewed: 2/22/2017