1. Community Health Workers Policy Recommendations to the State of Illinois Mid-America Regional Public Health Leadership Institute Technical Assistance Project December 2012

2. The MARPHLI Team Marilyn Green, Edwardsville Regional Health Officer, IDPH Mireya Hurtado, Director of Community Outreach, IDPH Kelly Jordan-Licht, Assistant Director, Community Health Services, Kendall County Health Department (IL) Stephen Konya, Chief of Staff, IDPH Amy Sagen, Health Policy Analyst, University of Illinois Hospital & Health Sciences System (formerly Office of Governor Pat Quinn) Team Mentors: Rev. Kirsten Peachey, Director, Congregational Health Partnerships, Advocate Health Care Guddi Kapadia, Assistant Director, UIC-SPH, MCPHP

3. Background Major Policy Shifts in Healthcare Passage of the federal Affordable Care Act (ACA) Medicaid Expansion in IL Establishment of an IL Health Insurance Exchange “We Choose Health” $25M Community Transformation Grant awarded to IDPH Created by ACA, competitively funded through CDC To promote healthy lifestyles, reduce health disparities, and control healthcare spending CHW priority proposed, but not funded

4. Business Case for CHWs CHWs contribute to overall health system savings through; (1)improved prevention and chronic disease management, which reduces costly inpatient and urgent care costs. (2)cost-shifting, with increased utilization of lower cost health services. (3)indirect savings associated with reallocation of expenditures within the health care system, e.g., by appropriate team allocations within the patient centered medical home. Studies show that savings and returns range from $2.28 to $4.80 for every $1.00 spent on CHWs. Source: The New York State Community Health Worker Initiative

5. Problem Description Inconsistent utilization of CHWs statewide Lack of statewide policies or common standards in Illinois No standard definition of CHWs Limited funding/reimbursement mechanisms Uncoordinated statewide curriculum/certification Unidentified career pathways and career ladder opportunities

6. Mission Initially, charged with developing recommendations to the State of Illinois related, but not limited to the following: 1.A standard definition of a Community Health Worker 2.A model for statewide certification 3.Foundation for developing CHW curriculum 4.Criteria to develop statewide performance standards and measures

7. State Policies on CHWs “There’s no need to re-invent the wheel” CA, TX, NY, MN, MA, MI IL

8. Approach Build on current efforts in IL and learn from other state models Developed standardized questionnaires One for in-state stakeholder groups One for surveying current practices in other states Utilized questionnaires in telephone and in-person interviews Researched other state models on-line Attended in-state CHW stakeholder meetings Attended CHW sessions at 2012 APHA Annual Meeting

9. Illinois Stakeholder Engagement Current CHW efforts in Illinois: Health Connect One Center for Excellence in the Elimination of Disparities (CEED) CHW Local Network Sinai Urban Health Institute HHS Region V, Dr. James Galloway IL Workforce Investment Board (IWIB) South Suburban College Health and Medicine Policy Research Group CHW Alliance (collaborative network) Individual CHWs in Illinois

10. State Public Policy Analysis Researched CHW policy models in other states and U.S. cities States – Alaska – California – Indiana – Massachusetts – Michigan – Minnesota – New York – Texas Cities – Boston – Minneapolis – New York City – San Francisco

11. Defining Community Health Workers

12. CHWs - Who are they??? Care Coordinator Addiction Treatment Specialist Case Worker Asthma Educator Community Follow-Up Worker Asthma Family Support Worker Community Health Advisor Case Management Technician Community Health Advocate Diabetes Family Support Worker Community Health Outreach Worker HIV/AIDS Family Support Worker Counselor Mental Health Aide Natural Researcher Cultural Mediator Nutrition Advisor Eligibility Worker Nutrition Educator Family Advocate Pre-Perinatal Health Specialists Family Support Worker Outreach Worker Health Advocate Patient Navigator Cultural Interpreter Source: CHW Network of New York City

13. Definition

14. American Public Health Association (APHA) Definition “A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds 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.”

