Authors: Logan Kelly, Center for Health Care Strategies

What’s the issue?

People in rural communities experience higher rates of chronic diseases, yet workforce shortages limit their access to preventive care and effective management of chronic conditions. Community health workers (CHWs) — also known as community health representatives, promotores, and peer navigators — are non-clinical staff who draw on shared life experiences to build trusted connections and help people achieve their health goals. CHWs provide health education, outreach, and navigation, among other services — helping to ease workforce shortages, improve health outcomes, and enable clinical staff to practice at the top of their license.

Transforming Rural Health Care Through Medicaid Innovation Series

This resource is part of a series exploring how states can leverage innovative Medicaid approaches to improve rural health care delivery and strengthen access, workforce capacity, and sustainability in rural communities. LEARN MORE

The Medicaid connection.

Many states reimburse CHW services through Medicaid, and in 2024 Medicare began covering these services as well. State agencies also frequently fund and administer CHW certification, training, and workforce development initiatives.

How can CHWs support priorities of the Rural Health Transformation (RHT) Program?

States can leverage CHWs to support the RHT Program’s workforce development and ensuring sustainable access to care priorities. Investments in this workforce align with several RHT Program categories, including provider payments, workforce, and appropriate care availability.

Opportunities and examples.

States have sought to expand access to CHW services through Medicaid levers and targeted investments in training and retention, including by:

  • Establishing and refining Medicaid reimbursement. More than half of states have pursued Medicaid reimbursement for CHW services through state plan amendments or Section 1115 waivers, including six of the ten states with the largest percentage of rural populations — Arkansas, Kentucky, Maine, South Dakota, Vermont, and West Virginia. Washington State recently implemented a CHW Medicaid benefit aligned with Medicare’s service codes, an approach that may help to streamline provider uptake.
  • Building training infrastructure and programs. Many states manage or fund core competency, specialization, and supervisor training programs, often in partnership with CHW associations and local educational institutions, like community colleges. Training programs can be a catalyst for high-quality CHW services. In Minnesota, state agencies partner with the state CHW association to lead a CHW training program that offers free online courses, apprenticeships, and scholarships. Other states, including Montana and Wyoming, have developed training programs in partnership with state rural health offices and educational institutions. The Oregon Office of Rural Health used grant funding to train CHWs in rural hospitals, clinics, or health departments. Training programs may be tailored to population-specific needs, such as supporting age-friendly care.
  • Supporting recruitment and placement. Rural hospitals and clinics often struggle to recruit and retain CHWs. New York State’s Career Pathways Training program funds education, job placement, and ongoing training, among other services, for people interested in becoming CHWs.
  • Establishing standards for CHW programs. States are promoting quality and consistency by creating certification standards for CHWs and CHW training programs, as well as through accreditation of CHW employers. Texas was the first state to establish training standards and to certify CHWs and training programs. In Tennessee, the state CHW association is partnering with the Medicaid agency and the National Committee for Quality Assurance on CHW program accreditation, an approach that can lead to greater payer support for these programs.
  • Addressing challenges in field-based service delivery. CHWs frequently meet with people in their homes and communities, which can be especially valuable to rural residents who face long travel to receive care. However, a recent study cited transportation as the largest overhead expense for CHW programs, and Medicaid does not cover provider travel. State strategies to mitigate these challenges may include authorizing longer CHW visits in rural regions, and incorporating travel assumptions as an input for rate development, as South Dakota has done.

Key considerations for implementation.

CHW programs are often launched through grants and pilots. While Medicaid and Medicare reimbursement offer more stability, Medicaid rates vary widely across states. States launching CHW reimbursement have also reported low uptake, often due to provider perceptions that rates do not cover service costs.

Potential impact.

Substantial evidence shows that CHW programs can improve health outcomes, including by supporting chronic disease management and access to primary care. Substantial evidence shows that CHW programs — including in rural regions — can improve health outcomes, including by supporting chronic disease management and access to primary care. Many programs demonstrate positive return on investment through cost savings from fewer emergency department visits and hospitalizations. Evidence and case studies highlight the impacts of CHWs in a range of settings, including primary care, geriatric care, and pediatric care.

What’s next?

As states design or refine strategies to expand CHW services in rural areas, they can partner across state agencies (e.g., public health, Medicaid, rural health) and with workforce development and training organizations, CHW employers, health plans, CHW associations, and CHWs themselves. With RHT Program resources, states can evaluate existing infrastructure for CHW services in rural regions and consider additional investments.

Additional resources for more information:

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