Is CHW Certification the Magic Bullet for Community Paramedics?

The number of mobile integrated healthcare and community paramedicine (MIH-CP) programs across the country still appears to be growing significantly. 

Leaders of early programs like those at MedStar (Texas), REMSA (Nevada), Allina Health (Minnesota) and UPMC (Pennsylvania) receive inquiries almost daily about starting and maintaining programs. The two most commonly asked questions center around training models for community paramedics and how to economically sustain MIH-CP programs.

There may be a perfect solution to both of those issues: community health worker (CHW) certification.

Who Are CHWs?

According to the Centers for Disease Control and Prevention (CDC), CHWs are front-line health workers who have a close understanding of the communities they serve. CHWs build 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.

The federal Office of Management and Budget’s Standard Occupational Classification system includes a unique occupational classification for community health worker (SOC 21-1094). Community health workers serve in urban, suburban and rural settings, commonly helping link people to needed healthcare information and services.

The Bureau of Labor Statistics definition says there are more than 48,000 people employed in this profession nationally, with a mean annual wage of $40,000. Their definition includes the following:

“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.”

Roles in the System

CHW roles and activities are tailored to meet the unique needs of local communities. They also depend on factors such as whether the CHW works in the healthcare or social services sector. Generally these roles may include:

• Helping individuals, families, groups and communities develop their capacity and access to resources, including health insurance, food, housing, quality care and health information; 
• Facilitating communication and client empowerment in interactions with healthcare/social service systems;
• Helping healthcare and social service systems become culturally relevant and responsive to their service populations; 
• Helping people understand their health condition(s) and develop strategies to improve their health and well-being; 
• Helping to build understanding and social capital to support healthier behaviors and lifestyle choices; 
• Delivering health information using culturally appropriate terms and concepts;
• Linking people to healthcare/social service resources; 
• Providing informal counseling, support and follow-up; 
• Advocating for local health needs; 
• Providing health services, such as monitoring blood pressure and providing first aid; 
• Making home visits to chronically ill patients, pregnant women and nursing mothers, individuals at high risk of health problems and the elderly; 
• Translating and interpreting for clients and healthcare/social service providers.

Managers of active MIH-CP programs who just read that list of potential roles may be scratching their heads and thinking, That sounds a lot like what our community paramedics do! And they are right, but there’s more.

Evidence-Based Interventions

Here’s the most interesting news: CHWs have been extensively researched, and the outcomes for the services they provide are evidence-based. Emerging MIH-CP programs have been building this base with case studies and data reporting, but peer-reviewed, published evidence is still a challenge, not because MIH-CP programs do not result in enhanced outcomes but due to the fact they’re still relatively new. 

The Agency for Healthcare Research and Quality (AHRQ)—the policy research arm of the Department of Health and Human Services (HHS)—released an evidence-based summary report developed by RTI International on the impact of CHW interventions. The report identified over 50 different studies of CHW interventions in published literature. It is interesting to note that AHRQ has published on several MIH-CP programs through its Healthcare Innovations Exchange and that RTI International was the program evaluation agency for the REMSA CMS Innovation award. Additionally, a 2011 report published in the American Journal of Public Health identified numerous publications citing improved health outcomes and other benefits of CHW interventions.

It is likely for this reason that the Patient Protection and Affordable Care Act (ACA) included CHWs as a specific delivery model to be explored further.

Economic Models

The ACA includes provisions relevant to CHWs. Section 5313 facilitates grants to promote CHW use by amending the Public Health Service Act to authorize the CDC, in collaboration with the Secretary of Health and Human Services, to award grants to “eligible entities to promote positive health behaviors and outcomes for populations in medically underserved communities through the use of CHWs,” using evidence-based interventions to educate, guide and provide outreach in community settings regarding health problems prevalent in medically underserved communities; effective strategies to promote positive health behaviors and discourage risky health behaviors; enrollment in health insurance; enrollment and referral to appropriate healthcare agencies; and maternal health and prenatal care.

The National Academy for State Health Policy provides a comprehensive summary of state CHW use and economic models for reimbursement. It identifies several states where the services provided by CHWs are either directly reimbursable or allowed administrative expenses for Medicaid payments. Here are a few highlights:

Washington—CHWs and other “allied healthcare staff” can be part of Washington’s health homes, which allows them to receive funding under Medicaid for each patient served.

New Mexico—Through a Medicaid 1115 waiver, Centennial Care has leveraged contracts with Medicaid managed care organizations (MCOs) to support the use of CHWs in serving Medicaid enrollees. CHW salaries, training and service costs are MCO administrative costs and embedded in capitated rates paid to Medicaid managed care organizations.

