Community Health Workers & Promotores in the Future of Medi-Cal Resource Package #1: The Role of CHW/Ps in Health Care Delivery for Medi-Cal Members A Project of the California Health Care Foundation Prepared By: Kathy Moses, MPH, Logan Kelly, MPH, and Audrey Nuamah, MPH, Center for Health Care Strategies Table of Contents Introduction ........................................................................................................................................................ 3 About the Project and Resource Package .......................................................................................................... 3 Key Concepts.................................................................................................................................................... 4 Key Implementation Approaches......................................................................................................................... 7 Assess Community and Organizational Needs.................................................................................................... 7 Identify Program Goals ..................................................................................................................................... 8 Design Scope of CHW/P Program and Roles....................................................................................................... 8 Develop CHW/P Position Structure and Supports ............................................................................................ 11 Recruit and Select CHW/Ps ............................................................................................................................. 12 Collaboration with Partner Organizations .......................................................................................................... 14 Infrastructure Barriers and Solutions ................................................................................................................. 16 Navigating Organizational Culture and Readiness ............................................................................................ 16 Creating Flexibility within a Structured Framework.......................................................................................... 16 Considering Human Resources and Policy Constraints ..................................................................................... 16 Integrating a New Role into Interdisciplinary Teams ........................................................................................ 17 Insights from CHW/Ps........................................................................................................................................ 18 Lessons from Whole Person Care and Health Homes ......................................................................................... 19 Resources and Tools .......................................................................................................................................... 21 Toolkits .......................................................................................................................................................... 21 Job Descriptions ............................................................................................................................................. 22 CHW/P Program Design.................................................................................................................................. 22 Examples of CHW/P Programs and Roles from California ................................................................................. 23 Examples of CHW/P Programs and Roles from Other States............................................................................. 23 Acknowledgments............................................................................................................................................. 24 A Project of the California Health Care Foundation 2 Introduction About the Project and Resource Package As California aims to improve the quality of life and health outcomes for its residents, particularly Medi-Cal members, one strategy is to better integrate community health workers and promotores (CHW/Ps) into health care delivered by managed care plans (MCPs) and providers. Medi-Cal MCPs, federally qualified health centers, hospitals, or community-based organizations (CBOs) can partner to deploy effective, evidence-based CHW/P programs to advance health equity and improve outcomes overall. To do this successfully, it is important to have a common understanding of the various roles of CHW/Ps. The California Health Care Foundation’s Community Health Workers & Promotores in the Future of Medi-Cal project aims to promote the role of CHW/Ps, within the context of the California Advancing and Innovating Medi- Cal (CalAIM) initiative.1 The primary audience for this project is Medi-Cal MCPs, and this project seeks to enhance Medi-Cal MCPs’ readiness to utilize CHW/P programs to advance health equity. To accomplish this goal, the project is developing a series of resource packages — informed and reviewed by stakeholders with a broad knowledge of the field and best practices — containing resources that support the integration of CHW/Ps into programs for Medi-Cal members. The packages will address: ► Roles of CHW/Ps in improving care delivery for Medi-Cal members ► Training for CHW/Ps and their employers ► Data collection and outcome measurement ► Program financing and sustainability The resource packages will be released between February and July 2021. In September 2021, the four resource packages will be adapted into a comprehensive toolkit with updates related to the CalAIM initiative. The resource package development occurs within a larger stakeholder