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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 individualized and culturally competent healthcare. CHWs often share similarities with the population they serve, such as ethnicity, socio-economic status, and language. 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, urban, 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 minority communities. CHWs act as a liaison between providers and consumers within rural and urban 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
  • Tracking progress in managing chronic conditions and achieving health goals
  • Translation and/or interpreting services
  • Basic health screening tests

This topic guide provides resources that identify different CHW models, demonstrate effective CHW programs, and outline the issues and challenges to the development of CHW 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 by improving their quality of care and health outcomes.

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

The DOL provides a description 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 changes. For additional duties and roles, see Roles of Community Health Workers and CHW Program Models from the Rural Health Information Hub's Community Health Worker Toolkit. Also, The Community Health Worker Core Consensus (C3) Project: 2016 Recommendations on CHW Roles, Skills, and Qualities provides detailed tables listing the skills of community health workers and their role in achieving health equity and addressing social determinants of health.

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, integrate, and/or 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.

When integrating a CHW program within a healthcare organization several factors should be addressed to ensure an effective team effort. For example, the healthcare staff should understand the role of CHWs on the healthcare team, including the extent of their services. Also, individual case conferences between healthcare team members that include CHWs may facilitate and support integration. See Integrating Community Health Workers into Complex Care Teams: Key Considerations for additional information regarding the recruiting, hiring, training, and retention of CHWs.

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 RHIhub's Funding by Topic: Community health workers section for a listing of funding opportunities. Also, the Grant Funding for Community Health Worker Programs 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.

Some states support the expansion of CHW programs with sustainable funding through Medicaid reimbursement. For information and case studies describing how states fund, train, and certify CHWs see How States Can Fund Community Health Workers through Medicaid to Improve People's Health, Decrease Costs, and Reduce Disparities.

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 Certification Requirements by State. More information on the certification of CHWs can be found on the State Certification Program 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. 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
  • Screening recommendations
  • Risk factors
  • Insurance eligibility and enrollment
  • Communication skills
  • Health promotion
  • Disease prevention and management
  • Service coordination skills
  • Use of technology

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. CHW training programs are also expanding to include specialties such as CDC's training focused on the prevention of heart disease and stroke, as well as training on the management of patients with complex diabetes offered through videoconferencing technology from New Mexico's Project ECHO. There is also interest in training CHWs to support individuals with behavioral health needs. In addition, the National Institute of Health (NIH) supports a CHW Health Disparities Initiative focused on reducing health disparities in underserved and minority populations by providing health education resources and training. The Training for Community Health Workers section of RHIhub's Community Health Worker Toolkit contains additional information on the development of a CHW training program. For information on the certification, credentialing, and qualifications of CHWs, see Community Health Worker National Education Collaborative; The Evolution, Expansion, and Effectiveness of Community Health Workers; and Community Health Worker: Academic Requirements.

The Community Health Worker Assessment Toolkit developed by the Community Health Worker Core Consensus Project (C3) provides information on how to track and foster CHW skills development. According to C3, assessing CHW skills can reduce turnover, improve their capacity to serve clients, and enhance their effectiveness when working in a team environment. The toolkit outlines the steps necessary to develop an assessment, and offers guiding principles and best practices for assessing CHW skills contributed by CHW supervisors, trainers, and employers currently doing assessments.

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 2019 Annual Report Promotora or Community Health Worker Training and Certification Program and Community Health Worker or Promotor(a) 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, and Community Health Worker (CHW) Toolkit: A Guide for Employers.

Last Reviewed: 11/14/2019