By Melanie Raskin
Now, more than ever, states are feeling the call to close the gap between the healthcare workforce they have and the healthcare workforce they need. That gap is deep and wide–as it is across the nation. With neighborhoods representing hundreds of countries, cultures, and ethnicities dotting the nation, it is clear that a broader, more diverse, and culturally-competent healthcare workforce is needed to provide crucial services.
Building the bridge across that gap is community health workers. Trusted and treasured public health professionals who are a part of and solidly invested in their service community, CHWs connect people to social and health services. Sometimes paid, sometimes volunteers, CHWs are local people working part- or full-time with clinics, health centers, nonprofits, public health departments, medical practices, faith organizations, and other agencies. They are committed to improving health knowledge and self-sufficiency in the neighborhoods they know and care about through outreach, education, informal counseling, social support, and advocacy… which also improves health outcomes.
Now, North Carolina is exploring a commitment of its own: to create a standardized system for training, delineating skills, paying, and better integrating CHWs into the current, corporate health system of hospitals, medical centers, and insurance carriers. The goal? Officially connect the dots between traditional health systems and boots-on-the-ground healthcare workers: in a word, empowerment… not just for CHWs, but also for patients.
The Case for Community Health Workers
Changes to healthcare law have created a new paradigm: the need to combine value pricing with more integrated team-based care. But to do that, first you have to understand the factors affecting how people receive care. Studies show that 
the biggest boosts to health are not from traditional healthcare, such as the doctor’s office or a hospital. The ability to thrive is actually based on where people live, work, pray, and learn. The Robert Wood Johnson Foundation (RWJF) found that a person’s health is 20 percent related to clinical care and 80 percent based on social and economic factors, health behaviors, and the physical environment.The problems come when communities lack quality (or any) resources or face barriers: People quickly go from thriving to barely surviving.
“We already experience immensely expensive downstream impacts associated with a lack of access to early childhood education; quality housing; childcare; and affordable, healthy food. All play a critical role in producing higher school dropout rates, delinquency, substance abuse, homelessness, and unprecedented rates of chronic disease,” says Kevin Barnett, Senior Investigator for The Public Health Institutein Oakland. He is part of The California Future Health Workforce Commission, a team tasked with defining credentials, training, and deployment strategies for CHWs to better serve California’s ever-expanding health needs with increased diversity and a solid plan to address health inequities by the year 2030.
“All of this costs a lot of money–and the cost is only going to go up,” says Barnett. “Hospitals are looking down the road and seeing many people in communities without access to the basics, which means they are much more likely to be sick and in our ERs. Plus, providers are now being told care is about value and every time a sick person comes in–and has to come back–they lose money. That has the potential to push these healthcare system leaders, who are among the biggest employers in communities across the nation, to seek more robust engagement in the civic arena about better grocery stores, housing, schools, job opportunities, and childcare. It is so much bigger and with vaster impacts–and it should be. Now, it’s going to be about investing in communities, which is very exciting.” Enter community health workers… and just in time.
The Case for Community Health Workers in North Carolina
As North Carolina’s population grows and ages, so will the need for CHWs. A July 2017 Census Bureau report concluded that of the 10.3 million people in the state, 16 percent were age 65 and older. That percentage is only going to increase. By 2030, one in five North Carolinians will be 65 or older; by 2035, this population will outnumber children under age 18.
This is especially relevant, based on a NC CHW Stakeholder Initiative survey last summer. Surveyed CHWs (168 in 42 counties) reported their largest client base was seniors over the age of 65 (47 percent) with multiple chronic diseases including diabetes (55 percent), heart disease (45 percent), and mental health issues (47 percent). CHW activities included connecting clients to healthcare (80 percent), food assistance (54 percent), and transportation (46 percent). Clients included the uninsured (52 percent), those living with a disability (46 percent) and rural residents (42 percent). Based on the forecasts, the role of the CHWs in the healthcare delivery process is only going to increase.