engagement process, with recommendations and input provided from a health plan council, an advisory council, and a stakeholder group. Insights from CHW/Ps are shared throughout this resource package. A list of the individuals participating in the process is included in the Acknowledgements section. The resource packages are designed to align with CalAIM objectives and to help MCPs more effectively meet the needs of California residents, including acknowledging the important role nonclinical interventions play in addressing health-related social needs and reducing health inequities. Two CalAIM components are particularly relevant for CHW/P programs: (1) a requirement for MCPs to provide an enhanced care management (ECM) benefit to address clinical and nonclinical needs for people with complex health and social needs; and (2) authorization for MCPs to deliver in-lieu of services (ILOS), which are cost-effective alternatives to covered services that improve health, such as housing navigation services. As the CalAIM proposal is finalized and MCPs develop their plans for these services, MCPs are uniquely positioned to lead the integration of this valuable workforce by including CHW/P programs in their strategies. A Project of the California Health Care Foundation 3 This first resource package, The Role of CHW/Ps in Health Care Delivery for Medi-Cal Members, highlights: ► CHW/P roles, core competencies, responsibilities, and the differences between them ► Strategies MCPs and their partners can use to design CHW/P programs and recruit and hire CHW/Ps ► Considerations for collaborating with partner organizations on CHW/P programs ► Infrastructure barriers and solutions to CHW/P implementation ► Key insights from CHW/Ps ► Lessons from California’s Whole Person Care pilots and Health Homes Program ► Curated resources and sample tools from established CHW/P programs to guide the implementation process Key Concepts Medi-Cal and Managed Care Plans Medi-Cal covers 13 million Californians, with more than 80% of all members enrolled in MCPs.2 Many MCPs integrate CHW/Ps into interdisciplinary teams in a variety of roles, such as supporting high-cost members in better managing their conditions, meeting their care plan goals, and connecting to community resources. Some MCPs have incorporated CHW/P programs through the state’s Health Homes Program (HHP)3 or through Whole Person Care (WPC)4 pilots. In these programs, MCPs have either directly employed CHW/Ps or have contracted with community partners that employ CHW/Ps. There is a strong body of evidence supporting the integration of CHW/Ps into interdisciplinary teams, including improved patient health outcomes, reduced acute care utilization, and improved patient engagement, as well as cost savings.5 As the HHP and WPC pilots transition to become statewide benefits under CalAIM’s ECM benefit, MCPs will need to apply lessons from these programs and develop strategies to work more with CHW/Ps. History of CHW/Ps According to the American Public Health Association, a community health worker 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, or intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.”6 Promotores de salud, or promotoras, are a subset of community health workers who serve Spanish- speaking communities and are characterized as lay health workers with the ability to provide culturally appropriate services informed by their lived experiences.7 This is particularly important in California, which has a large Latinx population. For this resource package, the term “CHW/P” is used to include others who perform the same work. A Project of the California Health Care Foundation 4 CHW/Ps have been present internationally and locally throughout history. Health care teams in the United States began formally including CHW/Ps in the 1950s, as described in a report authored by Visión y Compromiso.8 The first formal Promotoras program in California was started in 1988 and focused on HIV prevention. There was greater focus on CHW/P training in the 1990s, and City College of San Francisco established one of the first training centers in the country. Over the last 15 years, these programs have grown across California with an emphasis on integrating CHW/Ps into interdisciplinary teams. In 2009, the Bureau of Labor Statistics created an occupational code for CHW/Ps, and the Affordable Care Act in 2010 created new funding opportunities to expand CHW/P programs, such as California’s HHP. Although there are no national training standards — and, in California, CHW/Ps are not licensed or certified — there are common competencies and responsibilities. Titles CHW/Ps are often referred to by other titles, such as health navigators, health coaches, community outreach workers, and family support workers, among other titles.9 There are other closely related positions who conduct similar work within specific communities or health care settings. For example, in American Indian communities, this role is often referred to as a community health representative (CHR). CHRs provide meaningful outreach, health care services, and health promotion/disease prevention services that are tailored to the distinct cultures and practices of American Indian communities.10 In behavioral health and substance use services, similar roles include behavioral health peers (referred to as peers) or recovery coaches. Peers have had personal lived experience with substance use disorder or a mental health diagnosis. Regardless of the title, all CHW/Ps bring their knowledge of community resources and their own lived experience when working with patients who have complex needs, such as people with serious mental illness, people experiencing homelessness, or individuals who are currently or have been incarcerated. Many CHW/Ps are often members