Certification For Community Health Workers

Speaker 1: Okay, Dr. Klemp. We are going to hear from Rosalia Guerrero from the University of Texas School of Public Health, and I'll let you do the intro and set up this segment.

Dr. Klemp: Great. Well, thank you so much, Stuart and Dr. Rosalia Guerrero. Rosalia is, as Stuart said from the University of Texas School of Public Health. And she's currently the project manager for the community health worker program, but also serves as adjunct professor for Texas Southern University Health Management Department, and really has been part of the dialogue in Texas for a long time. And I'm hoping today that we can learn a little bit more about that experience. Because one of the things that is happening, and there is sort of that movement, is sort of state-by-state, tackling the need for accreditation and putting this level of standard on our community health work, navigators and workforce. But do we tackle that as one-offs, do we learn from the lessons of Texas and other states? So, I'm hoping we learn from you today and we look forward to your discussion.

Dr. Guerrero: Hi. And thank you for having me. This is great. I hear there's a lot of community health workers and patient navigators out there. So, greetings to all of you. I'm very excited to be here. I will say one of my most treasured titles is that of certified community health worker instructor, which we're able to have here in Texas. So, I'll be speaking about that today briefly. If you go to the next slide?

As I mentioned, my job here today was to talk about the history of certification for community health workers in Texas. But I would like to start by saying that community health workers have been around for a very, very long time. Texas certainly did not invent them. The United States didn't invent them. They've been around for a time in different types of communities. So we just want to keep that in mind as we're moving forward: every community is different, so every community health worker program will be different. But (here’s) a little bit about how we got started here in Texas. Please move to the next slide.

There's a little timeline. Texas is an interesting case in the South because our model for community health workers actually came from Mexico, where they were called promotoras de salud, which is basically health promoters, people who promote health, and we see them in all areas of Mexico and Latin American countries in the 1970s. And really in the 1960s, when we had farmworkers come up into the United States, in the agricultural industry, they also brought all their health issues, which would be - people still got pregnant and people still had diabetes, people get hurt, still needed their vaccines.

And what we saw in the healthcare industry is that many times they came with one of these promotoras, which was usually a family member, but someone who, along the migrant stream from Texas all the way to Yakima, Washington, would educate themselves on healthcare in that particular community. And that way, helping their community, just like they did back home.

In the 80s, this led way to the migrant health promotion. It's a program sponsored by the federal government that’s still around today to provide health care to migrant farmworkers and also pay for some of the work that the community health workers were doing. By this time, they were starting to call them community health workers. One of the early sponsors of community health workers, oddly enough, maybe not, was Blue Cross Blue Shield. They offered all community health workers who would go along in the migrant stream with the farmworkers, they would offer them pay and also health insurance for $8 a year. This was in the 80s and 90s. They still continued with that program until they went from being a non-profit to for profit.

In the 1990s, and up until this time, community health workers are basically minding their own business, literally the business of health, and they would be with the foreign workers and all along the border, they were very well integrated into the health care system and no one really paid them any mind, outside of that. But when NAFTA came around in the 90s, Clinton famously went to the border to talk about all these great promotoras and the economy. And what he was faced with was, again, migrant farmworkers living in less than substandard housing. By this time, we had colonias, which are basically shanty towns outside of town. And he saw that we had these community health workers that would go out there and he's like, what is this, we need to support this more, and really do something with the border communities.

So, at this time is when there was the start of the talk about who are these community health workers and how should we best support them? Or on the opposite end, maybe regulate them? We don't know who these people are. They don't come from a traditional educational system. Some of them don't even have papers. So, how is it that they're working within our health care industry?

By 2000, this led to the establishment of the US Mexico Border Health Commission, which really started to work, very focused on community health work and the model and how it should be best dealt with. And by 2001, community health worker certification is legislated in the state of Texas, which makes it unique. I think it's the only one in the United States, where it's actually legislated, it's a law that promotes and protects community health workers, provides for their education, and this is directed by the Texas Department of State Health Services, our state health department, which provides certification for community health workers. And that department still exists. And, and community health workers were still being used in a lot of the health care industry in Texas. But still, you found them more along the border, and then came along the Affordable Care Act in 2010. And what's interesting about the Affordable Care Act, they mention community health workers, specifically, more than a dozen times, and in 2010, there's a resurgence of this conversation around certification.

And when I say community health workers, I'm really talking about an umbrella. Today we're talking about patient navigators and the indigenous communities, you have community health representative. So, the community health worker certification basically encompasses everybody. If you want to move to the next slide.

What certification basically got us was a department, which is one of the pros that I'll talk about. One of the support mechanisms was actually having a program carved out within the state health department. So that means the staff, that means programs, that means activities. So, when I talk to community health workers, I provide a training, a certified training. I'm through the University of Texas School of Public Health, I make sure to always remind them, I'm not certifying you I'm just providing this training. Who certifies you is the state health department. And community health workers receive a license with a unique number and their picture on it. And this has been a source of professional pride for community health workers in Texas, which number a little bit over 5,000 today throughout the state.