According to Tish Singletary, Community Health Worker Program Coordinator in the NC Department of Health and Human Services’ Office of Rural Health, CHWs are the trusted, contextual experts of the communities they serve. They are both the outward- and inward-facing professional partners to healthcare systems and other organizations that want to practice whole person health. “Team-based care is a combination of whole-person care and accountable care communities,” she explains. “That means there is no stopping of the healthcare community and beginning of CHWs. We need to include CHWs in the conversation about the care of the client/patient. The health outcomes for that client/patient are dependent upon the entire team. The healthcare community (aka team) all need to value the expertise of each other and create a level of service that is client/patient-centered. In turn, the client/patient should feel valued in the process. Time and again, I have heard feedback from CHWs who have clients that have reported negative experiences with the healthcare community, including cultural barriers, lack of time, and perceived disrespect and mistrust of the healthcare community. CHWs can empower and build the confidence of clients to address their needs with healthcare providers. CHWs can also assist the healthcare providers in building their confidence working with those patients.”
It makes sense that the community should be an active participant in the healing of the community. “One of our CHWs working through FaithHealthNC had a referral from the ER who needed help in something socially-driven,” says Jeremy Moseley, Project Administrator of Community Engagement for FaithHealth NC and a team member in the NC CHW Stakeholder Initiative. “When the CHW and client got together, they realized they not only knew each other but were actually related. You can’t train or design that kind of connection. If you have people from the community–with an ingrained sense of community–serving the community, they provide avenues of support the traditional healthcare system can’t. There’s faster trust and a sense of connection. CHWs have a social intelligence that is really just as smart as medical strategies and techniques. You need that to navigate these complex communities. It’s a lot like surgery: You have to know the body to do surgery. The same goes for communities.”
How Credentialing NC CHWs Will Look
The credentialing process is all about building an infrastructure for sustainability for CHWs in North Carolina. But how do you accomplish that when you have thousands of people working to connect people to wholeness with more than 150 job descriptions ranging from HIV Peer Advocate to Asthma Outreach Worker to Wellness Ambassador to Diabetes Navigator to Addiction Treatment Specialist to Care Coordinator to Mental Health Worker to Bilingual Family Advocate to Parent Aide? You do it carefully and slowly. The state aims to implement a standardized core competency training, create a certification process, develop a NC CHW Network, ensure CHWs are being paid a family-supporting wage, and develop a process that includes a potential for specialized training. The plan is to phase in some elements, such as CHWs supporting the Medicaid system in 2020. And it will be a rolling process: Current CHWs will be grandfathered in–some will go the employment route and some will go the certification route. It’s a plan built for success–for CHWs andfor communities.
CHWs Make a World of Difference to Patients
More and more in this constantly changing healthcare world, we’re discovering that it takes a village to care for the 
village. CHWs are a vital part of that village. North Carolina is working to formalize the status of CHWs and ensure their meaningful contributions for years to come. “I envision that CHWs will become integral healthcare team members, as valued as they are in the communities they serve,” Singletary concludes. “In a perfect world, there will be a coordinated network of CHWs which allows them a platform to coalesce around their professional needs and advocate for themselves and the needs of their communities beyond health. This future will include intentional multi-sector partnerships that work to eliminate those environmental and social factors that negatively impact health outcomes and value the efforts of CHWs as part of an equation to eliminate those factors.”
Jeremy Moseley agrees that the future of NC CHWs is bright with promise–as is the health of North Carolinians. “I am excited about credentialing CHWs, giving them the respect they deserve, fixing the social determinants, and creating workforce opportunities in–and for–the neighborhoods that need them the most. I expect a more understanding world that realizes there are assets and resources that are positive in communities that we have not tapped into yet, like CHWs. These are pieces that can give us life and more wellness instead of focusing on disease, sickness, and death. The goal is to leverage those pieces and change the way we think about healthcare and public health.”