of the very communities they serve. These connections are, in large part, why this workforce can effectively meet the needs of Medi-Cal members and strengthen the health care system’s ability to advance health equity. CHW/Ps often work as part of an interdisciplinary team, particularly in a clinical setting. For this resource package, the general term “interdisciplinary team” is used to refer to others with whom the CHW/P coordinates on a regular basis (care team or supervisor). In addition to MCPs having an understanding of the team a CHW/P coordinates with, it is helpful to differentiate between clinic-based and community-based CHW/Ps because the populations their programs focus on—the programs, people they reach, support needed, and related infrastructure challenges—are different. Roles CHW/Ps serve a range of functions within health care systems and in communities, and these functions are commonly referred to as roles. The Community Health Worker Core Consensus Project (C3 Project) produced a framework to support the development of CHW/P policies and standards.11 Through this work, the C3 Project identified 10 core roles for CHW/Ps, such as care coordination, case management, and systems navigation, as well as advocation for individuals and communities. Across all these roles, CHW/Ps’ work often focuses on addressing health-related social needs and acts as a bridge between the community and health care and social service systems. CHW/Ps also help foster trusted relationships, which are essential to helping individuals get the care they need in a way that reflects their preferences. When programs are established, creating clear guidelines for CHW/P roles helps to foster an environment where CHW/Ps can thrive and can also help people who work with CHW/Ps better understand their contributions. A Project of the California Health Care Foundation 5 Each organization typically develops a unique scope of work Exhibit 1. Examples of CHW/P Daily Tasks for their employed CHW/Ps, which includes all the roles and ► Coordinating medication reviews tasks that CHW/Ps perform within a specific program or project. The mix of roles and tasks varies based on the ► Accompanying patients to provider visits program goals, needs of patients served, and needs of the ► Meeting patients in the community employing organization. Some examples of the day-to-day ► Helping patients to navigate housing tasks of CHW/Ps are included in Exhibit 1. ► Supporting the reentry population Competencies ► Conducting health coaching As MCPs look to design and implement CHW/P programs, ► Developing shared care plans they will need to clearly identify the relevant scope of work ► Enhancing care transitions and competencies for CHW/Ps. Competencies are defined as ► Completing health risk screenings the skills and qualities that a CHW/P can achieve. A skill is the ability to do something well based on knowledge, practice, ► Linking to needed community resources and aptitude, and qualities are personal characteristics or ► Assisting with benefit applications traits such as patience and compassion.12 ► Building health literacy Health Equity ► Encouraging patient activation and Historically, immigrants, people of color, and people with wellness self-management low incomes have experienced the impacts of systemic ► Teaching about the importance of racism, xenophobia, and trauma, which have, in turn, preventive health care impacted their access to health care and social supports in a variety of detrimental ways. Interventions to reduce health disparities often seek to improve the quality of care as well as meet health-related social needs such as housing, nutrition, personal safety, and transportation. However, MCPs and CBOs frequently struggle to successfully address these issues. CHW/Ps are uniquely positioned to help improve health outcomes among people who face unacceptable barriers to care because of their race, ethnicity, socioeconomic level, immigration status, or ZIP code and can do so by engaging patients with open communication, trust, empathy, and empowerment. As noted in a report from Families USA, including CHW/Ps on care delivery teams can advance health equity in diverse communities, including among patients with serious mental illness and chronic disease.13 CHW/P programs can also promote health equity by both employing and then equitably paying historically underrepresented individuals. Doing so supports a health care workforce that better reflects the communities served, while also providing employment opportunities in those communities. “Our greatest strength as CHW/Ps is the ‘medicine’ that came out of our traumas that we now use as our experience to make sure we're helping others. It goes along the lines of restorative justice: if hurt people hurt people, then healed people heal people.” — Community Health Worker A Project of the California Health Care Foundation 6 Key Implementation Approaches This section describes core activities for MCPs to consider in building or expanding the CHW/P workforce in programs for Medi-Cal enrollees. These activities include (1) assessing community and organizational needs, (2) identifying program goals, (3) designing CHW/P program scope, (4) developing CHW/P position structure and supports, and (5) recruiting CHW/Ps. Assess Community and Organizational Needs The health needs of a community drive the development and scope of CHW/P programs. These needs could be determined through a community health needs assessment or community focus groups. MCPs considering creation or expansion of CHW/P programs may be interested in more effectively addressing member needs such as chronic conditions, health-related social needs, and preventable acute care utilization, as well as focusing on the needs of high-risk patients and/or historically