History of Community Health Workers in America2019-02-12T19:32:39+00:00

History of
Community Health Workers
In America

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Community Health Workers out in the community.

Community Health Workers, also known as Promotoras, are frontline public health workers who are also members of the community they serve, improving the quality and cultural competence of service delivery.

The history of Community Health Workers in America is long and varied, as Community Health Workers have been a rallying voice within the American Public Health Association since the 1970s.2 In recent years,  Community Health Workers have been gaining national recognition for their ability to address the unique health and social issues within their communities.

Community Health Workers (CHWs) offer services and insight that can span the scope of any health care model. In a national study on the Community Health Worker workforce4, Health Resources and Services Administration defined the key areas of CHW activities as;

  • Creating more effective linkages between communities and the health care system
  • Providing health education and information, adding that “they are effective in delivering basic health messages in a culturally appropriate way.”
  • Assisting and advocating for underserved individuals to receive appropriate services
  • Providing informal counseling
  • Directly addressing basic needs
  • Building community capacity in addressing health issues

In a healthcare system with rising costs, another compelling quality of Community Health Worker programs is their cost effectiveness. In 2018, MHP Salud’s Community Health Worker led cancer prevention program, demonstrated a return on investment (ROI) of $3.16 for every $1 spent and a program for Medicaid-eligible adults, instated by the Molina Health Care System of New Mexico, reported a $4 return for every $1 invested.3  While plenty of such examples exist, MHP Salud regularly evaluates its programs to demonstrate the social and financial benefit of the Community Health Worker profession.

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CHWs represent MHP Salud at health fair

Community Health Worker, A Timeline  

 Below is a brief look at the landscape of Community Health Workers over the years;

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1950s –1960s –  Using community health workers to address basic health concerns has at least a 50-year history. 16  The most well-known of these earlier programs points to the Chinese barefoot doctor program18. These barefoot doctors acted as primary health-care providers in their rural communities but were perceived as peers because of their continued involvement in farming.

By the 1960s China had developed and institutionalized community health workers nationwide, prompting a boom of CHW-led programs in other countries, including the U.S.

By the 1970s, Community Health Workers became a rallying voice within the American Public Health Association (APHA).  A Community Health Worker-led section was initially created within APHA called the New Professionals Special Primary Interest Group (SPIG).   In 2000, the group changed its name to the Community Health Worker Section and continues to “to promote the community’s voice within the health care system.” 5

The Community Health Worker Section adopted the following definition for a Community Health Worker:

A Community Health Worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the Community Health Worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

A Community Health Worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy.

1980s – MHP Salud

With a small grant from the United States Department of Health and Human Services, National Migrant Worker Council, Inc., an association of Catholic sisters, religious leaders and volunteers conducted a community assessment with farmworkers in the Midwest and designed the original Migrant Health Services Directory and the Camp Health Aide Program.

The council, which would come to be known as MHP Salud, officially launched its first Camp Health Aide Program in the mid-80s using a community-centered health worker model. With the success of this program, MHP Salud would go on to develop various successful Community Health Worker-led interventions throughout the mid-west, Texas and Florida.

 June 1998– National Community Health Advisor Study

Completed in 1998, the National Community Health Advisor Study helped identify core roles, competencies, and qualities of Community Health Workers. With little existing literature on the role of CHWs on the health care system, this study helped provide guidance to policymakers and practitioners on a number of areas that could improve the status of the CHW field.6

March 2007– HRSA National Workforce Study

In 2007, the Health Resources and Services Administration provided a comprehensive, national report on the Community Health Worker workforce. Health care costs were high, and Community Health Workers were beginning to be seen as a cost-effective way to address health concerns in underserved communities. This study was vital in providing much needed missing information to private insurers, business enterprises and the Federal government to propose changes in health care delivery and financing3, with the inclusion of CHWs.

2010– Bureau of Labor Statistics

The Bureau of Labor Statistics assigned an occupational code to 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. Excludes “Health Educators” (21-1091).

As the interest in Community Health Worker programs grew, the demand to have more adequate information grew. Assignment of an occupational code made the exchange of accurate information more timely.

March 23, 2010– Patient Protection and Affordable Care Act

As health care in the U.S. enters an era of pivotal change, Community Health Workers have been identified as an important component in the “health care workforce”.  Community Health Workers are cited in three sections of the Patient Protection and Affordable Care Act (PPACA):

With more funding available, health centers across the nation were able to seek federal funding for CHWs and CHW-led programs. This act also officially acknowledged Community Health Workers as legitimate health industry professionals which opened a variety of new employment pathways.

