SummaryThe Minnesota Community Health Worker Alliance (a broad-based, statewide consortium of community health workers, public agencies, and nonprofits) prioritizes building the community health worker field as a key strategy for addressing health disparities in the state. To this end, the Alliance has created a set of integrated workforce building blocks including a scope of practice; a statewide, competency-based curriculum and certificate program; and awareness-building strategies directed to key audiences including providers, policymakers, and the public. This work led the way for the passage of State legislation authorizing Medicaid payment for specific community health worker services provided under clinical supervision. Long term, the Alliance is aimed at addressing health disparities by fully integrating community health workers into the health care, public health, and social service systems. The Alliance has made significant progress towards its goals, through an expanding network of community health worker education partners; the growing number of trained community health workers; and the increased integration of community health workers into the Minnesota health system, through incorporation into a variety of health care settings, including the state's certified health care homes workforce, and enrollment as Medicaid providers.Suggestive: The evidence consists of post-implementation data on the number of community health workers being trained through the established curriculum, along with various indicators of the degree to which community health workers have been integrated into varied care settings and the number of individuals enrolled as Medicaid providers.
Developing OrganizationsMinnesota Community Health Worker Alliance
The Minnesota Community Health Worker Alliance
Use By Other OrganizationsWhile Minnesota and Alaska are the only states to have established Medicaid reimbursement for specific community health worker activities, several states have community health worker certification programs, including Alaska, Indiana, Nevada, North Carolina, and Ohio. Massachusetts passed legislation in 2010 establishing a formal board of certification for community health workers, which is currently developing certification criteria. More than two dozen organizations outside Minnesota have purchased the Minnesota community health worker curriculum.
Date First Implemented2003
The Minnesota Community Health Worker Policy Council, precursor to the Minnesota Community Health Worker Alliance, was formed in 2003-2004 by the Healthcare Education Industry Partnership under the auspices of the Minnesota State College and University System. To further its goal of addressing health disparities, the Council quickly adopted a broader community health worker field-building agenda that went beyond community health worker education, and encompassed workforce development and financing strategies. The Minnesota State legislature approved unit-based reimbursement of community health workers under Medicaid in 2007, with the Centers for Medicare and Medicaid Services granting approval in 2008.
Insurance Status > Medicaid
Like many states, Minnesota faces deep racial and ethnic health disparities, rapidly rising health care costs, and growing shortages in the primary care workforce, particularly among those who are able to provide culturally appropriate care to increasingly diverse populations. While community health workers have the potential to address these problems, serious barriers block their widespread employment. These include lack of awareness by providers and administrators combined with lack of standardized training and lack of sustainability funding. Together these factors have impeded the integration of community health worker services in primary care.
- Health disparities: Minnesota is consistently ranked among the healthiest states in the nation. However, health disparities among different groups exist. Overall, populations of color and American Indians experience shorter life spans; higher rates of infant mortality; and a higher incidence of diabetes, heart disease, cancer, and other diseases.1 Health disparities are an important challenge for Minnesota as the state has a large and growing immigrant and underserved community. For example, Minnesota is home to the country’s largest Somali and second-largest Hmong populations, and has significant numbers of immigrants from Central and South America. Minnesota also has sizable African American, Native American, and deaf communities.
