Hello everyone. Thank you for inviting me, Ellen, and thank you all for your interest in community health workers. Funding And Integrating Community Health Workers Through Medicaid Gail Hirsch, Massachusetts Office of CHWs MA Department of Public Health February 17, 2017

Sustainable Funding: Only Part of Sustainability Tie to multiple key state strategies: CHW Professional Identity: Definition Scope of Practice Core Competencies Build consensus on value – providers, payers, policy-makers We’re here to talk about sustainable funding through Medicaid, and I’m here to tell you about some strategies we have used in Massachusetts. I’d like to make the case that we can’t get to Medicaid financing without addressing other key state strategies too. On these next couple slides, I am going to list out some strategies that I believe are working for us. Then, I will give some examples of those strategies and offer some ideas for what you can do in your state. Number #1- Build consensus on professional identity: Who are they? How are they unique? Definition What do they do? What is their scope of practice? What are their skills? Identify core competencies. #2 - Acceptance of value among providers, payers, and policy-makers: Are they effective In terms of outcomes, cost and quality? Yes, and growing evidence indicates they: Address impacts of SDOH (Medicaid interest in) Are successful at building trust Are willing to go where others won’t (heroes and heroines)

Key State Strategies for Sustainability Workforce Infrastructure: Training Occupational Regulation Concrete tools for team integration CHW Voice and Organization Public health agency support Build Workforce Infrastructure: Training Capacity and Resources Consider Occupational Regulation, such as certification Concrete tools for team integration – “HOW TO” CHW Voice and Organization – MACHW support Public health agency support (and leadership and vision)

Key State Strategies for Sustainability Convene advocacy partners: Track national trends & other states Identify barriers Develop models for CHW inclusion in emerging care and payment plans  Convene advocacy partners to: Track national trends & other states Identify barriers: Medicaid busy; who makes decisions; what do they need? Develop actual models for CHW inclusion in emerging models of care and payment

Be Ready for Windows of Opportunity In Massachusetts, we have worked on some of these strategies for a number of years, and were ready when state health reform was drafted and implemented: 2006, 2012 (payment reform). Medicaid redesign (more later)

Massachusetts CHW Definition CHWs are public health workers who apply their unique understanding of the experience, language, and/or culture of the populations they serve in order to carry out one or more of the following roles: Without going into what the definition is, it’s important to note that defining CHWs was our first policy initiative. We brought diverse players to the table; that creates buy-in. Roles: Providing culturally appropriate health education, information, and outreach in community-based settings, such as homes, schools, clinics, shelters, local businesses, and community centers; Bridging/culturally mediating between individuals, communities and health and human services, including actively building individual and community capacity; Assuring that people access the services they need; Providing direct services, such as informal counseling, social support, care coordination, and health screenings; and Advocating for individual and community needs. 

What distinguishes CHWs? Hired primarily for their understanding of the populations and communities they serve Conduct outreach a significant portion of the time Experienced serving in community settings BE CLEAR; you will get asked. Hired primarily for their understanding…..

Core Competencies Outreach Methods and Strategies Individual and Community Assessment Effective Communication Cultural Responsiveness and Mediation Education to Promote Healthy Behavior Change Care Coordination and System Navigation Use of Public Health Concepts and Approaches Advocacy and Community Capacity Building Documentation Professional Skills and Conduct Create consensus on core competencies. These ten each have detailed sub-competencies to serve as a foundation for “Core Competency Training.”

State CHW Certification: Chapter 322, Acts of 2010 CHWs drafted bill Intent: recognize & strengthen the field Voluntary & competency-based Certifies CHWs; approves training programs 11-seat Certification Board; 4 seats for CHWs; at state public health dept. Identifies scope of practice Cost neutral CHWs drafted bill. Intent: recognize & strengthen the field (not barrier, field of dreams) Voluntary & competency-based Certifies CHWs; approves core training programs 11-seat Certification Board appointed by the governor; at the state health dept.; 4 seats for CHWs Regulations identify scope of practice Set up to be cost neutral

Honoring the Grassroots Work Multiple paths to entry: grandparenting Reduce barriers: language, citizenship status, cost No minimum educational requirements Training available & accessible Acknowledges value of shared lived experience, regarding background checks Massachusetts Is taking acre as it develops its certification program to be responsive to the needs of the field: Multiple paths to entry, grandparenting Reduce barriers, such as language and cost No minimum educational requirement Training available & accessible Acknowledges value of shared lived experience with regards to background checks

Feedback: Employers “…they will realize this is an important person on the health care team, that they are bringing value…” We know it’s important to pay attention to the IMPACTS of CERTIFICATION, so we are studying that. Here is how CHW employers and CHWs felt about the PROSPECT of certification. “…they will realize this is an important person on the health care team, that they are bringing value…” "The long-term hope is that eventually CHWs will become a billable entity under some forms of insurance, and that at that point it may be important to be able to say that a person is certified." "The long-term hope is that eventually CHWs will become a billable entity under some forms of insurance, and that at that point it may be important to be able to say that a person is certified." Source: Qualitative in-depth interviews 11 11

Feedback: CHWs “…It’s acknowledgement that you are up-to-date with standards, with knowledge, with training, with the capacity to provide services to clients…" Here is what CHWs said. As you can see, both CHWs and employers have hopes that certification will advance the field. Our regulations are currently under administrative review by state government. After that will be a period of public comment, before certification “goes live.” “…It’s acknowledgement that you are up-to-date with standards, with knowledge, with training, with the capacity to provide services to clients…" "Doctors, and organizations, and supervisors, and everybody I think would accept it more, or respect it more…It's like a nurse, a nurse is respected because they have a license...and I think a CHW would be respected if they had something like that." "Doctors, and organizations, and supervisors, and everybody I think would accept it more, or respect it more…It's like a nurse, a nurse is respected because they have a license...and I think a CHW would be respected if they had something like that." Source: Qualitative in-depth interviews 12 12