July 15, 2013– Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) created a new rule which allows state Medicaid agencies to reimburse for preventive services provided by professionals that may fall outside of a state’s clinical licensure system, as long as the services have been initially recommended by a physician or other licensed practitioner. The new rule for the first time offers state Medicaid agencies the option to reimburse for more community-based preventive services, including those of Community Health Workers. The rule took effect on January 1, 2014. The rule diversified streams of funding for CHW activities and programs, providing new opportunities to advance the role of CHWs!

The new rule now states,

“(c) Preventive services means services recommended by a physician or other licensed practitioner of the healing arts acting within the scope of authorized practice under State law to—

Prevent disease, disability, and other health conditions or their progression; Prolong life; and Promote physical and mental health and efficiency.”

2013 — A number of states have taken to diverse, individual initiatives to advance the Community Health Worker infrastructure, professional identity, workforce development, and financing:

  • 15 states and the District of Columbia have enacted laws addressing Community Health Worker infrastructure, professional identity, workforce development, or financing
  • 6 states have created Community Health Worker advisory boards
  • 8 states have established a Community Health Worker scope of practice
  • 5 states have enacted workforce development laws that create a certification process or require Community Health Workers to be certified
  • 6 states have authorized the creation of standardized curricula
  • 4 states have authorized a certification board for setting education requirements and governance for the certification process
  • 7 states have authorized Medicaid reimbursement for some Community Health Worker services
  • 7 states have encouraged or required the integration of Community Health Workers into a team-based care model

The development of these initiatives opened up new opportunities to understand how CHWs could navigate the U.S. health care system successfully. The Centers for Disease Control, with the help of state reports and CHW interviews, developed the Technical Assistance Guide for States Implementing Community Health Worker Strategies which outlined ways states could support their programs.

2014 — CDC publishes the Policy Evidence Assessment Report, on the policy components of Community Health Workers

The CDC identified 14 Community Health Worker policy components and examined them using the Quality and Impact of Component (QuiC) Evidence Assessment method. The study found a strong evidence base has emerged in support of many policy components that could comprise a CHW policy. 8 of the policy components fell into the Best category, 3 into Promising and 3 in Emerging. The study further strengthened the consideration of CHW interventions in policy options to improve chronic disease outcomes.1

2014 —  Bureau of Labor Statistics reports that there are about 115,700 employed health educators and CHWs.

With the resources to collect data from CHW-led programs across the U.S., the Bureau of Labor Statistics can now determine accurate job growth rate for the profession. From 2014 to 2016, CHW jobs are predicted to grow by 18% further suggesting that CHWs are an efficient, cost-effective way to address health needs in underserved communities.

2016- 16 states report having CHW standard operating procedures or certification laws in place.

With the growth in the CHW profession came changes to requirements to become one. Although this may have potential policy impacts, some have expressed concerns as these requirements may “devalue the skills and attributes that make CHWs unique”.

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The Future of Community Health Workers

National support and policy changes have renewed interest in integrating the CHW model across different health care systems. The Health Resources and Services Administration defined the many known service outcomes of the model as;

  • Improved access to health care services
  • Increased health and screening
  • Better understanding between community members and the health and social service system
  • Enhanced communication between community members and health providers
  • Increased use of health care services
  • Improved adherence to health recommendations
  • Reduced need for emergency and specialty services4

The Department of Labor Statistics expects the CHW profession to grow 16% by 2026,17 faster than the national average! This provides further evidence of the effectiveness of Community Health Workers across the nation!

MHP Salud and the Community Health Worker Model

MHP Salud has over 30 years of experience in designing and implementing Community Health Worker programs across the county. We offer free resources, as well as training and consulting services to support organizations that want to invest in the Community Health Worker model. For more information about how we can help you, please email us at info@mhpsalud.org

How MHP Salud Can Help You

Resources

  1. Patient Protection and Affordable Care Act, 42 USCA §294q (2010).
  2. Patient Protection and Affordable Care Act, 42 USCA §280g-11 (2010).
  3. Medicaid and children’s health insurance programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, premiums and cost sharing, exchanges: eligibility and enrollment; final rule.
  4. Centers for Medicare & Medicaid Services. 78 Fed Reg 42160 (July 15, 2013). The relevant section is, “a. Diagnostic, Screening, Preventive, and Rehabilitative Services (Preventive Services) (§ 440.130)” (paragraph citation: 78 FR 42226)
  5. NHLBI CHW Health Disparities Initiative Email August 28, 2013
  6. Centers for Disease Control and Prevention, “A Summary of State Community Health Worker Laws”
  7. https://www.bls.gov/oes/2017/may/oes211094.htm
  8. https://www.bls.gov/ooh/community-and-social-service/health-educators.htm
  9. https://www.who.int/hrh/documents/community_health_workers.pdf
  10. https://www.cdc.gov/dhdsp/pubs/docs/CHW_Policy_Brief_508.pdf