- Healthcare workforce under-representation of racial and ethnic minorities: Minorities are significantly underrepresented among physicians, nurses, and other health professionals in Minnesota. Key impediments to minorities accessing quality health care include language barriers and living in underserved areas, problems that research suggests can be addressed by racially and/or ethnically diverse providers.2
- Rapidly rising costs: Though Minnesota spends less per capita on health care than the U.S. as a whole, State health care expenditures have grown (and are expected to continue growing) rapidly. Total expenditures more than doubled between 1998 and 2008, and are expected to double again between 2008 and 2018.3
- Widespread shortages in primary care workforce: As of April 2011, the Health Resources and Services Administration had designated 128 geographic areas in Minnesota as having a shortage of primary care health professionals. Parts of 30 Minnesota counties—mostly in the western and northern parts of the state—are designated as health professional shortage areas.4
- Unrealized potential of community health workers:
- Benefits of community health workers: Various studies support the benefits that community health workers can provide to the care team. Community health workers have been shown to improve the provision of culturally competent care, enhance access to and the cost-effectiveness of care, and improve chronic disease care. For example, a Denver study of 590 men receiving community health worker–led case management found that these services increased use of primary and specialty care and reduced use of urgent care and inpatient and outpatient behavioral health care. The program yielded $2.28 in cost savings for every dollar spent on it.5 A second example comes from the Southeast Asian Birthing and Infancy Project in Massachusetts, which used trained, bilingual, and bicultural community health workers to provide enhanced prenatal care for ethnic and linguistic minorities, including general health advocacy and education services. The program significantly increased enrollment in early prenatal care, with the proportion of young pregnant woman waiting until their third trimester to register for such care falling from 40 percent to 5 percent in the first 2 years of the initiative.6
- Barriers to realizing these benefits: As yet, community health workers seldom function as integrated members of primary care–based teams. Few primary care organizations make use of community health workers, and those that do may use them in an “add-on” role. Barriers to community health workers playing a more formal role include lack of provider awareness about the valuable role that community health workers can play, inadequate training and certification programs to ensure an ample supply of qualified community health workers, and lack of a consistent funding mechanism to reimburse organizations for community health worker services. A workforce analysis from the Health Resources and Services Administration found that community health worker positions tend to be short-term and low-paid, with little recognition from other health care professionals.7
Description of the Innovative Activity
The Minnesota Community Health Worker Alliance, known for nearly a decade as the Minnesota Community Health Worker Policy Council, prioritizes building the community health worker field as a key strategy for addressing health disparities. To this end, the Alliance created a set of integrated workforce building blocks including a scope of practice; a statewide, competency-based curriculum and certificate program; and awareness-building strategies directed to key audiences including providers, policymakers, and the public. This work led the way for the passage of State legislation authorizing Medicaid payment for specific community health worker services provided under clinical supervision. Key elements of this initiative are outlined below:
- Defining community health worker scope of practice: The Council (now known as the Minnesota Community Health Worker Alliance) created a standardized scope of practice for community health workers in the state, highlighting five central roles, outlined below:
- Bridge gap between communities and health/social service systems: As members of the local community, community health workers are well positioned to facilitate communication between provider and patient to clarify cultural practices, educate community members about appropriate use of the health care and social service systems, and educate the health and social service systems about community needs and perspectives.
- Help patients navigate health and human services systems: Community health worker roles include promoting access to primary care through culturally competent outreach and enrollment strategies, making referrals and coordinating services, educating patients on the knowledge and skills needed to obtain care, providing followup services to facilitate continuity of care, enhancing access to coverage by assisting clients in enrolling in public assistance and other programs for which they qualify, and linking clients to and informing them of available community resources.
- Advocate for individual and community needs: Community health worker roles include engaging communities and individuals in advocating for themselves, articulating and advocating on behalf of the needs of the community and individuals (especially those unable to speak for themselves), and understanding the resources and support available in local communities.
- Provide direct services: Community health workers provide direct services to patients and providers, including providing culturally appropriate information on health, wellness, and disease prevention and management; assisting clients in self-management of chronic illnesses and medication adherence; organizing and/or facilitating support groups; providing referrals and linkages to preventive services (e.g., screenings); and conducting health-related screenings.
- Build individual and community capacity: Community health workers work to identify individual and community needs. They help build the capacity of individuals for wellness. They help build the capacity of communities by addressing the social determinants of health. They also mentor other community health workers to build their capacity. They promote their own professional development through continuing education and peer support.
- Competency-based training and credentialing program: With support and guidance from the Council (now known as the Minnesota Community Health Worker Alliance), a multistakeholder committee developed a standardized curriculum and certificate program for community health workers. Representatives of educational institutions did the bulk of the work, taking into account the input of other committee members. Additional details on the resulting curriculum, certificate process, and other training appear below:
- Curriculum: The initial 11-credit curriculum later expanded to 14 credits so that students could receive specialized training in health promotion and disease management, including areas such as diabetes, cancer, mental health, and oral health. Open to experienced community health workers and new entrants into the field, the revised curriculum consists of competency-based training to prepare students to play the roles outlined above (12 credits), along with an internship in a community health service setting (2 credits). Full-time students attending either daytime or evening classes can complete the curriculum in a semester, while part-time students typically require a full school year. The course is offered by community colleges, a private university, and a vocational training center. Tuition ranges from $3,000 to $10,000, depending on the campus, and financial aid is available to qualified students. The Alliance is currently creating an online version of the curriculum to expand access to community health worker education in rural education. Credits earned by community health worker students in the Minnesota State College and University System may be applied to other health occupations training programs.
- Certificate of Completion: After successfully completing the program, students receive a certificate that is required by the Minnesota Department of Human Services to apply for enrollment as a provider for Minnesota Health Care Programs and qualify for Medicaid payment for health education services delivered under clinical supervision. Each individual receives a unique Minnesota provider identification number, which their employer can use to bill for their services.