Funding and Integration for CHW Services and Training “Achieving the Triple Aim: Success with Community Health Workers” Massachusetts made its “business case” for CHWs in this paper, which has circulated widely and includes models for payment and care delivery. Those taking the risk must perceive an added value. Preventive screening and timely treatment Diabetes, hypertension, cardiovascular disease High cost patients: reduced hospitalizations, including readmission rates Medication and care plan adherence No-shows Chronic disease self-management Immunization Breast and cervical cancer screening Adequate prenatal care and well-child visits Patient satisfaction Asthma

Key Roles for Public Health Convene key partners Lead collaborative efforts Dedicate staff & resources: Office of CHWs Consistent messaging Public health department investment can help pave the way for Medicaid interest. Here are some ideas to approach your state public health department with.

Key Roles for Public Health Support CHW voice: MACHW Research & disseminate best practices Policy development Occupational regulation: visible workforce investment, surveillance Be a resource: Massachusetts, regionally, nationally Here are more ways public health departments can advance the field.

State Infrastructure WHAT DOES A STATE OFFICE DO? Financing policy. Workforce development: Training and certification. Technical assistance and organizational readiness OCHWs funded by CDC chronic disease funding. *********************************************************** TA Collaborative: have the tools Training Consortium – consistency of training IntraAgency: communication/consistent messaging Key TA learnings (based on our experience, as Audrey discussed): Recruitment, hiring, critical. Require mature emotional availability; trauma specialist; they’ve shown they can cope. (Heidi on hiring): Good job description & selection/screening critical. Possible ways: 1) Social worker interview: assess ability to candidate to “stand beside”; 2) CHW team interview; 3) Whole team: role plays (CHWs play patients) to see how candidates approach the problem and work with patients; test boundaries. 4) 3 month probation. Both Clinical and Programmatic supervision important; Supervisor training critical; Team case review meetings.

Opportunities: Medicaid & DSRIP Caution: Do not put sole burden of “fixing” Social Determinants of Health on CHWs CMS rule change 2014: State plan amendment CHW Community of Practice (CoP): Statewide partners advocate for CHWs in new ACOs Medicaid knows they need to address SDOH, and they have some awareness that CHWs do that. YES, and CHWs can’t do it alone. 2013 –Federal Medicaid Rule Change Effective January 2014: We developed a proposal for high utilizers Allows Payment for Preventive Services by Non-Licensed Individuals, including CHWs Requires amendment to state Medicaid plans CoP poised to work with Medicaid – 2015-16: Show up at Redesign meetings

Opportunities: Medicaid & DSRIP Provided MassHealth with 3 evidence-based CHW models for high-risk populations: Pediatric asthma home visiting Maternal and child health CHWs CHW care coordination CoP poised to work with Medicaid – 2015-16: Show up at Redesign meetings Researched & provided 3 evidence-based models to MassHealth: High risk pedi asthma; high-risk care coordination, high risk MCH

Medicaid & Other State Opportunities DSRIP Statewide Investments in workforce CHWs educating members on ACOs Determination of Need program Community Benefits: AG Office 2012 Payment Reform law: trusts up for reauthorization in 2017 Prevention and Wellness Trust Fund Health Care Workforce Transformation Fund Training and certification: “shovel-ready” for Statewide Investments Investments in CHWs to educate members on ACOs DoN regs – SDOH Community benefits: watching DoN 2012 Payment Reform law: trusts up for reauthorization in 2017 Prevention and Wellness Trust Fund – 9 partnerships, all have CHWs Health Care Workforce Transformation Fund

What You Can Do: Is there a CHW association or network in your state? Connect with CHW activities at state health department & state public health affiliate Identify allies & decision-makers at Medicaid National resources: APHA, CDC, NASHP, ASTHO, BCBS Foundations, TFAH, HRSA, DOL/BLS Is there a CHW association or network in your state? Join and support it. They need support. Look into CHW activities at state health department & state public health affiliate Identify allies & decision-makers at Medicaid National resources for policies, tracking, state info: Alphabet soup -APHA, CDC, NASHP, ASTHO, BCBS Foundations, TFAH, HRSA, DOL/BLS SOC, HRSA and DOL collaborate on an apprenticeship program for CHWs

Be a guardian (or we will end up where we didn’t intend to) What You Can Do: Nat’l CHW association (in development) Provider champions & CHWs: go to key Medicaid open meetings, tell their stories Resources for workforce development Organizational readiness is critical Sustainability tied to integrity of the field - Be a guardian (or we will end up where we didn’t intend to) STAY TUNED: National CHW association in development Identify provider champions & CHWs to tell their stories; go to key stakeholder meetings; bring CHWs Identify resources for workforce development – DOL, HC workforce; Apprenticeship Organization readiness is critical – provider champions; have the tools Sustainability must be tied to integrity of the field, or we will end up where we didn’t intend to: Act as a a GUARDIAN

Thank you, and questions? Gail Hirsch gail.hirsch@state.ma.us Mass. DPH Office of CHWs: www.mass.gov/dph/communityhealthworkers Massachusetts Association of CHWs (MACHW): www.machw.org