SUMMARY OF CURRENT TRAINING OF COMMUNITY HEALTH WORKERS

Community health workers in Virginia and nationally receive training through various methods. Nationally, the most common type of training is "on-the-job." There are three major trends in implementing CHW training and certification. These trends are:

1. on-the-job training or a practicum to improve program capacity and enhance standards
2. community college - based training providing academic credit through formal education
3. state level certification that legitimizes the work of CHWs and enhances reimbursement opportunities for CHW provided services (*1)

TOWARD DEVELOPMENT OF A STATEWIDE CORE CURRICULUM FOR CHWS

Standard training in combination with self-defined core tasks and activities are cited as important steps toward professionalization (*2). Many CHWs are concerned at their lack of recognition among policy makers and health care professionals. CHWs, CHW supervisors, and CHW program directors recognize that the potential for CHWs to improve the effectiveness and sustain programs includes the adoption of skin standards for CHWs (*3). The adoption of skill standards is viewed as necessary to achieve a label of "provider" of a defined set of services (*4). Attaining the label of "provider" is necessary to recognition, integration of CHWs into health professional teams, and third-party reimbursement for CHWs.

The increasing recognition of the important role CHWs can play in the delivery of health and human services has led to increased demand for CHWs. In order for CHWs to gain wider acceptance throughout the health services sector, the often-times significant gaps in CHW preparation have to be addressed. (*5) Workshops, lectures, and non-credit continuing education opportunities exist beyond basic education and training. However, core, standardized programs provide CHWs with greater opportunities to develop the contextual framework in which they perform their work compared to “piecemeal" workshops and similar opportunities (*6).

Virginia CHWs were asked to rank core competencies identified by the National Community Health Worker Study according to their perceived importance. The core competencies by order of CHW ranking included verbal communication, client advocacy skills, service coordination skills, outreach skills, teaching skills, understanding poverty, informal counseling skills, organization skills, written communication, how to work as a team, conflict resolution skills, documentation skills, self-care skills, and leadership skills. Many respondents commented about the difficulty of ranking the knowledge, skills, and abilities (KSAs) as they considered all of them important.

Sample of Core Knowledge, Skills, and Abilities Education Offered by Virginia CHW Programs

Utilizing the knowledge, skills, and abilities listed by Virginia CHWs, CHW programs were asked to identify how much training time was devoted by the program to providing each knowledge, skill, and ability. It was difficult to assess the amount of core training being provided by Virginia CHW programs. While offering education and training to CHWs, CHW programs provide a combination of core knowledge, skills, and abilities within current training. “Teasing-out" core competencies from these trainings was difficult for program respondents.

Formalizing Core Knowledge, Skills, and Abilities for CHWs

The core skills required of CHWs have evolved around programs that early on recognized the importance of core skills for CHWs. The identification of core CHW skills gained momentum through research produced through the 1998 National Community Health Advisor Study (NCHAS). The study articulated core roles of the CHW and skills necessary to complete these roles. The NCHAS was an important vehicle in communicating research about CHWs to a national audience. The NCHAS recommended that CHW program staff use the core skills identified in the study when recruiting and hiring CHWs.

The seven CHW core roles as described by the NCHAS included:

1. Bridge cultural mediation between communities and health and social service system
2. Provide culturally appropriate health education
3. Assure people get the services they need
4. Provide informal counseling and social support
5. Advocate for individual and community needs
6. Provide direct service
7. Build individual and community capacity

The NCHAS suggests that the core roles of CHWs (listed above) be used along with community strengths and needs assessment when developing CHW programs. The study also recommends that these core roles be used to explain CHW work to those outside of the field. This recommendation is critical to integrating CHWs into healthcare teams so that these teams are able to access vulnerable populations.

EDUCATION AND TRAINING OF CHWs: BEYOND A CORE CURRICULUM

CHW training and education can be categorized in many ways. For this study, formal education and training beyond a core curriculum is being characterized as non-academic continuing education for programs that offer academic credit. Programs that offer academic credit may also include a CHW's core curriculum and offer additional education and training that build upon the CHW's core education.

Non-Academic Credit Continuing Education

As described earlier, the majority of CHW training occurs on-the-job. Continuing education is decentralized, and is most often provided by CHW programs. A 2002 program survey completed by the Virginia Center for Health Outreach found that 70 CHW program sites reported a median of four hours of monthly inservice or continuing education hours.

The amount of continuing education received by CHWs is often dependent upon program resources. As program resources diminish, continuing education budgets (travel, fees, lodging) are reduced or eliminated.

Academic Credit Training Programs

Historically, many CHW programs have worked with community colleges to establish academic credit for CHW training (*7). According to the NCHAS, partnerships between CHW programs and community colleges have gone through periods of demand when there were large numbers of CHWs seeking credit. These programs dissolved as either demand or resources, whether personal or program, became increasingly limited (*8).