- Quarterly training for practicing community health workers: The Minnesota Community Health Worker Peer Network (a separate community health worker–led network associated with the Alliance) offers networking opportunities and training sessions four to six times per year on topics chosen by participating community health workers.
- Developing a stable source of funding: Recognizing the necessity of sustainable funding for community health workers to move from occupying a temporary position to part of the mainstream system, in 2005, the Blue Cross Foundation commissioned the National Fund for Medical Education at the University of California–San Francisco Center for the Health Professions to conduct the first national study of sustainable financing mechanisms for community health workers. The study helped inform the Council's evaluation of different payment streams for community health worker services. Through the distribution of nonpartisan research and analysis on evidence-based return on investment, the Council raised awareness of the value of community health worker services in addressing health disparities and various options for support including Medicaid. Additionally, health plan members voiced support for this approach and indicated that they would also reimburse community health worker services if the changes were made. As a result, policymakers saw a need for sustainable funding for the community health worker workforce to effectively tackle growing health disparities in Minnesota. The original policy was presented as Medicaid budget neutral with a potential result in net cost savings to Minnesota Health Care Programs. The Minnesota legislature made the following modifications to State laws governing Medicaid:
- Community health worker as Medicaid-approved provider: In 2007, the legislature passed (and the Federal government approved) a statute that included a Medicaid payment option for community health workers health education services, thus making these community health worker–provided services eligible for reimbursement. Requirements for reimbursement include receiving a certificate from an accredited Minnesota post-secondary school that offers the statewide community health worker curriculum and supervision by a physician or advanced practice nurse who is also enrolled in the state’s Medicaid Program. A time-limited grandfathering process was outlined in the statute for those community health workers with 5 or more years of supervised experience.
- Allowing others to serve as supervisors: In 2008, the legislature authorized certified public health nurses working in a unit of government and dentists to serve as supervisors of community health workers. In 2009, the legislature authorized mental health professionals to serve as supervisors. The Federal government approved both changes.
Context of the InnovationThe Alliance is a consortium of more than 30 organizations representing all major stakeholders in the Minnesota health care system, including educational institutions (both colleges and universities), government agencies, providers, professional associations, insurers and other payers, and foundations. These groups partnered together to address health disparities through a community health worker–based strategy that would also expand and diversify the health care workforce, increase provider cultural competence, and help achieve the triple aim (better outcomes, healthier populations, and lower costs).
The Minnesota Community Health Worker Policy Council, precursor to the Minnesota Community Health Worker Alliance, was formed in 2003-2004 by the Healthcare Education Industry Partnership under the auspices of the Minnesota State College and University System. The organization's name was changed to the Minnesota Community Health Worker Alliance and its committee structure was formalized in 2010. The Alliance incorporated as a nonprofit in 2011 and developed a new governance board in 2012.
ResultsThe Alliance has made significant progress in implementing its strategy for addressing health disparities, through a growing network of community health worker education partners, an increase in the number of trained community health workers, and the increased integration of community health workers into the Minnesota health system through incorporation into a variety of health care settings, including several of the state's certified patient-centered medical homes, and enrollment as Medicaid providers.
Suggestive: The evidence consists of post-implementation data on the number of community health workers being trained through the established curriculum, along with various indicators of the degree to which community health workers have been integrated into varied care settings and the number of individuals enrolled as Medicaid providers.
- Growth in the number and type of schools that offer the certificate program: The certificate program has been offered by six schools including community colleges, a private university, and a vocational training program. Two additional schools are in the process of gaining approval to introduce the program in 2013-2014. In addition, courses within the training program are accepted by other educational institutions as credit toward degree or certification requirements in other health-related fields, which allows community health workers to more easily pursue training in nursing and other health professions.
- Expanding cohort of community health worker certificate holders: Each year, the program trains an average of 50 to 70 individuals. There are now more than 500 community health worker certificate holders in Minnesota including approximately 65 who were grandfathered based on their supervised experience without having to complete the formal training program.
- Formal integration into a variety of health care settings: More than 100 organizations currently employ community health workers in Minnesota. Recent Wilder Research Center survey data from a sample of Minnesota community health workers show that community-based organizations are the largest single employer category with 56% of community health worker respondents, followed by public health (12%), other (11%), hospitals (7%), and clinics (6%).
- Greater recognition as part of medical health care team: Community health workers have received increased recognition as an integral part of health care teams in Minnesota. Three health care home programs in the Twin Cities have embedded community health workers on their teams so far. Hennepin County Medical Center, Minneapolis, the county’s safety-net hospital, has hired and trained 14 community health workers for its program as care coordinators. NorthPoint Health and Wellness Center, Minneapolis, a federally qualified health center, employs 4 community health workers in its program, and HealthEast Care System, the largest health provider serving St. Paul and its suburbs, is in the process of hiring a total of 14 community health workers as "care guides."