Minnesota—In May 2007 the legislature passed a provision allowing for reimbursement of registered Medicaid providers for services by CHWs as follows: 

• Services are provided under medical supervision (multiple types of professionals qualify to supervise); 
• The CHW has completed training following a standard curriculum; 
• The CHW must register as a Medicaid provider but may not bill the state directly; 
• The CHW may be an employee or contractor of the billing provider. 

Maine—Practices involved in Maine’s health homes program must include a community care team (CCT), and CHWs are explicitly listed as potential team members. The CCTs are reimbursed through Medicaid health homes. Maine’s state innovation model grant includes five CHW pilot sites.

Oregon—A state Medicaid Plan Amendment created patient-centered primary care homes, which explicitly include CHWs in description of providers for four of six core services: health promotion, comprehensive transitional care, individual and family support services, and referral to community and social support services. Only certified CHWs will be reimbursed. 

Education and Training

Like EMS providers, some states require CHWs to complete an approved training program and have state-level certification. These training and certification programs are not administered through the state EMS office but rather by a local health department, another agency at the state level or, more commonly, a college or university. Related educational trends include community college-based training that provides academic credit and career advancement opportunities through formal education, and on-the-job training offered to improve capacities of CHWs and enhance their standards of practice.

Examples of states with CHW programs and their certification approaches include:

Texas—The first state to develop legislation to govern CHW activities in 1999, Texas offers a CHW certification program and requires CHW programs in health and human services agencies to hire state-certified CHWs when possible.

Ohio—Ohio developed a CHW certification program in 2003 that is administered by the State Board of Nursing and also maintains a list of approved community health worker programs.

Oregon, Nevada and Washington—These states have implemented state-level standards for training and education for CHWs and provide training at the state level.

Arizona, Southern California, Colorado and Virginia—Curriculum and CHW programs are offered at community colleges; states may be moving toward certification.

Massachusetts—State established a Board of Certification of Community Health Workers, which is establishing education standards, training program curricula and requirements for certification.

Minnesota—Minnesota’s CHW certification curriculum contains the following learning objectives (as you read these, consider if these are logical and practical applications for a community paramedic):

• Define the CHW scope of practice;
• Identify and use 9-1-1 system appropriately and ethically;
• List personal safety strategies;
• Create a personal safety plan;
• Identify and recognize signs of stress;
• Identify and utilize coping strategies for managing stress and staying healthy;
• Define outreach and identify ways to connect with community;
• Identify strategies to provide clear, accurate agency information to clients in the community;
• Identify ways to gather information about community resources;
• Prioritize client information into an effective plan or timeline;
• Define critical thinking; discuss critical thinking as it relates to the community health worker role;
• Provide clients with information based on individual needs and desires;
• List types of forms that comprise a client record;
• Explain what kinds of information must be included in client record;
• State reasons for timeliness of documentation and its practical applications;
• Accurately use healthcare terminology in client record;
• Create and maintain records following legal principles when documenting;
• Identify, create and maintain an organized system of community resources;
• Use a range of effective communication skills to interact with clients and provide accurate and relevant information/documentation;
• Interact effectively within the community and its culture by building trust, being culturally responsive and working within diverse team settings;
• Network within the community and throughout the healthcare system to provide needed services and resources for clients and their families.

Applicability to EMS-Based MIH-CP Programs

EMS-based MIH-CP programs have to an extent been struggling for legitimacy with the rest of the healthcare system. CHW programs have already accomplished that goal, not only in the U.S. but worldwide. The CDC, AHRQ, WHO and other notable organizations are promoting the CHW model due to the outcomes evidence. 

Perhaps the magic bullet for EMS-based MIH program recognition and economic sustainability is to cross-certify community paramedics as community health workers. In essence, you’d have a CHW on steroids: on one hand evidence-based training, education and intervention competency, and on the other the clinical intervention component. With the ACA encouraging grants for CHWs and numerous state Medicaid plans already allowing CHW use as a reimbursable expense in healthcare delivery, this may provide a potentially robust pathway for reimbursement. 

Based on this research, MedStar has budgeted to send our community paramedics to CHW school. How about you?

Matt Zavadsky, MS-HSA, EMT, is the chief strategic integration officer at MedStar Mobile Healthcare, the exclusive emergency and nonemergency EMS/MIH provider for Fort Worth and 14 other cities in North Texas and the recipient of the EMS World/NAEMT 2013 Paid EMS System of the Year.