To be certified in the state of Texas, you had to have gone through a 160-hour course in the eight core competencies of community health work. You have to take it from a certified Training Center, and certified training instructors, and all those different phases are certified by the state of Texas.

Another nice thing about the program is that every year they keep statistics, so you can go on to the state website and you'll get a report every year: How many community health workers there are, what's their education, what's your background, age, all these demographics. So that's really nice to have as well. If you want to move on to the next slide.

What I wanted to spend some time on is what I was asked when Stuart first called me: what has worked in the state of Texas? I will say I've been around a community health workers since before they were certified. And at that time, I was living on the border. And there was a state commission that came and said, let's call you certified community health workers and we're going to be professionals. And I wasn't too keen on that. I was actually one of the people with like the little sign, you know: no certification in Texas. This is terrible, community health workers are beautiful and organic, they come from the community, we're going to lose all that.

And what happened was like the community health workers are saying, Hey, we like this idea of being called professionals. We've been doing the work. We go out there, we work shoulder to shoulder with nurses and doctors. So why shouldn't we be labeled as professionals? Why shouldn't we get a wage? Sometimes, most during that time, community health workers were usually volunteers. I still remember sometimes they get gifts or something. And those were now days gone by, of course, the models spread beyond the border after certification.

There was an educational system that was set up. I think that's one of the primary products that came out of this is for the first time, community health workers had access to training that they did not have access to. Training centers were set up just to provide this education.

It supported research out in the community was very difficult for universities to do research in rural areas. So, basically, they would do research at college universities, you know, they basically researched themselves. But once community health workers were certified, they were able to be hired to go and interact with their own community and ask what their community needs are.

And then, of course, the state office was created, which is very important, because they're the ones that support all the activities of the community health workers here in Texas.

So all in all, it's been a good run. We're now coming on our 20th year of certification in Texas. So, I got a chance to look back and say, well, what could we have done differently or how can it have improved? If we knew then what we know now, what would we do different?

One of the things I noticed is that there's very little support for healthcare organizations, or hospitals of people who employ community health workers. And that might seem counterintuitive, like why they need support their employers? It's that they don't get a lot of support in integrating community health workers. I've seen great community health worker programs within healthcare organizations, and I've seen very bad community health worker programs within organizations. And a lot of that has to do it with the lack of education of the employer. So, more support to organizations letting them know how to integrate community health workers, would be a great service that the program could provide or under new legislation, but does not currently.

In the previous talk, there was mention of this lack of standardization. That's true. If you've seen one community health worker training program, you've seen one community worker training program. Besides the eight core competencies, training programs are provided no guidance as to what a curriculum should be. That was done purposefully for good reason, because the training program should reflect the community that it is in. So, if you would like to have a training program that is based more on breast health navigation, you can do that here in Texas. So, to a certain degree, that lack of standardization, again was done on purpose, but for the same reason, sometimes it's very difficult to gauge quality of education.

There’s also still a big need for community health worker associations, the professional associations, which are very important, but they're unlike like, let's say nursing or physician medical associations. They're able to advocate for themselves quite well, but community health workers are usually on the lower spectrum of the pay grade. So again, working long hours, not a lot of pay, so they don't have the resources to go to Las Vegas and get together and talk about how they're going to further their profession. So, it would be great if the state could support that as well.

One of the things that is not traditionally a part of the community health worker program in Texas, is to talk about so how will community health workers be financed? Having the training that's all well and good, promoting their profession? That's great. But still in Texas, there is, and in many, many states, there’s not a way to reimburse programs that are actually paying, employing community health workers and sometimes that's why pay is so low because they can't get reimbursed for that. So sometimes that comes out of the administration pool, which is very small. So not that the state should pay for community health workers, but they should leave the conversation around round reimbursement for community health workers.

And then the other thing: the community health worker program at the state is very siloed. Just like a lot of them, but community health workers touch so many parts of health, that they should really reach out into the other programs. And that's it for me.

Dr. Klemp: Great, I think that you provided a lot of context. And I think that last slide, there's a couple of questions I'd like to ask you because I feel like you've definitely showed both sides of the coin, right? There's the pro of standardization. But there's the con of standardization. So you want to be able to have the breast health educators or the screening and outreach coordinators, have that sub specialty. But there's still the need to have some of that standardization because that all will lead to, hopefully, the reimbursement of the service, as now we've shown sort of an aggregate of what value it provides.

So, as you look at that kind of both sides of the coin, what's your sense of where this should go based on your experience? Or where do you feel from different agencies of where they want that to go?

Dr. Guerrero: Well, definitely, the Community Health Worker Program is here in the state of Texas still very much so wanted, and people are still excited about it. It's growing, if it's anything, but at the same time, it needs to change.

Just recently, we started working groups within the state of Texas to talk about, through the advisory board because it has an advisory board, let's talk about financing. Let's talk about how we're going to modernize using technology. We started talking about telehealth and community health workers.

So, the idea is to always be keeping it new, and advancing community health work and supporting them in that way. So it's not so much okay, well, it could be better, let's do something different. Well, it's more of let's keep what we have, just let's just make it better by engaging more people and more importantly, more community health workers.