- Enrollment as Medicaid providers: According to the Minnesota Department of Human Services, approximately 30 community health worker certificate holders from hospital, clinic, and local public health are enrolled for Medicaid payment for health education services that they provide to Minnesota Health Care Program clients. Since the community health worker role is still new to the clinical and public health environments where the payment is authorized (i.e., hospitals, clinics, dental offices, community mental health centers, local public health), each enrolled community health worker represents a delivery system change with human resources, credentialing, billing, medical records, and other implications that involved the cooperative efforts of many individuals in different departments. Community nonprofits that employ community health workers are now beginning to explore contractual arrangements with providers and health plans for specific community health worker services.
Planning and Development Process
Key steps included the following:
- Initial research: The Blue Cross and Blue Shield of Minnesota Foundation conducted research to learn about the needs of local employers and community health workers. This process, which included employer surveys and focus groups with community health workers, identified the need for standardized community health worker training and for community health worker peer support and continuing education. As part of this effort, the Minnesota Department of Health provided information on patient populations that could benefit most from greater use of community health workers.
- Forming curriculum committee: The Council formed a committee composed of community health workers and representatives from educational institutions, providers, payers, and other organizations to develop the curriculum. The group included substantial representation from federally qualified health centers, which were viewed as prime community health worker employers because of their focus on the underserved.
- Forming policy committee: At the same time, the Council formed a policy committee to explore and develop policy responses to the need for sustainable funding for the work of community health workers to address health disparities. The committee met monthly and its work was informed by a white paper commissioned by the Blue Cross and Blue Shield of Minnesota Foundation on potential models for financing community health worker services.
Resources Used and Skills Needed
- Staffing: The Alliance has one part-time contractor—its interim executive director. Similarly, the Policy Council was also staffed part-time with grant support. Board members and representatives of member organizations allocated time to create the scope of practice, design and implement standardized training, develop communication tools, and build allies and support for community health worker education and employment to improve the health of Minnesota communities.
- Costs: Earlier work was supported with several grants totaling $460,000. Current efforts are also grant-supported at a lower level and fundraising continues to sustain the work.
Funding SourcesRobert Wood Johnson Foundation; Mayo Clinic; Fairview Health Services; Susan G. Komen Foundation; Minnesota Department of Health; Blue Cross Blue Shield of Minnesota Foundation; Otto Bremer Foundation; Randy Shaver Cancer Foundation; UCare Minnesota; Minneapolis Foundation; Minnesota State Colleges and University System; Health Partners; Delta Dental of Minnesota; Blue Cross and Blue Shield of Minnesota Foundation
A group of foundations and other stakeholders supported development and implementation of the community health worker curriculum. Key funders included The Robert Wood Johnson Foundation ($300,000 over 4 years) and the Blue Cross and Blue Shield of Minnesota Foundation ($150,000 to $160,000 over 2 years). Other funders include: UCare Minnesota, Health Partners, Minnesota Department of Health, Otto Bremer Foundation, Fairview Health Services, Delta Dental of Minnesota, Minnesota State Colleges and University System, Minneapolis Foundation, Randy Shaver Foundation, Susan B. Komen Foundation, and the Mayo Clinic.
Tools and Other Resources
More information on the Community Health Worker Alliance is available at: http://www.mnchwalliance.org.
A detailed description of the curriculum is available at: http://s472440476.onlinehome.us/wp-content/uploads/2013/05/EducationCurriculum.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .). The curriculum is available from the Minnesota State College and University System, which holds the copyright. It is offered at no charge to Minnesota post-secondary schools committed to community health worker education and for purchase by organizations located outside of Minnesota.
Getting Started with This Innovation
- Enlist all interested parties, including payers: Key stakeholders include providers, payers, community not-for-profit organizations, State and local public health departments, post-secondary schools, professional/trade associations, and community health workers.
- Conduct detailed needs analysis: This analysis can help to determine the number of community health workers needed, which communities need them, how many community health workers are already available and how they are paid, prospective employers of community health workers, and available training resources.
- Work with colleges and universities: These organizations can help develop the curriculum and staff the training and certificate programs, particularly in areas with a need for many additional community health workers. The curriculum available from the Minnesota Community Health Worker Alliance can provide a starting point.
- Involve community health workers in all aspects of the initiative: Community health workers need to "be at the table" to weigh in on decisions and ensure strategies to allow them to meet the needs of local communities.
