Increasing Community Health Workers’ Role in Supporting Medicaid Members

Community health workers (CHWs) are frontline public health workers who come from and/or have deep roots in the communities they serve. Many states are leveraging CHWs to build trusting relationships with patients, including Medicaid members, to serve as a link between health and social services, to provide assistance navigating the health care system, and to improve the quality and cultural responsiveness of service delivery. The use of CHWs increased during the COVID-19 pandemic, during which states relied on CHWs to help supplement workforce shortages and build a more equitable care delivery system. In September 2022, the Biden-Harris administration announced $225 million in funds to train over 13,000 CHWs to support COVID-19 vaccination efforts and ensure trusted messengers on health care were deployed to communities in need. This trend has continued nationwide in Medicaid programs, with at least 29 states, including Washington, DC, reimbursing CHWs for services provided to Medicaid members.

This article offers examples of how states have leveraged CHWs to support Medicaid members as well as design considerations for states looking to implement CHW programs in Medicaid.

State Examples of CHWs in Medicaid

CHWs have been working with and in their communities for decades to assist with the provision of health care. Many state Medicaid programs have successfully integrated CHWs to improve the health of individuals, children, and families enrolled in Medicaid and help address unmet health and social needs. The following examples illustrate the different approaches that states have pursued to utilize CHWs to serve Medicaid members:

Design Considerations for Leveraging CHWs

The examples above demonstrate the various ways states can use CHWs to serve their Medicaid members. Since every state is different, state Medicaid programs must assess various factors when considering how to design a program that leverages CHWs to support Medicaid members. The below design components provide states with a potential framework for incorporating CHWs into their Medicaid programs.

• State’s Goals: At the outset of its policy design work, a state should determine its goals for using CHWs in its Medicaid program. Key considerations for the state’s goals may include:
  • The gaps and needs that Medicaid members face in the state;
  • The available CHW workforce; and
  • How the unique skills and experiences that CHWs bring can be leveraged in existing Medicaid initiatives, such as care management programs and outreach/engagement efforts to connect members to needed services and supports.
• Landscape Assessment and Community Engagement: As part of setting goals for leveraging CHWs, states should perform a landscape assessment of how CHWs are currently working in the state. This assessment can involve interviews with key stakeholders such as a state’s CHW association, public health departments, clinics and other medical providers, CBOs, and CHWs working in the state. At the outset and throughout the policy design process, states should consider a stakeholder engagement process that includes:
  • Seeking feedback directly from CHWs on any preferences for how to be integrated into the Medicaid delivery system (e.g., direct employment by health plans or providers, billing Medicaid and having their services codified through a fee schedule);
  • Gathering input and testing the feasibility of the state’s proposals; and
  • Proactively identifying challenges that arise as the state begins implementing its CHW program and addressing these concerns.
• Medicaid Authority: States typically choose between using their Medicaid managed care contracts and/or Preventive Services SPAs to authorize CHWs’ services in their Medicaid programs. States can leverage Medicaid managed care contracts to require health plans to deploy CHWs, set reimbursement policies, and establish other program design elements, such as encouraging the broad use of CHWs by establishing targets and financial penalties (e.g., New Mexico) or a required CHW-to-enrollee ratio (e.g., Michigan). Preventive Services SPAs can be pursued with or without Medicaid managed care contract authorization. The Preventive Services SPAs use a reimbursement model that is typically tied to an established Medicaid fee schedule. Under these SPAs, CHWs provide services under the supervision of a licensed provider, as defined in the SPA (e.g., California, Oregon).
  
  While identifying the preferred Medicaid authority, states should also consider the following questions:
  • How will the state provide a sustainable, ongoing funding source for CHW initiatives to promote the stability of the state’s CHW strategy? Funding considerations can help determine staffing arrangements for CHWs, whether these are based on percentage of Medicaid members served, a staffing ratio, or a caseload ratio for each CHW. The funding allocated to the CHW program can also influence the scope and numbers of CHWs deployed to serve Medicaid members.
  • Do CHWs need to become Medicaid providers in order to participate in the state’s CHW initiative, or can they be employed directly by health plans, providers, or other entities within the Medicaid delivery system?
  • What types of supervision will the state require of CHWs who are delivering services to Medicaid members (e.g., licensed clinician)?
• Populations and Communities of Focus: States can specify target populations and communities of focus for CHWs to serve in their respective Medicaid strategies. Key considerations when identifying these populations and communities of focus may include:
  • Communities that have historically been marginalized from the health care system or have struggled to access their Medicaid benefits in order to engender trust with Medicaid members;
  • Populations identified in the state’s broader health equity strategy and related initiatives to improve health disparities; and
  • Medicaid members identified as being at risk for or experiencing poor outcomes as outlined in the state’s Medicaid Quality Strategy.
• CHW Services: States should consider the specific activities that CHWs are qualified to perform and most effective at doing, which may vary based on the diverse needs of the populations they serve and the local context in which CHWs operate. In general, CHWs have proven to be effective at:
  • Promoting wellness and prevention;
  • Driving attention to upstream populations and services outside of care coordination;
  • Serving as a trusted partner and engaging and educating members who may struggle to navigate the complex health care system;
  • Enhancing communication between members and health care providers;
  • Advocating for members and supporting them in receiving culturally and linguistically appropriate care;
  • Leveraging lived experience and understanding of the community to build trust and successfully engage members in screenings; and
  • Employing knowledge of community-based services and application processes to expedite member applications, support access to health-related social need services, and promote timely movement off relevant waitlists.
• Training and Certification: Training guidelines and requirements for CHWs working in Medicaid should ensure that CHWs have the core competencies needed to perform their jobs effectively, such as those explored through the CHW Core Consensus Project. When developing their training and certification requirements, states may consider how to leverage existing training programs and curricula, including local and state-developed programs. In addition, states may want to establish a certification process through a state government agency or leverage an existing certification process, such as certification programs and registries developed by a state CHW association.¹ The certification process can be a useful tool to validate a CHW’s skills, training, and experience.
• Monitoring and Oversight: It is imperative that states establish monitoring and oversight mechanisms for their CHW initiatives. Key monitoring and oversight components can include:
  • An initial plan for deploying CHWs;
  • Routine monitoring to address implementation issues;
  • Quality measures to evaluate the performance of the CHW program; and
  • A consideration of the administrative burden on health plans, providers, and CHWs.

Conclusion

_{¹ The National Association of CHWs maintains a repository of state and regional CHW networks and associations by state as well as certification and training programs.}