15. Designing Curriculum in Illinois

16. Curriculum Recommendations: Inclusive – language/education Popular education model Clinical fieldwork required Evidence based – best practices Core skill set – first aid/CPR Tiered advancement (levels 1, 2, 3, etc.)

17. Promising Practices Framework Source: Community Health Worker National Education Collaborative (CHW – NEC)

18. Career Pathways, Reimbursement and Portability

19. Career Pathways Recommendations: Align current IL CHW advocacy groups with the IL Workforce Investment Board (IWIB) Provide training through various levels of educational and geographic settings Define a tiered system of classifications within the CHW field Develop a “grandfathering” protocol for existing CHWs Identify positions for CHWs to transition from and into, along entire healthcare system’s career ladder (nursing, physicians, consultants, etc.)

20. Source: California Workforce Investment Board (CWIB), Health Workforce Development Council, Career Pathway Sub-Committee, Sept. 2012

21. Career Pathways Source: The Community Health Worker Initiative of Boston

22. How will they get paid?

23. Reimbursement/Funding Sources Federal or State Government Agencies Charitable Organizations Insurance (both Public and Private) Government General Funds Private Sector Companies Individual Consumer

24. Funding Mechanisms Source: National Fund for Medical Education, Advancing Community Health Worker Practice and Utilization: The Focus on Financing

25. Govt. or Charitable Foundation Grants/Contracts Source: National Fund for Medical Education, Advancing Community Health Worker Practice and Utilization: The Focus on Financing

26. Insurance – Direct Reimbursement Source: National Fund for Medical Education, Advancing Community Health Worker Practice and Utilization: The Focus on Financing

27. Govt. General Funds – Operating Budgets Source: National Fund for Medical Education, Advancing Community Health Worker Practice and Utilization: The Focus on Financing

28. Private Sector – Contract/Employment Source: National Fund for Medical Education, Advancing Community Health Worker Practice and Utilization: The Focus on Financing

29. Reimbursement/Funding Recommendations: Sustainable funding sources need to be expanded (i.e. Medicaid, private sector, health insurance plans, etc.) Analyze current funding mechanisms for effectiveness/expansion (pursue waiver or SPA for Medicaid) Ensure a minimum living wage for CHWs, if chosen as a career path While establishing system for reimbursement, avoid creating barriers for “volunteer” employees Clarify/define which health professionals can serve as supervisors of CHWs for Medicaid reimbursement models

30. Portability Recommendations: Consider standardized or widely accepted skills and credentialing, to enable CHWs to work for different organizations both within the same state, as well as across state lines. Enable State credentialing authority to provide an “endorsement” of CHWs who have received certification in other states that meet similar standards. Ensure transferability of state recognized CHW course work/training into curriculums for other healthcare degrees/certifications (career ladder - advancement opportunities).

31. Establish a Statewide Board

32. Development of a Statewide Board Recommendations: Convene an internal state task force to conduct an assessment of the potential impacts of incorporating CHWs into the state’s public health programs and the state health care system Consider legislative action to formalize and standardize CHW training, curriculum and certification that includes the establishment of an advisory board that will assist in the development of training, curriculum and certification of CHWs Establish an advisory board to assist in the development of training, curriculum and certification of CHWs. Members of the board should include, but not be limited to; Community Health Worker(s) CHW employers Educators in community health worker related curriculums Members of public health associations Health researchers Members of the public.

33. Integration of CHWs in Rural Areas

34. Rural Area Considerations Be sensitive to rural community differences, such as; Safety Cultural/language barriers Internet Access/Wireless Connectivity Referrals Resistance to change issues Access to required education/credentialing Create a “fair playing ground” for; Grants Contracts Reimbursement rates Training

35. Next Steps Present Recommendations State government leadership Statewide boards and commissions CHW stakeholders Collaborate with partners to develop statewide standards and policies on CHWs

36. Thank You! Questions?