under-resourced communities. As organizations develop goals for CHW/P programs, they should carefully balance input from health care leaders and community members to establish a shared set of principles and goals for the program. Before launching a CHW/P program, MCPs also need to assess their organizational readiness for these programs, including buy-in from senior leadership. MCPs who answer yes to the questions in Exhibit 2 may especially benefit from CHW/P programs. Exhibit 2. Organizational Assessment ► Does your organization experience lack of trust and barriers to patient engagement, especially among members who have more complex health care needs? ► Do your organization’s clinical indicators and feedback from frontline staff demonstrate that you may need to improve your approach in meeting the needs of historically underserved populations? ► Would your members — or a subset of your members — benefit from supports such as a. Accompaniment to medical appointments b. Assistance using telehealth technology to access care c. Access to the appropriate resources to address their social needs d. Relationships that uncover barriers that may prevent members from realizing health goals e. Choice of cultural and linguistic preferences when accessing health care ► Does your organization have difficulties linking to community-based organizations to address the social needs of your members? ► Have you assessed member health disparities to identify populations who might benefit from a CHW/P program? ► Does your organization struggle to engage members who have behavioral health needs, are experiencing homelessness, or are “hard to find”? ► Does your organization underserve particular demographics or geographic areas due to cultural and linguistic barriers? ► Do you have the budget or approval for appropriate expenditures to recruit CHW/Ps appropriately and at the highest level of competence? A Project of the California Health Care Foundation 7 Identify Program Goals As organizations begin to develop CHW/P programs, they will need to identify the concrete goals they wish to achieve. All CHW/P roles and responsibilities will flow from these program goals. CHW/P programs are designed to achieve different goals and outcomes with distinct populations. For example, programs may aim to address health- related social needs, increase use of preventive care, provide nutrition and physical activity coaching, strengthen community engagement, or improve patient activation among prioritized populations. By identifying program goals and measurable outcomes upfront and then matching program roles and responsibilities to the outcomes, a specific description of CHW/P roles and expectations can be developed with input from both the MCP and their contracted providers. Clearly mapping program goals and outcomes assists those care team members who are responsible for program success. MCPs should set CHW/P program goals with an eye toward outcomes, using the following guiding questions: ► How will your organization measure patient activation or trust? ► How does your organization document and measure health-related social needs? ► What clinical measures would you use to identify the needs of populations served, and who would administer these? ► What are the intended outcomes? ► How would your organization measure success? ► How would return on investment be demonstrated? ► How will CHW/Ps be involved in identifying needed program or system improvements? It is also critical to develop a communication plan or strategy during initial program planning to keep internal and external stakeholders informed regarding program goals, gain and maintain organizational buy- in, and communicate the value and lessons from the CHW/P program. Note that outcome measurement and data collection will be addressed in more depth in a future Community Health Workers & Promotores in the Future of Medi-Cal resource package. Design Scope of CHW/P Program and Roles Once MCPs understands who they are trying to reach and what issues they are trying to address, they can tailor a program designed to meet these needs by considering who is best positioned to serve the population and in what setting (e.g., community or clinic). Then MCPs can establish the responsibilities of the interdisciplinary team and clearly identify specific items to be addressed by the CHW/P position. When determining the size and scope of a CHW/P program, it can be helpful to consider the following factors: ► Program goals ► Size of the target population and the appropriate CHW/P caseload ► Health disparities and social care needs of the population ► Cultural and linguistic needs of the population ► The capacity of the population to engage with technology and telehealth ► Geographic service area, including considerations for travel time and available transportation ► Data infrastructure, including electronic documentation tools and data exchange capabilities14 A Project of the California Health Care Foundation 8 Important elements of CHW/P initial program plans, as listed in a United States Agency for International Development toolkit, include (1) clearly defined CHW/P roles; (2) opportunity for advancement; (3) individual and program performance evaluation; (4) incentives/compensation; (5) community involvement; (6) documentation and information management; and (7) linkages to health systems, among other elements. For more information and examples on designing CHW/P program, see CHW/P Program Design in the Resources and Tools section of this package. MCPs will also need to closely engage staff at all levels to integrate CHW/Ps into their workforce structure, which requires system transformation with capacity-building and careful planning. Conducting training and engagement at the beginning of program development