The sustainability of current programs, expansion of existing programs, and development of new academic credit programs for CHWs will depend upon a number of factors. Many of these factors are interdependent. These factors include:

• Recognition of CHWs as important members of the health and human services workforce by policy makers and other health and human service professionals
• Integration of CHWs into interdisciplinary health professional teams
• Available CHW career advancement opportunities where there is dependency upon academic credit programs
• Adoption of formal core knowledge, skills and abilities across CHW programs
• Partnerships between CHW programs and community colleges and other institutions of higher learning
• Reimbursement for CHW-provided services

MAXIMIZING THE ROLE OF COMMUNITY HEALTH WORKERS

Eliminating health disparities among racial, cultural, and economically disadvantaged populations has remained a priority of the U.S. Department of Health and Human Services since it was first expressed in the document Healthy People 2000 and reaffirmed in Healthy People 2010 (*9). CHWs are considered to be important members of the healthcare workforce in reducing barriers to health and human services among vulnerable populations.

The integration of CHWs as members of health care teams within the context of roles where research has shown CHWs to be particularly effective is a promising strategy for improving health outcomes and efficiencies within health and human service delivery systems.

FINANCING OF CHWs

CHWs are considered to be important members of the healthcare workforce in reducing barriers to health and human services among vulnerable populations. The integration of CHWs as members of health care teams within the context of roles where research has shown CHWs to be particularly effective is a promising strategy for improving health outcomes and efficiencies within health and human service delivery systems.

Most funding for CHW programs is derived from state, federal, and local sources. Some programs receive private funding from foundations and private community agencies such as United Ways. Funding is often time-limited and may be targeted to specific issues or population groups (*10).

A stable source of funding offers CHW programs the, opportunity to maximize the promise of CHWs and establish strategies of integrating CHWs into health and human service teams. One element of along-term solution to the unpredictability of CHW program funding is for states to recognize the unique and important role CHWs play in accessing hard to reach population groups. This includes fully utilizing outreach and education dollars that are available through Medicaid and State Children's Health Insurance Plans (SCHIP).

Medicaid offers CHWs several options for funding in addition to SCHIP initiatives. Through the Medicaid waiver system, CHWs may be able to utilize Medicaid funding avenues (*11). Application for Medicaid waivers is accomplished through collaborative work between CHW program and CHW advocates and state Medicaid offices (*12). Another Medicaid funding option is the Administrative Claiming program. Administrative Claiming takes advantage of a provision in Federal law permitting states to claim federal financial participation for administrative expenses state’s incur in operating their Medicaid programs.

RECOMMENDATIONS

RECOMMENDATION 1: Virginia’s Community Health Worker programs, in collaboration with the Virginia Center for Health Outreach at James Madison University should adopt core knowledge, skills, and abilities (KSAs) and the elements within each that are essential to development of a curriculum that supports the understanding and practice of each KSA.

RECOMMENDATION 2: Upon the adoption of core knowledge, skills, and abilities, Virginia’s Community Health Worker programs should recognize an individual CHW’s achievement of each KSA, regardless of the CHW program providing the KSA.

RECOMMENDATION 3: In collaboration with and the cooperation of Virginia’s Community Health Worker programs, the Virginia Center for Health Outreach should develop the necessary data collection system to register the attainment of core knowledge, skills and abilities of individual Virginia CHWs.

RECOMMENDATION 4: The Virginia Center for Health Outreach, in collaboration with Virginia’s Community College System and other institutions of higher learning, should explore and develop ways to provide CHWs with educational opportunities that offer academic credit and identify career pathways.

RECOMMENDATION 5: Health professions training programs should identify opportunities within existing curricula to educate students and practicing professionals regarding the role of CHWs in an efficient and effective health and human service delivery system.

RECOMMENDATION 6: The Commonwealth of Virginia, in collaboration with public and private agencies, should seek opportunities to support demonstration projects that integrate community health workers within existing health and human service delivery systems that care for vulnerable populations.

RECOMMENDATION 7: In collaboration with the Virginia Department of Medical Assistance Services, the Virginia Center for Health Outreach and CHW programs should examine opportunities for additional Medicaid reimbursement that utilize CHWs.
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(*1) Southwest Rural Health Research Center, Community Health Worker (CHW) Certification and Training: A National Survey of Regional and State-Based Programs at 34 (2005) [hereinafter Southwest Rural Health Research Center].
(*2) University of Arizona, The Final Report of the Nation Community Health Advisor Study at 92 (1998) [hereinafter Final Report of the National Community Health Advisor Study].
(*3) see Southwest Rural Health Research Center at 34.
(*4) Id.
(*5) Mary Beth Love, PhD, et al., CHWs Get Credit: A 10-Year History of the First College-Credit Certificate for Community Health Workers in the United States, 5 (4) Health Promotion Practice 420 (October 2004).
(*6) Id.
(*7) Id.
(*8) Id.
(*9) Mary Ann Nemchek DNS, RN and Rosemary Sabatier, BSN, FN, FNP, State of Evaluation: Community Health Workers, 20 (4) Public Health Nursing 260 (August 2003).
(*10) Marguertie J. Ro, DrPH, Henrie M. Treadwell, PhD, Mary Northridge, MS, PhD, National Center for Primary Care, Morehouse School of Medicine, Community Health Workers and Community Voices: Promoting Good Health, at 40 (2003).
(*11) Id. at 41.
(*12) Id.

[Interim Report - See House Document No. 8, 2005 (HD8)]