Across the nation, states are pursuing strategies to meet Medicaid members’ health and social needs, including coverage and requirements for deploying community health workers (CHWs). Because CHWs can build trust and connect members to resources for whole-person care, they are ideally positioned to help identify and address these needs and provide insights into how programs can be designed to meet community member needs.

This brief offers guidance to help managed care organizations (MCOs) and Medicaid agencies, along with providers, community-based organizations, and funders, incorporate CHW expertise in the design, implementation, and quality improvement of CHW programs. It draws from the Center for Health Care Strategies’ (CHCS) work in New Jersey, where a CHW Advisory Board was convened to provide practical input and identify best practices to help Medicaid MCOs develop CHW-led pilot programs under the state’s Section 1115 waiver. The brief addresses three broad themes: (1) incorporating CHW insights in program design; (2) supporting the CHW workforce to ensure their success; and (3) engaging CHWs in ongoing program improvement activities.

Incorporate CHW Insights into Program Design

Medicaid MCOs often develop CHW programs based on member data, desired outcomes, state requirements, and cost considerations, adhering to evidence-based chronic disease management principles. However, these programs frequently overlook the valuable insights of CHWs themselves, missing the opportunity to tailor initiatives based on their firsthand expertise. Engaging CHWs as advisors in this process can enhance program design by leveraging their insights and understanding of members’ lived experiences to inform a wide range of planning activities. CHW insights can help define program goals, identify the priority population, design the intervention, develop the tools and processes for implementation, and monitor health outcomes.

Based on input from CHW advisors, the following approaches can help MCOs develop programs that incorporate CHWs’ practical, on-the-ground experience into existing care coordination models and member supports.

• Determine the CHW hiring approach. Early on, MCOs must decide how to integrate CHWs into their workforce. Should they directly hire CHWs or contract with an external community-based organization that employs CHWs? Balancing the business side of this decision with the pros and cons from a CHW perspective is crucial. CHW advisors suggest that MCOs consider, for example, how the decision affects issues like CHWs’ connection to the team, access to data, and job satisfaction.
• Address the whole-person needs of the population served.  The selection of the prioritized population and eligibility criteria may be based on specific state-defined requirements. For example, an individual may need to have a specific chronic condition or reach a particular emergency department or hospital utilization threshold to qualify for the program. However, CHW program interventions should not focus solely on addressing the member’s chronic condition. To succeed, CHW programs should consider the member’s broader health and social needs and personal goals. For example, CHWs pointed out that while a member can be referred to the CHW program due to uncontrolled diabetes, a CHW should take a whole-person approach, addressing medication compliance and diet, and exploring more upstream needs, like transportation.

  It is essential for MCOs to ‘right-size’ their programs for success, centering on what it will take for clients to trust and meaningfully engage with the CHW, versus designing around the bottom line.

• Build flexibility into caseloads. Member needs vary greatly, from those requiring short-term, low-touch interventions to others needing longer-term, high-touch approaches. CHWs shared that accounting for these differences in program design enables them to support all members effectively, and described experiences when caseloads were too high or unmanageable. Discussion around caseloads helped MCOs consider options for a flexible caseload, or a caseload range based on the type and frequency of member needs. This approach allows for a thoughtful and tailored response rather than a static number that may be used to penalize CHWs for not meeting a goal.
• Set realistic expectations for program operations. From week to week, a CHW engages in myriad tasks, from making outreach attempts, assessing member needs, traveling to meet members, setting goals, identifying new resources for members, meeting with team members, and documenting member engagement activities that influence programmatic outcomes. Early input from CHWs on the design of these tasks and their roles, responsibilities, organizational processes, and workflows can help the MCO build an effective program. CHWs recommended that MCO leadership and program managers may even consider spending a day with a CHW to better understand the realities of their day-to-day work.
• Budget for workforce sustainability. Short or unreliable funding cycles can affect the tenure and turnover of CHWs on teams. For example, CHWs shared that a short pilot or grant-funded position may not support staff retention, resulting in CHW turnover and disruption of member relationships. Part of valuing the workforce includes committing to investments to sustain positions, provide equitable compensation (including livable wages, overtime, and benefits), and support career ladders or other growth opportunities for the workforce.

Support the CHW Workforce for Success

When employing CHWs in program interventions, MCOs must create a supportive work environment that acknowledges their unique role and needs. Unlike other MCO staff, CHWs spend significant time out of the office, regularly face secondary trauma, and need to be prepared to respond to a wide range of member needs. CHWs suggested the following recommendations to maximize the success of the CHW workforce.

• Establish clear roles and responsibilities. MCOs need to understand the unique contributions that CHWs make to clearly identify and communicate their role to others across the organization. CHW advisors warned that failure to do so could result in CHWs working below their skill set or in a role framed in a medical or clinical context or being “overmedicalized” rather than focused on the dynamic and whole person-centered work that is their strength. Further, it can lead to confusion among team members regarding delineating specific responsibilities among staff. The Community Health Worker Core Consensus Project developed a widely recognized resource defining 10 roles and 11 core competencies for CHWs.