can support long-term buy-in. The typical structures of health care systems, however, can hinder efforts to easily integrate CHW/Ps. Other barriers can include different funding streams for physical and behavioral health and a lack of data sharing across physical health, behavioral health, community-based organizations, and social systems (such as criminal justice). It will be important to identify creative solutions and develop workflows and systems that address these challenges and smooth the path to implementation. “I feel like oftentimes, CHWs do not get the credit that they deserve. We talk to doctors and nurses all day. We connect to the housing authorities and health plans all day. All the while also communicating with our patients. I feel like the medical field may not realize how much we do to assist individuals.” — Community Health Worker Define CHW/P Roles MCPs will need to designate clear roles for CHW/Ps and should communicate the scope of these roles to CHW/P candidates as well as to staff at all levels of the organization. This will be helpful in making sure that roles are not duplicative and do not become too overmedicalized. CHW/P roles will depend on the needs of the prioritized population, intended goals of the program, and roles of other interdisciplinary team members. Organizations can identify the competencies and responsibilities required to successfully fulfill the job description. To have a robust understanding, MCPs should engage diverse staff to provide input on potential CHW/P roles, including organizational leadership, CHW/Ps within their organizations, CHW/Ps who are employed at external organizations, and staff who will work with CHW/Ps (e.g., social workers, nurses, primary care providers, social workers, substance use disorder counselors, and others). Identifying CHW/P roles — and clearly communicating what those roles are across organizational staff and leaders — can prevent CHW/Ps from becoming, as Cheryl Garfield and Shreya Kangovi at the Penn Center for Community Health Workers described, “just another cog in the clinical wheel: scheduling appointments, pinging patients to take their meds, or even performing menial tasks. CHWs can do so much more.”15 Absent a clear definition of the CHW/P role, it may become overmedicalized and will not allow for the dynamic and person-centered work that CHW/Ps can effectively manage. Program leaders noted how CHW/Ps can quickly be pulled into supporting case managers in managing specific chronic conditions, which reduces the time available to directly support members in A Project of the California Health Care Foundation 9 navigating systems more broadly. This problem is especially relevant when CHW/Ps are employees of a health plan. These roles must be defined carefully in relation to other organizational positions to avoid potential duplication of responsibilities. As previously mentioned, the C3 Project identified core CHW roles and competencies, informed by CHW/P associations and networks across the country, that reflect the breadth of work undertaken by CHW/Ps across diverse settings (see Exhibit 2).16 The California Healthcare Workforce Alliance reported that the most common roles performed by CHW/Ps in California-based clinics and health centers include (1) supporting patients with gaining access to medical and community services; (2) health screening, promotion, and education; and (3) advocating for patient health needs.17 MCPs may also employ CHW/Ps in similarly related roles, but may spend more time connecting via phone than out in the community given their organizational structure. The use of phone and video to connect with patients is on the rise recently due to the COVID-19 pandemic. Given the convenience of phone and video for some — though not all — Medi-Cal members, this trend may continue in a post-pandemic world. CHW/Ps are most effective when they are supported to play a wide range of roles, which advances their ability to build individual and community capacity for greater health and well-being. MCPs may also benefit from employing CHW/Ps to lead community engagement work. For example, health plans struggling with member engagement and integrating member voice into operations can employ CHW/Ps to liaise with member advisors and support their participation in short-term projects such as quality improvement projects or communications reviews. These types of efforts, with a CHW/P serving as a hub for member engagement, can supplement other MCP initiatives such as member advisory groups. “I would say my biggest lesson learned with regards to the way care teams have been staffed under health homes is really thinking about greater role definition, especially differentiating between the care coordinator and the CHW roles and responsibilities.” — Managed Care Plan A Project of the California Health Care Foundation 10 Develop CHW/P Position Structure and Supports Once CHW/P roles have been established, MCPs can design the structure for CHW/P programs, which includes supervision, workload, interdisciplinary team integration, and pathways for CHW/P advancement. Establish CHW/P Supervisory Models Developing a supervisory framework that leverages the strengths of this workforce is critically important to the success of CHW/P programs. Research on CHW/P supervision indicates that poor supervision in CHW/P programs can result in low morale and poor productivity, while effective CHW/P programs include coaching and peer-to-peer support.18 An employer guide developed by the Minnesota Department of Health describes how CHW/P supervisors can help champion and integrate CHW/Ps within interdisciplinary teams, which can lead to improved productivity and work flow across the whole team.19 Some characteristics of supportive supervision for CHW/Ps, as identified