Empowering Community Health Workers: The Unsung Heroes Transforming Healthcare  

The saying “not all heroes wear capes” is certainly true with community health workers. A community health worker (CHW) is a frontline public health worker with lived experience and local knowledge, making them especially effective at helping individuals through health education, care navigation, individual  advocacy, and resource linking. Often, they work in neighborhood clinics, community-based organizations, churches, housing facilities, and schools, or engage by phone or video calls. Above all else, they build trust, understand the needs and interests of clients, and help them overcome social determinants of health (SDoH) challenges — housing, food access, transportation, etc. — often experienced by underserved communities. Their approach is most importantly based on local context and guided by culturally sensitive, person-centered strategies. 

Challenges in recognition and reimbursement: Navigating systemic barriers

CHWs go by many names — care navigators, health advocates, promotores, and community health representatives — and often don’t have advanced degrees or clinical licensures. In addition, CHW certification or other credentialing standards, which other providers like physicians, nurses, or social workers have, are regulated at the state level or are sometimes optional. Despite their invaluable contributions to health and well-being, CHWs have historically not been recognized and fairly compensated by the healthcare ecosystem, while also facing systemic barriers to integrating into the healthcare ecosystem.

Consequently, organizations employing CHWs have had to navigate precarious funding streams, relying on public health contracts, philanthropic grants, and donations to sustain their programs. This reliance on “soft funding” not only undermines the stability of CHW initiatives but also hampers their ability to effect lasting change within communities.

Momentum for CHW recognition

Recent years have witnessed a groundswell of support for CHWs, catalyzed partly by their indispensable role during the Covid-19 pandemic. In September 2022, the Biden administration awarded $225 million to train over 13,000 CHWs, and an additional $50 million annually was appropriated as a part of the 2023 Consolidated Appropriations Act to build up the CHW workforce capacity. Many community colleges and other workforce development organizations now offer CHW certificate training programs, and state CHW associations, created to organize this workforce locally, are growing in size and becoming more  influential in developing policies and practices that prioritize provider sustainability and quality care.

In April 2019, the National Association of Community Health Workers (NACHW) was founded by a majority of CHWs and cross-sector allies. NACHW continues to grow its membership in all 50 states and across dozens of U.S. tribes, territories, and freely associated states as more individuals endorse the organization’s vision to unify across geography, language, race, ethnicity, sector, and lived experience, and to support communities in achieving health, equity, and social justice.     

Driven by the strong leadership of Denise Octavia Smith, inaugural executive director and a CHW herself, NACHW will continue to utilize its growing membership of CHWs and allies; the growing body of evidence demonstrating the effectiveness of CHWs; and high-profile celebrations, such as National CHW Awareness Week, to elevate this dynamic workforce.      

Medicaid reimbursement reform: Paving the way for sustainable funding

The increasing interest in CHWs has spurred several states to enact changes in Medicaid program policies, with determinations varying from state to state. Some states have opted to grant 1115 waivers to help fund CHWs, while others are creating new pathways to utilize billing codes tailored specifically for CHWs. These codes allow organizations employing CHWs to bill for services ranging from health and social screenings to health education, individual advocacy, and resource linking. Notably, “non-traditional” organizations, including community-based organizations and nonprofits, are now eligible to receive payments for these services—a significant shift in healthcare reimbursement practices.

According to the 2022 KFF report from the Annual Medicaid Budget Survey, more than half of states have approved Medicaid reimbursement for CHWs, with 29 out of 48 responding states already permitting such payments. Fifteen states have authorized Medicaid reimbursement for CHW services through state plan amendments, with more states soon joining this list, but positive policy change does not equal adoption. In most cases (11 states), health plans play a significant role in the CHW provider credentialing process, the review of submitted claims, and payments. However, unless they are motivated to engage in these programs and support this developing workforce, CHWs may never get paid for the work they are already doing.

Challenges in implementation: Navigating complexities at the state level

Despite these strides, the current landscape of state CHW programs remains fragmented and inconsistent. This lack of uniformity poses challenges for community-based organizations and contributes to minimal participation from those engaged in this vital work. A 2024 report by Families USA underscores these challenges. 

Community-based organizations, which often employ CHWs, cite additional hurdles. These include stringent provider approval requirements, tedious eligibility verification, a lack of suitable technology systems, and difficulties in collaborating with health plans and providers, which often have extensive credentialing processes and additional reporting requirements. This complexity extends to medical coding and tracking work for billing purposes, which are often different for each health plan partner. Representatives from various community-based organizations have expressed their frustrations, emphasizing the need for greater support and resources to navigate these obstacles effectively, as well as higher billing rates for services completed.

It’s clear that proactive policies alone do not guarantee equitable access to CHW services. More comprehensive efforts are required to equip CHWs and community-based organizations with the necessary expertise, skills, technical resources, and funding to enhance their capabilities and empower underserved communities effectively.

Transformative impact: CHWs in Medicare and the national healthcare landscape

On November 2, 2023, the Centers for Medicare and Medicaid Services released the Physician Fee Schedule, which announced that in 2024, community health workers supporting Medicare members could bill for their services. This recent policy change represents a significant milestone in recognizing the contributions of CHWs at the national level, while legitimizing the vital work of CHWs within the broader healthcare landscape. 

Building capacity and infrastructure: Technology’s role in CHW empowerment

By integrating CHWs into healthcare systems, organizations can improve access to health and social resources, alleviate the burden on other healthcare providers, promote culturally sensitive care approaches, and ultimately reduce overall healthcare costs in a scalable manner. However, many CHWs work in nonprofit community-based organizations, which operate with short-term programmatic grants, smaller team sizes, and outdated documentation tools, including paper and Excel spreadsheets. These financial, workforce and infrastructural factors lead to programmatic ebbs and flows and create substantial barriers for organizations interested in new reimbursement mechanisms. Additional challenges include potential competency gaps by nonprofit leaders, extensive administrative and compliance requirements with submitting claims, and variable technology skills among workers. 

This is where the power of emerging technologies — care navigation platforms, mobile applications, telehealth and remote monitoring systems, and AI-powered virtual assistants and documentation tools, to name a few — has the biggest potential to help community-based organizations overcome these challenges. If developed well, technology can meet the extensive compliance and billing requirements, improve work efficiency, and boost clinical and financial outcomes, all while presenting flexibility for the diversity of organizations employing this workforce. This has led technology companies to scale tremendously across the country and partner with health plans to supercharge CHW organizations.     

Looking ahead: Unlocking the potential of CHWs in a changing healthcare paradigm

Despite the known challenges for CHWs and community-based organizations, as well as uncertainties surrounding federal and state funding priorities, there is undeniable momentum from leaders across the political spectrum toward empowering this transformative workforce. Widespread training initiatives, advocacy efforts, and technology innovations could help to unearth equitable social care now, ensuring that CHWs receive the recognition, support, and sustainable funding they deserve. At the same time, the healthcare industry’s renewed focus on community-based care models underscores the pivotal role of CHWs in bridging care gaps, with research and claims data further validating their economic and social impact. Most importantly, policymakers, healthcare providers, health plans, and CHWs themselves must be at the table to develop scalable strategies that deploy impactful programs and ensure long-term sustainability.

Photo: Irina_Strelnikova, Getty Images

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