Provide a brief description of community health workers and how they are regulated in Connecticut and other states.

Community health workers (CHWs) help members of a community access health and social services. According to the American Public Health Association, they are “frontline public health workers who are trusted members of or have an unusually close understanding of the community served.” This relationship allows the CHW to (1) serve as a liaison between community members and health and social services, (2) facilitate access to these services, and (3) help improve the quality and cultural competency of service delivery. Generally, CHWs include community health advocates, outreach educators, doulas, patient navigators, and peer health promotors, among others.

CHWs typically work for nonprofit organizations, government agencies (e.g., local health departments), community health centers, home care agencies, and hospitals. Generally, they are funded through a combination of private, local, state, and federal funds. Some states, such as Minnesota and North Dakota, allow CHWs to participate in Medicaid and receive payment for certain care coordination and patient education services.

Regulatory requirements for CHWs vary across states. According to the Association of State and Territorial Health Officials (ASTHO), most states, including Connecticut, do not require CHWs to obtain state certification or licensure. Six states (Maine, Massachusetts, New Mexico, Ohio, Oregon,

and Texas) have laws and regulations establishing CHW certification programs. Eleven states

(Florida, Indiana, Michigan, Minnesota, Mississippi, Nebraska, Nevada, New York, Rhode Island, South Carolina, and Washington) do not have laws, but have state certification programs. Certification programs are often administered by states agencies or local health departments. Additionally, Maryland and Illinois enacted laws establishing a CHW taskforce or advisory council to create certification requirements.

Although Connecticut does not regulate CHWs, in 2014 the state received a four-year, State Innovation Model (SIM) federal grant that included funding to promote the use of CHWs, including establishing a state certification program. Additionally, 2017 legislation requires the director of the SIM Initiative Program Management Office to study the feasibility of creating a CHW certification program. The director must report on the study to the Public Health and Human Services committees by October 1, 2018 (PA 17-74).

CHWs generally serve as a bridge between communities and health care providers. Examples of CHW roles include:

1. community outreach and mobilization,

2. client advocacy and empowerment,

3. disease prevention and chronic disease management,

4. navigating the health care and social service systems,

5. serving as a community and cultural liaison,

6. case management and care coordination,

7. delivering home- and community-based support services, and

8. health promotion and coaching (see Figure 1).

*Source: www.mnchwalliance.org

Connecticut does not regulate or license CHWs, but has promoted their use. In 2014, the state received a $45 million State Innovation Model (SIM) four-year test grant from the federal Centers for Medicare and Medicaid Services. Approximately $1 million of the grant funds must be used to promote the use of CHWs, including (1) conducting a workforce needs assessment, (2) establishing a training curriculum and certification program, (3) developing and evaluating a placement and community college partnership program, (4) developing sustainability models, and (5) facilitating stakeholder meetings.

Additionally, 2017 legislation establishes a statutory definition for CHW and, based on that definition, requires the director of the State Innovation Model Initiative Program Management Office to study the feasibility of creating a community health worker certification program. The

director must do this within available resources and in consultation with the Department of Public Health Commissioner and the office's Community Health Worker Advisory Committee. The study must examine the fiscal impact of implementing the certification program and make recommendations on:

1. requirements for initial certification and renewal, including training, experience, and continuing education requirements;

2. methods for administering the certification program, including an application; standardized assessment of experience, knowledge, and skills; and an electronic registry; and

3. requirements for recognizing training program curricula that are sufficient to satisfy certification requirements.

The director must report on the study and recommendations to the Public Health and Human Services committees by October 1, 2018 (PA 17-74).

The following examples illustrate different ways states regulate CHWs.

Indiana. The state's Division of Mental Health and Addiction and Department of Health established a CHW training and certification program. To obtain certification, a person must be at least 18 years old, a resident, and have at least a high school diploma or equivalent. Applicants must complete a three-day training and final exam. The training covers various topics, such as communication skills, prevention, chronic illness, outreach, behavioral health, and advocacy, among others. After obtaining certification, CHWs may serve clients in outpatient medical and behavioral health settings, such as hospitals, medical clinics, schools, and community centers. To maintain certification, CHWs must complete 14 hours of continuing education credits annually.

Massachusetts. In 2010, the state legislature enacted a law establishing a voluntary certification program for CHWs (Chapter 322 Acts of 2010). The law created a Board of Certification of CHWs, located within the Department of Public Health's Division of Health Professions Licensure to oversee the voluntary certification program. In June 2017, the board held public hearings on its proposed regulations to implement the certification program. (The regulations have not yet been finalized.) The proposed regulations would require CHW certification applicants to successfully complete either (1) 80 hours of classroom training in a combination of health topics from a state-approved training program or (2) 4,000 hours of relevant work experience. To maintain certification, a CHW must complete 15 hours of continuing education every two years.

Minnesota. The state allows CHWs to participate in Medicaid and receive payment for care coordination and patient education services. To become a Medicaid provider, a CHW must either (1) obtain certification from the State Colleges and Universities System's CHW curriculum or (2) have at least five years of supervised experience with a Medicaid-enrolled physician, registered nurse, or advanced practice registered nurse. (The latter requirement is a grandfather provision that applies only to certain CHWs). All CHWs must work under the supervision of the health providers listed above. Certification is only required for CHWs receiving Medicaid reimbursement.

Ohio. The Ohio Board of Nursing administers the state's CHW certification program. The program is voluntary, but the law prohibits anyone from using the title “CHW” without obtaining state certification. Applicants must be at least 18 years old, have a high school diploma, or equivalent, and successfully complete a board-approved training program. The training program must include at least 100 hours of classroom instruction, 130 hours of clinical instruction, and a standardized examination. Certificates must be renewed biennially after completing 15 hours of continuing education (Ohio R.C. §§ 4723.81 and 4723.82).

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