by community health worker Orson Brown and colleagues, include availability for technical and psychosocial supports, such as timely help in reviewing patient cases and emerging issues, and a trauma-informed approach that recognizes that CHW/Ps may experience many of the same challenges they are helping patients to address.20 Supervisors should provide consistent monitoring and coaching, prioritize CHW/P safety, and lead individual CHW/P performance assessment. As CHW/Ps frequently spend much of their time in the field, supervisors will also need to be comfortable managing employees who are not based inside the four walls of the workplace. CHW/P supervisors may or may not have clinical training, with positions such as nurse care coordinators, clinic managers, or program managers with Master of Public Health or Master of Social Work degrees. Additionally, some organizations employ senior CHW/Ps to provide mentorship and support or direct supervision to CHW/Ps. Factors affecting the ratio of CHW/Ps to supervisors will include the number of CHW/Ps employed, activities implemented by CHW/Ps, and roles and responsibilities of existing staff. As one example, the American Hospital Association recommends a CHW/P to supervisor ratio of 6:1.21 The IMPaCT Model, developed at the Penn Center for CHWs in Philadelphia, creates teams of six CHWs and two senior CHWs who are managed by one full-time manager (typically a social worker) and one half-time coordinator.22 Identify CHW/P Caseloads When assessing the number of members assigned to each CHW/P, employers should consider the complexity of member health and social needs, the number of program focus areas, available tools to assist CHW/Ps in their work, documentation requirements, and the distance and time needed for travel between clients.23 Many programs prioritize a low CHW/P to member ratio, which creates more flexibility for meaningful member engagement and education. These ratios may also vary within a program, especially if certain CHW/Ps focus on high-intensity areas that require additional time, such as securing housing. As one example, Los Angeles County Department of Health Services employs over 200 CHWs, who each have a caseload of between 10 to 35 individuals. Medi-Cal members who are prioritized for this program include individuals with high levels of risk A Project of the California Health Care Foundation 11 related to homelessness, re-entry status (formerly incarcerated individuals), and physical and behavioral health conditions. Build Position Supports Clear protocols and job aids can guide CHW/Ps in their work. Integrated teams collaborate frequently and establishing CHW/P guidelines will help support CHW/Ps to be effective in their work while practicing within their scope and training. Programs employing CHW/Ps as part of an interdisciplinary team should develop: (1) a needs assessment; (2) individual care plans; (3) risk screening including health-related social needs; (4) tracking tools to document intervention and support patient monitoring; (5) interdisciplinary team meetings; (6) data collection tools to track outcomes; and (7) electronic health record authorization.24 Tools such as assessments, checklists, flowcharts, member educational materials, and interview, assessment, and data collection forms can help CHW/Ps to organize their work and maximize their productivity.25 Examples may include templates for medication reviews, plans of care, activity logs, personal emergency visits, and supervisory visits. Finally, programs will need to clearly identify protocols and pathways for CHW/Ps to understand when an issue should be escalated to other team members. These program protocols will be detailed in a future Community Health Workers & Promotores in the Future of Medi-Cal resource package. Effective CHW/P programs that retain high-quality CHW/Ps as members of interdisciplinary teams have several common features in their program design. Many of these programs create pathways for CHW/P advancement, such as through a senior CHW/P position, as well as opportunities for increased compensation with more experience. They also develop a salary scale that considers market rates, level of education, lived experience, and skills, and have opportunities for full-time positions with salary increases over time. Employees in other positions, such as care coordinators, may be strong candidates for the CHW/P position and salary flexibility may be a cost- effective strategy to recruit employees with the right skills and experience. Finally, these programs may consider providing training opportunities for otherwise qualified individuals who may not have requisite skills and experiences, such as computer literacy or written English proficiency. Recruit and Select CHW/Ps Create Job Descriptions MCPs looking to hire CHW/Ps who meet these core qualifications may benefit from tailored recruiting strategies to reach talented individuals. Identifying the right candidates is critically important. As Brown and colleagues describe: “. . . being a CHW is not merely a job, but a calling; success in the role depends on certain personal qualities such as being a natural helper, being creative, and being resourceful.”26 Employers should develop job descriptions that clearly define (1) CHW/P roles and specific tasks, both independent and within the team and employer organization and (2) CHW/P competencies and qualifications, including personal skills, technical skills, language requirements, and educational requirements if applicable. Employers should ensure that the skills required for a CHW/P position align with listed experience and educational background qualifications. Many CHW/P job descriptions cite the importance of lived experience. Employers should define the specific nature of lived experience that is most relevant for the given program and position, and state this within the qualifications. This may be hard to include from a legal or human resources perspective and may need to be addressed more broadly at a policy level. Finally, ‘lived experience’ should not be equated with ‘inexperience.’ CHW/Ps have valuable knowledge and skills that are gained through life experience and should be reflected in an appropriate salary scale. MCP employers will also need to consider that this salary scale and pay rate is a commensurate with others in the health care workforce, in order to demonstrate the worth and sustainability of the workforce. A Project of the California Health Care Foundation 12 Job descriptions that emphasize the attributes that will support candidates in being successful CHW/Ps, such as empathy and familiarity with specific communities, may help reach a broader base of candidates than job descriptions that place a greater emphasis on educational and training requirements.27 Organizations might also experience challenges in crafting job descriptions for the first time, and may benefit from reviewing sample job descriptions in the Resources and Tools section of this package. Use Effective Recruiting Strategies In addition to describing core CHW/P roles, the C3 Project identified a set of 11 core CHW/P skills along with best practices for assessing these skills during recruitment and in ongoing training (see Exhibit 3).28 These skills should guide organizational efforts related to role definition, recruitment, and training. The skills and qualities of CHW/Ps enable them to successfully achieve their roles and including employees with these skills within the interdisciplinary team elevates the impact of the entire team. Both traditional and nontraditional recruiting tools may Exhibit 3. Core CHW Skills support health plans and their partners in recruiting high- quality candidates. Although employer websites may be ► Communication valuable, other methods to reach candidates who are trusted ► Interpersonal and relationship-building in their communities may include: ► Service coordination and navigation ► Capacity-building ► Conducting outreach to CHW associations ► Advocacy ► Education and facilitation ► Posting fliers at community locations such as CBOs, ► Individual and community assessment recreational centers, houses of worship, high schools ► Outreach and community colleges, and local businesses ► Professional conduct ► Conducting outreach to health clinics, community ► Evaluation and research organizations, and community leaders ► Knowledge base ► Hosting large group recruiting sessions in community settings ► Advertising in radio, community, and ethnic media, and at social and sporting events As CHW/P work depends on effective one-on-one interactions, the interview process should be designed to identify candidates with strong interpersonal traits. Supervisors can use direct questions, as well as role-playing and problem-solving scenarios that can provide a more nuanced understanding of applicants’ qualities. Clear assessment criteria to support the hiring process will help leadership make informed choices about hiring and clearly identify potential training needs for newly hired CHW/Ps. Organizations should consider including CHW/Ps on hiring panels to help identify strong candidates. Develop CHW/P Onboarding Training Once CHW/Ps are selected, initial and ongoing training is important. Training for both CHW/Ps and other members of the interdisciplinary team will be addressed in more depth in a future Community Health Workers & Promotores in the Future of Medi-Cal resource package. A Project of the California Health Care Foundation 13 Collaboration with Partner Organizations Designing and implementing a CHW/P program often requires MCPs to collaborate with multiple partners. MCPs can identify opportunities to leverage the skills and assets of external organizations such as providers, health systems, CBOs, training organizations, and state and county authorities. As a partner, these organizations can lend specific expertise through their experience and can enhance the MCP’s efforts to support members via the CHW/P workforce. One key program design decision is whether MCPs will hire CHW/Ps directly or contract with another organization and locate the position therein. Exhibit 4 (next page) outlines pros and cons for MCPs as they consider options around hiring CHW/Ps directly at the plan level versus contracting with another organization to hire, support, and supervise the workforce. Other key areas for MCPs to address as they collaborate with partners to develop CHW/P roles include ► Partnering with training organizations. Training organizations have the benefit of working with a variety of employers and understand the desired roles and requirements across these organizations; therefore, they can anticipate the training needs of both employers and CHW/Ps. ► Coordinating with hospital systems. A key care connection point for patients is upon discharge from the hospital. By coordinating with hospital discharge planning, MCPs can determine the roles they intend the CHW/Ps to play regarding this crucial care transition. ► Convening partners. Bringing like-minded partners with similar goals together to collectively address member needs and determine a framework for roles and responsibilities may support higher rates of success and avoid duplication of efforts. “Most plans don’t have enough members to justify hiring population- specific CHWs [for smaller populations]. With the proper relationships and infrastructure, they can access these CHWs via partnerships with social service agencies or other plans. Through Head Start, we funded a CHW from North Africa who was based at two low-income elementary schools to help