Q&A with Dr. Alana Knudson, Co-Director of the NORC Walsh Center for Rural Health Analysis

The HRSA Federal Office of Rural Health Policy has funded rural communities to implement community health worker (CHW) programs as part of the 330A Outreach Authority program, which focuses on reducing health care disparities and expanding health care services in rural areas. One product of this work is a toolkit to help other communities benefit from what has been learned, developed by the NORC Walsh Center for Rural Health Analysis, as part of NORC’s ORHP-funded Rural Health Outreach Tracking and Evaluation Program. Health Workforce News had the opportunity to interview one of the key authors of this toolkit, Walsh Center Co-Director Dr. Alana Knudson, regarding what her team discovered about effective CHW programs in rural communities.

Who is the audience for the toolkit you developed and how might they use it?

The Community Health Workers Toolkit is designed to assist rural communities in implementing community health worker (CHW) programs. The toolkit includes resources and tools to support the implementation of rural CHW programs as well as promising practices which have been used by existing rural CHW programs. The toolkit highlights CHW program models, training approaches, implementation strategies, sustainability, and evaluation strategies. It is designed in a question and answer format, and links to external resources and CHW programs.

There seems to be a lot of diversity in how community health workers are used in communities across the nation. Can you tell us about the models you identified for CHW programs?

It is true that CHWs serve different roles across programs, depending on the needs of the community and other factors such as their training. CHWs in rural programs typically serve as a member of the care delivery team, Promotora, care coordinator/manager, health educator, outreach and enrollment agency, community organizer and capacity builder. Most of the 330A Outreach Authority grantees that we spoke with implemented a Promotora model. In this model, CHWs live within the community that they serve and possess social, cultural, and economic characteristics that are similar to the target population. Promotoras provide a connection to the health care system by offering outreach, advocacy, education, mentorship, and translation services. In the U.S., this model has been used to reach Hispanic communities, including migrant and seasonal farm workers and their families, as well as individuals living in border communities.

What kinds of things do organizations need to consider when implementing a community health worker program?

Three issues that rural CHW programs should consider are training, education, and liabilities. First, the organization will need to determine whether the CHW needs to have any specific education, training or certification. CHWs may be certified health professionals or possess on-the-ground experience but no formal training. Depending on the type of program, the CHW’s responsibilities may range from conducting outreach and education to delivering health services as a member of the care delivery team. Second, depending on the CHWs’ education, their responsibilities, and other factors (e.g. funding, resources), programs may seek CHWs to serve as volunteers or hire them as full- or part-time paid employees. Finally, liability concerns related to transportation are critical to consider. CHWs may need to transport patients to medical appointments in their own vehicles or drive long distances through rural and frontier areas to conduct outreach. They may also face risks while conducting home visits. Safety is a top priority for rural CHW programs, and organizations have provided CHWs with safety kits, wireless internet access, and other resources for travel. CHWs are always encouraged to discontinue specific program activities if they feel uneasy. Some CHW programs have insurance to cover liabilities and ensure on-the-job safety.

Were there things that you learned about community health workers and how they are used that you found particularly interesting?

The scope of CHWs’ activities is incredibly broad and there is great diversity across the 330A Outreach Authority grantees’ programs. We learned that some rural programs are collecting qualitative and quantitative data on their CHW program activities. However, most of the grantees did not have formal program evaluations in place to evaluate the impact of their programs. Evaluation has been a challenge for rural communities, given the time, resources and expertise required. Some programs have empowered CHWs to collect evaluation data. We learned that this strategy is more effective when the CHWs are involved in the evaluation design, so they are familiar with the evaluation strategy and the data collection methods.

What have been some of the barriers to creating sustainable community health worker programs?

There are a few factors that impact the sustainability of CHW programs. First, evaluation is a tool that can help CHW programs to demonstrate the return on investment of their activities to other stakeholders in the community. Since rural CHW programs may not have adequate data, they may be unable to demonstrate outcomes or make a “business case” for their program. Another barrier is funding. Rural programs must be able to identify a means to continue to operate their programs through grants or third-party reimbursement. Third-party reimbursement for CHW services, like health education, may provide new opportunities for sustaining these programs. This could be problematic, however, because a third-party reimbursement model may also require that CHWs are credentialed at the state-level. This credentialing requirement may limit the flexibility of CHWs to perform the activities that would most effectively address the community’s needs. Despite these barriers, one key strategy that CHWs programs have employed is building community partnerships, such as steering committees and networks, to create a sense of ownership for the CHW program, secure in-kind resources, and share ideas.

What impact will the Affordable Care Act and the Department of Labor’s creation of a Standard Occupational Classification for CHWs have on eliminating those barriers and changing the landscape related to Community Health Workers?

Health care reform may offer new opportunities for sustaining rural CHW programs. The ACA recognizes CHWs as members of the health care workforce and allows Congress to allocate funding to establish a federal grant program to support the use of CHWs in medically underserved areas. Future grants could be made available to health departments, clinics, hospitals, federally qualified health centers, and other private organizations for promising programs using CHWs. The CHW toolkit can be used as a resource for these future programs, rather than building new programs from the ground up.

In 2009, the Department of Labor created a distinct occupation code for CHWs, which will facilitate the collection of better data on the utilization of CHWs across the country. Generally, this will give CHWs more opportunities in this field, as funders may recognize CHWs as accepted members of the health care workforce, which, in turn, may encourage organizations to implement programs in rural areas that utilize CHWs. Both the ACA and the Department of Labor’s recognition of CHWs may change the landscape in the future with CHWs playing an expanded role in the improvement of health in rural communities.

Alana Knudson can be reached knudson-alana@norc.org or 301-634-9326.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.

The Community Health Workers Toolkit is available on the Rural Assistance Center web site, as part of RAC’s new Tools for Success section.