Stuart: So I just want to weigh in, Dr. Klemp and Dr. Guerrero, hearing what has worked well in Texas, and Dr. Guerrero, thank you very much for also sharing where you think you can move forward, we hope in the short term. So, where does that leave us, Dr. Klemp, in New York State? What's a good baseline or a good starting point for community health workers? Not to – I know it's a loaded question, but I know you're going to give us an overview of the scope of practice survey we did with navigators here, and we'll hear it from two public policy experts. But what do you think, just to get us started, and also we'll want to hear from our audience what they think as well because this is important work.

Dr. Klemp: So, my first disclaimer is that I am going to play one on TV, right? So, I'm not an expert in accreditation, I am obviously on the Leadership Council of AONN and have been for about eight years, so I've been watching this movement, and I'm a provider, right. And luckily, in my practice, I'm director of the survivorship program, which I do have a very rural footprint, but my practice has been telehealth for years. So, I work in where I definitely see the need. And but I do not want to own being an expert in accreditation.

So, having done my disclaimer, I feel like I'm torn with two sides, kind of like we just discussed. I feel like there needs to be accreditation and standards around a discipline, because that is what allows us to move the needle forward in oncology, where if we're talking about cancer screening, we're talking about breast cancer, we're moving that forward.

I think the importance of where cancer care is going is something called alternative payment models, which is a bunch of services, navigation being a core piece of that bundle, right? It's sort of the thread that ties on how patients access care. So, if we're going to build into payment models, the need for navigation, care coordination, the community health worker model, then how do we demonstrate that that is done with any consistency if we don't have any standards or accreditation around?

So, I feel like we have to move in that direction in order for people to get paid accordingly and organizations can't just afford to eat all that cost like we talked about. They have to have a budget where that that fits into that. So, putting my business cap on and my clinical cap on I think that's one way to achieve that.

Stuart: What do you think Dr. Guerrero, because Dr. Klemp makes a really good point. We can talk about how we achieve greater pay equity for community health workers, certainly, and for patient navigators, but in order to talk about the cost effectiveness, we still need to, particularly for community health workers, talk about the efficacy. And you can't really talk about efficacy unless there are some certification and training standards. I think we would agree that that's important. You’ve got some standards in place and yet you showed us, Dr. Guerrero, the umbrella of the different disciplines within community health workers. So even in the community health worker lane, there are multiple functions, different roles. And so how can we streamline those roles, achieve greater certification, and then we can talk about

pay equity? Is that a fair question?

Dr. Guerrero: Right. What well, certification really isn't the solution. It's actually the start of something, you have to start with certification. And then you can move towards things like pay equity, and standardization and growth.

And here in Texas, and I think it's very important to note, that just because we have certification, we do not undervalue at all the community health workers that choose not to be certified. That's perfectly fine. There are people that love to work out in the community. They're working with their church and their schools and this is a calling for them.

Certification allows for the community health worker to move into a space where the healthcare field is very special. You have rules and regulations, and they want to move into that space, so, once you pass your certification, then you can start talking about reimbursement. And one of the things about reimbursement that I learned over the years is that for to get reimbursement from insurance, whether it be Medicaid or Medicare or private insurance, basically there's two types of caps. There's the administration cap, which is basically just like 10% to pay, for like the CEO because we don't want the CEO to be making $5 million, and things like that. And then the other 90% is for reimbursement.

Community health workers, because they don't have that financing and they’re not in that reimbursement model, you have to pay them out of that 10%. And so, until you have certification, and then move forward to talk about reimbursement, and you can't talk about reimbursement without certification, then you can move into that 90% of finance and get out of that 10% admin.

Dr. Klemp: And can I just follow up with that too, real quick before we transition to the scope of practice? How do your advocates feel? So you know, if you talk about it from the stakeholder of the community health worker, and then let's talk about it from the stakeholder of maybe our advocacy groups or professional organizations, what is their feeling in Texas? And how do they either help push things or, you know, kind of what's their role in this?

Dr. Guerrero: Well, again, talking about community health worker associations, it's important that we help community health workers advocate for themselves, because then after a while advocates are really talking about what their interests are, which, community health worker is, is a part of that but again, I go back to my history when I was like, we love community health workers, they’re so natural, they come from the community, you know. But then the community health workers were like hey, we're not getting paid, you know?

So, I think it's important that community health workers speak for themselves. And that advocates, that's the best way they can help is to support community health workers, that they use their own voice, and at the same time, educate them as to how the health industry works.

When we talk about these financing models, you might think that well, community health workers, they're not going to understand, that they will if you spend the time, so they have to be at the table.

And that's why here in Texas, the advisory board for the state, a community health worker program passed to consist of 51% community health workers, because we never want to lose that we can't lose that voice, or else we'll get lost and all the financing lingo and things like that, and so we definitely don't want to lose that. We want to protect that original and keep the spirit of the community health worker, no matter what model gets chosen, because it's no good if we find a great financing model, but we've basically washed away everything that makes a community health worker, a community health worker.