Community health workers (CHWs) have been garnering greater visibility in recent years as the field has placed heightened attention toward the role of social determinants of health in reducing health disparities and achieving health equity. CHWs aim to be a closer link into the community than traditional health care providers might be able to reach. Cultural competence, language, geographic distribution, and cost all contribute to the growing success of CHWs.
As administrators, clinicians, and researchers working in primary care safety-net health systems, the authors have directly observed the benefits of including CHWs in primary care practice to help meet the health and social needs of marginalized populations. Moreover, as payment models for health care shift from clinical fee-for-service payment to broader value-based payment models, CHWs may serve a crucial role to expand the impact of primary care and build the connections among primary care, public health, and community health organizations.
This question of whether CHWs should be certified or licensed comes up frequently and as payment models provide more resources to support CHWs, the issue is becoming an important policy debate. In this article, we describe the benefits and risks of CHW licensure and certification.
Enhance Professional Credibility
The Bureau of Labor Statistics (BLS) estimates that there are 58,670 CHWs employed nationwide. These CHWs work in a variety of fields including health care, in-home, childcare, social care, community, and religious settings. CHWs in most or all of these settings work in alignment with employees holding different professional certifications. In health care specifically, CHWs may work closely with social workers, physicians, nurses, and medical assistants. When the CHW role is professionalized, “community health workers become integrated into care teams along with doctors, nurses, and other professionals [and] ultimately, community health workers become part of the professional culture of medicine and grow and develop along with the health care system.” This professionalization will allow CHWs with certification and their colleagues to have mutual understanding of the CHW role within the workplace.
The BLS estimation of the number of CHWs in the US is likely an underestimation given that this segment of the workforce is known by a plethora of different names, both professionally and nonprofessionally, such as promotores de salud, health aides, lay supporters, and outreach workers. Each of these CHW subsets, along with a number of others, bring their own attributes to the CHW role and presumably have different perceptions in their communities. The American Public Health Association defines a CHW as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” Standardizing the certification for CHWs has the potential to bridge these various subsets into one collective understanding across multiple disciplines.
There is currently no national consensus on the competencies that should be included in CHW certification; however, the CHW Core Consensus Project outlines a list of standard competencies and skills they recommend for CHWs. These are:
- Interpersonal and Relationship-Building
- Service Coordination and Navigation
- Capacity Building
- Education and Facilitation
- Individual and Community Assessment
- Professionalism and Conduct
- Evaluation and Research
- Knowledge Base
As states adopt CHW certification standards, some states, such as Rhode Island, also offer a “grandfathered” CHW certification option using documented hours of community engagement and past trainings as the basis. Certification offers a way to control the foundational skills and knowledge of CHWs while also tailoring to local population and needs.
Professional Development And Career Opportunities
Numerous studies have built the business case for CHWs by showing reductions in health care costs due to the positive impact CHWs have on their communities’ health. For every dollar allocated for CHWs generates $2.47 in savings. CHWs also improve chronic disease control, mental health, quality of care, and hospitalizations. Standardizing CHW certification has the potential to further link the CHW role to these positive financial and health outcomes and build the case for growing the CHW workforce.
Some states build professional development into the CHW certification process by mandating continuing education. Florida, for example, requires biennial CHW recertification. Indiana requires 14 hours of continuing education credits each year to maintain CHW certification. The communities and professional setting in which CHWs work change over time and continuing education provides an opportunity for CHWs to learn how to continue to support their patients during change. Employers who directly hire CHWs state that they favor tangible training, such as CHW certification, over more intangible types of education.
Differences In Certifying Entities
One of the first questions that comes to mind when pondering CHW certification is who determines the certification process. Certifying entities range broadly from state to state from community colleges to state CHW associations to state departments of health and human services. Because CHWs are known by many names, CHW certification titles also differ from state to state. Georgia, for example, knows CHWs as “Resource Mothers” and require them to complete an initial Resource Mother Certification course along with continuing education. These differences in naming could prove to be confusing for CHW employers and CHWs moving around the country.
Mandatory certification could exclude CHWs or potential CHWs from the profession based on legal residency status and based on incarceration history. This would not only affect the current business practices of some CHW employers but would also affect the CHW population as a whole. The Transitions Clinic Network “employs CHWs who have been involved with the criminal justice system to connect with other formerly incarcerated individuals reentering society and link them to primary care.” If criminal history were a disqualifier for CHW candidacy, the Transitions Clinic Network, as well as current CHWs with criminal history, would be forced to adjust their practices.
Currently, states hold the power to determine CHW certification requirements, pass CHW legislation, and appoint certifying entities. Alaska, for example, operates a robust CHW certification process owned by the Community Health Aide Program (CHAP). Alaska CHW certification requires the completion of a 3–4-week training course, a number of patient encounter hours, 200 hours of “village clinical experience,” and passing both the CHAP exam and math exam. New York, on the other hand, has no regulations on CHW certification. The vast differences between state CHW regulations may make it difficult for CHWs if they should decide to move to another state as recertification may be necessary.
States also differ in Medicaid reimbursement practices for CHW services based on CHW certification policies. States such as Texas, Oregon, and Minnesota require CHW certification to be eligible for payment from public payers; however, they are in the minority. As of December 2021, 27 states do not reimburse for CHW work through their Medicaid program. The value of CHWs, from a health services standpoint, is largely determined by their revenue-generating potential and differences in state certification and reimbursement practices spark risks to the nationwide reputation of this role.
“Us Versus Them”
Certifications and degrees are used to gain knowledge and expertise and to increase competitiveness as a job candidate. There is currently no national standard for CHW certification; consequently, CHWs are valued “for their contribution to community health, not for the savings they generate for health plans or providers. CHWs are embedded in the community, not in a clinician’s office or hospital.” Institutionalizing the CHW role through certification could transform the value of CHWs to also being acknowledged for their contribution to medical savings for health systems, especially given the field’s greater focus on value-based care.
Financial And Linguistic Barriers To Certification
President Joe Biden announced his support for the CHW workforce and strategy to increase the CHW workforce by 150,000 during his presidential campaign. The administration also noted the often-humble backgrounds that many CHWs come from; CHWs are frequently economically vulnerable and often come from marginalized communities. CHWs are also a racially diverse workgroup with 65 percent of the workforce being Black or Latinx and 10 percent of the workforce being Native American. More specifically, the CHW workforce is largely composed of women of color. This racial diversity also brings linguistic diversity, which may prove to be a barrier in seeking CHW certification.
There are many risks and benefits to CHW certification that are worth considering. Ultimately, there are two paths to take concerning CHW institutionalization: to certify or not to certify? CHWs are currently closely associated and intertwined with the communities in which they serve. There is risk of the severance of this association in the institutionalizing of their role. On the other hand, CHW certification provides standardization in the competencies and practices of CHWs and could provide improved integration of CHWs into their professional cohort. Overall, CHWs are a valuable asset to communities and provide positive outcomes to those they serve. We present the pros and cons to certification; however, we strongly believe that the evidence supports the addition of CHWs to primary care, public health, and community organizations to improve population health.