- Engage funders as partners: Funders can often contribute more than funding, such as technical assistance, consultation, communications expertise, volunteers, event planning, and evaluation assistance.
Sustaining This Innovation
- Modify curriculum as necessary: Over time, the curriculum can be expanded to increase the scope of practice and/or otherwise improve the skills of those receiving training. Also, continue to invite input to improve the curriculum for the next revision and utilize technology best practices for learning, access, and affordability.
- Monitor policy developments: Periodically assess strategic and policy options to expand the scope or reach of community health workers.
- Build organizational infrastructure and capacity: Consider the best way to organize, support, and site this work to stay value-based, relevant, and effective.
- Plan and launch a multimedia community health worker identity campaign: Boost awareness and understanding of the community health worker role and its value to community members, providers, policymakers, and the media.
- Integrate workforce strategies: Integrate these strategies with health reform opportunities and look to make them system-wide.
- Document impact with data and stories: Compile and synthesize research, program evaluation, testimonials, and examples to build a strong case for community health worker impact.
- Develop community health worker leadership: Promote community health worker leadership development for governance, committee, spokesperson, and organizational roles.
- Develop partnerships: Continue outreach and education to build allies and partners to meet shared goals; learn from best practices across the U.S.
Contact the InnovatorJoan Cleary
Minnesota Community Health Worker Alliance
c/o American Cancer Society, Midwest Division, Inc.
2520 Pilot Knob Road, Suite 150
Mendota Heights, MN 55120
Director of Project Design and Development
Minnesota State Colleges and Universities
Innovator DisclosuresMs. Cleary reported funds were provided to the Alliance by the Blue Cross and Blue Shield of Minnesota Foundation. Ms. Cleary received funds from the American Cancer Society through her position providing interim management of the Alliance; The American Cancer Society is the fiscal agent for the Minnesota Community Health Worker Alliance and manages the Alliance's funds. Ms. Cleary was formerly employed by the Blue Cross and Blue Shield of Minnesota Foundation from 1999 to 2010. Ms. Willaert reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
Blue Cross and Blue Shield of Minnesota Foundation. Community Health Workers in Minnesota: Bridging Barriers, Expanding Access, Improving Health, 2010. Available at: http://bcbsmnfoundation.com/pages-mediacenter-tier3-Publications?oid=7146&category=all#.
Cleary J, Eastling J, Itzkowitz V. Community Health Workers in Minnesota: Bridging Barriers, Expanding Access, Improving Health. Blue Cross and Blue Shield of Minnesota Foundation; 2010.
Community Health Worker Project of the Minnesota Department of Health. Available at: http://www.health.state.mn.us/ommh/projects/chw.html.
Dower C, et al. Advancing Community Health Worker Practice and Utilization: The Focus on Financing. National Fund for Medical Education, Center for the Health Professions. University of California–San Francisco, 2006.
Fedder DO, Chang RJ, Curry S, et al. For the patient. The effectiveness of a community health worker outreach program on healthcare utilization of west Baltimore City Medicaid patients with diabetes, with or without hypertension. Ethn Dis. 2003 Winter;13(1):146. [PubMed]
Hardeman R, Decker Gerrard M. Community Health Workers in the Midwest: Understanding and Developing the Workforce. Wilder Research Center, 2012.
Available at: http://www.wilder.org/Wilder-Research/Publications/Studies/Community%20Health%20Workers%20in%20the%20Midwest/Community%20Health%20Workers%20in%20the%20Midwest%20-%20Understanding%20and%20Developing%20the%20Workforce,%20Full%20Report.pdf.
Rosenthal E, Brownstein J, Rush C, et al. Community Health Workers: Part of the Solution Health Affairs, 29, no.7 (2010):1338-1342. Available at: http://content.healthaffairs.org/content/29/7/1338.abstract.
Rural Assistance Center. This resource has a summary of community health worker certification and curriculum efforts from other states. The resource is available at the Rural Assistance Center Web site.
3 Minnesota Department of Health. Minnesota Healthcare Spending and Projections, June 2010.
4 Minnesota Department of Health. Health Workforce Shortage Study Report, January 15, 2009.
Whitley EM, Everhart RM, Wright RA. Measuring return on investment of outreach by community health workers. J Health Care Poor Underserved. 2006 Feb;17(1 Suppl):6-15. [PubMed]
6 Massachusetts Department of Public Health Community Health Worker Advisory Council. Community Health Workers in Massachusetts: Improving Health Care and Public Health, December 2009.
7 Health Resources and Services Administration, U.S. Department of Health and Human Services. Community Health Worker National Workforce Study, March 2007.
|Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.|
Original publication: September 12, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 26, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.