  There is a need for balance when assigning roles to CHWs. Our primary job is to be with members and in the field. However, our experiences and knowledge can help inform other aspects of the overall program, if time is adequately allocated to do so. One caution: avoid over-medicalizing CHW tasks when integrating us into MCO programs. Our patient-centered contributions are different and unique.

• Provide foundational, specialized, and continuous training. CHWs need an array of training: foundational training on core competencies, specialized topics based on their client’s conditions and needs, and training related to organizational practices and workflows. Additionally, training needs to be ongoing and not provided only during onboarding. Further, CHWs shared that access to ongoing professional development opportunities bolsters job satisfaction and productivity for CHWs. MCOs may want to determine if a standardized training program or statewide CHW certification exists that could provide appropriate foundational training.
• Integrate CHWs into broader teams and provide tailored supervision. MCOs can consider ways to support CHW integration into care management teams and across interdisciplinary teams. This can be mutually beneficial as CHWs experience the support of other staff and can teach MCO colleagues about health-related social needs and community-based resources. Supportive supervision is a widely recognized approach for CHW supervision. This concept values the unique contributions of CHWs, creates space for mentoring and problem-solving during check-ins, and provides a trauma-informed and safety-focused lens to supervision.

  CHWs pour our whole selves into our work, which is often very personal and rewarding. However, we also run a high risk of empathy fatigue, vicarious trauma, and burnout. Providing CHWs with ways and space to address this together — to share, process, and decompress from our work — is one way to show us we are valued and appreciated

• Invest in wellness. Employing the CHW workforce requires MCOs to invest in their mental health, overall wellness, and psychological safety. Examples include extra mental health days not part of regular paid time off, off-site group activities for CHWs to come together as a team, gym access, and “lunch and learn” activities. MCOs may appreciate learning more about how to create a culture that encourages regular reflection and supports CHWs in taking time to process their own trauma to help their clients.
• Provide appropriate equipment, tools, and resources. Given the specialized roles and responsibilities of CHWs, MCOs should consider adapting the resources provided for staff. For example, although an MCO may provide a laptop to employees, CHWs, given their role in the field, may prefer a tablet since it is lighter and simpler to use when conducting assessments and setting goals with members. Other needs may include a cell phone with data, an electronic platform for client notes, assessment tools, data management, and links to community resources. Additionally, mileage support or bus passes are critical to support CHW’s work in the community.

  I like to use an approach called ‘Do It Now’ with my clients to help build a trusting relationship and let them know that I care. It is based on immediate action to their identified need — picking up the phone while I’m with a client to help them call about a utility bill, a transportation need, or access to food or mental health supports.

• Encourage and celebrate CHWs’ superpowers. Empathy, active listening, authenticity, and accountability to clients are key attributes of CHWs. When combined with lived experience, cultural competency, and community connection, these attributes are the foundation of building trust and strengthening relationships. CHWs shared that these “superpowers” help them understand and address members’ barriers to achieving their goals and other blind spots that MCOs and providers may have when working with a member. By supporting CHWs in meeting members where they are and taking the time to build relationships, MCOs can achieve improved health and social outcomes for members that they often cannot accomplish on their own.

Engage CHWs in Ongoing Program Improvements

After programs are implemented, CHWs have a frontline perspective to understand how the program is going and what needs to be adapted or changed. They also have lived expertise that can help center member needs and experiences to help drive health equity in the program improvement process. MCOs can engage CHWs in ongoing program refinements, data collection, and quality monitoring. Following are opportunities for MCOs to involve CHWs in optimizing the program.

• Revise program, tools, and workflows. Once the program has begun, there may be a need for course correction regarding core program elements, including team member roles, caseload management, or areas for additional training. CHWs use tools such as member assessment and workflows every day and pointed out that they have first-hand input on how to improve these resources to maximize results and productivity and tailor to member needs.

  CHWs understand members and communities in a way that MCOs do not. We also have a front-row seat to how the program is going, what works, and where improvements can be made. Engage us in all aspects of the program, from the initial design to beyond once the program is up and running.

• Involve CHWs in program outcome measurement. Involving CHWs in ongoing feedback acknowledges their contribution to member outcomes and the program’s overall results. By doing so, MCOs contribute to CHW job satisfaction and increase health equity. Health Leads gathered lessons from the field on the benefits of integrating CHWs in quality improvement efforts. This includes defining measures, collecting related data, designing quality improvement strategies, and interpreting results.

Conclusion

MCOs have access to member and population health data, including service utilization, chronic disease prevalence, cost of care, and evidence-based models for care coordination. They often also have flexibility in how they design programs to meet needs and health outcomes goals. CHWs have the lived experience, on-the-ground expertise, and passion to meaningfully and effectively engage Medicaid members with complex health and social needs. In supporting this workforce, MCOs and CHWs can collaborate to co-create programs that leverage evidence-based best practices and person-centered, community-based, practical expertise.