North African immigrant families better understand Medicaid benefits and access social services.” — Oregon Coordinated Care Organization A Project of the California Health Care Foundation 14 Exhibit 4. Pros and Cons for MCPs Hiring CHW/Ps Directly vs Contracting with Another Organization to Hire MCP Hires Directly MCP Contracts Out PROS PROS ► MCPs can develop a more direct understanding ► MCPs can place the CHW/P resources closer to the and appreciation for the value of the CHW/P communities they are serving. This supports the workforce as a result of working with them directly CalAIM ECM requirement that members receive ► MCPs can build internal care management services services where they want, including home or the that include the role of CHW/Ps community ► MCPs can better control staffing ratios by ► MCPs can rely on the strong, existing expertise of deploying CHW/Ps across all their members partner organizations to hire, support, and eligible for these services supervise CHW/Ps ► MCPs can achieve better integration of CHW/Ps ► MCPs can leverage the strengths of CBOs with a within their interdisciplinary teams history of integrating CHW/Ps into their workforce, ► MCPs can incorporate CHW/Ps into overall who may have a better sense of appropriate roles operational costs, which may be a more and responsibilities sustainable payment model than that for a ► CBOs are often trusted members of a community contracted CBO and have strong relationships. MCP members can ► CHW/Ps will experience limited barriers around benefit from these existing connections, which can data sharing be hard for MCPs to build from scratch ► CBOs can support MCPs in finding culturally specific programs, organizations, and services ► CBOs often have more direct access to other social supports that they can connect members to CONS CONS ► MCPs may not already have the supervisory ► Low-volume providers may not have adequate structure or organizational culture necessary to panel size to support the organizational capacity- support a CHW/P in being successful building and training that is needed to support a ► MCPs may be limited in reaching populations with CHW/P program distrust of health care systems ► Lack of infrastructure at some CBOs impedes ► MCPs may run the risk of over-medicalizing the contracting, reporting, and payment CHW/P’s role, and potentially disconnecting the ► Data-sharing barriers may be more prevalent CHW/P role from the community they seek to serve or are a part of A Project of the California Health Care Foundation 15 Infrastructure Barriers and Solutions Managed care plans may experience infrastructure challenges related to defining CHW/P roles and developing CHW/P programs. Some of these challenges are described below, along with potential considerations for how organizations can navigate these infrastructure barriers. Navigating Organizational Culture and Readiness MCPs and their contracted partners integrating CHW/P programs will have to navigate challenges related to the different organizational cultures between health care and community health, based on different priorities, values, and norms of each. For example, many program approaches, including the promotor model, focus on broader community transformation toward wellness and health equity as a primary goal, whereas MCPs may be more focused on specific outcomes.29 Relationships between CHW/Ps and clients are much different than relationships between traditional health care workers and clients, as CHW/Ps have a much greater focus on relationship-building and often share common life experiences and backgrounds. Although assessing organizational readiness is key to starting a CHW/P program, MCPs do not always have the tools or resources to do this assessment. The CalAIM initiative may provide the impetus for a culture shift allowing for a foundation to do this assessment. Creating Flexibility within a Structured Framework When defining CHW/P roles, employers will need to balance more prescribed responsibilities versus creating the flexibility for CHW/Ps to “do what they know best.” Developing trust with members, as forged by shared life experience, is critical to CHW/Ps’ success. Narrowly defining their roles and activities to focus on more clinical tasks, as described by Brown and colleagues, “dilutes the very strength for which they were hired.”30 For example, instead of initially addressing the members’ presenting symptom or condition, CHW/Ps can identify members’ health- related social needs first in order to then have an impact on their chronic physical and behavioral health issues. MCPs will need to carefully consider appropriate roles as they relate to CHW/P scope of practice, workload, and considerations for reimbursement. Considering Human Resources and Policy Constraints Employers must balance developing job qualifications that do not create barriers for talented potential CHW/Ps with strong community connections along with internal human resources considerations. For example, certain minimum qualifications related to employment history or language, technical, or other skills may restrict individuals from applying who would bring valuable skills in connecting with members. Additionally, some individuals with lived experience may be well positioned to work with prioritized groups (such as those fluent in certain languages, from particular geographic areas, or live with specific disease conditions) in the community. As MCPs prioritize hiring CHW/Ps with lived experience, there needs to be the recognition that those from the Medicaid community have been particularly impacted by mass incarceration and having a criminal record should not be a barrier to employment.31 Similarly, the hiring process in local county government A Project of the California Health Care Foundation 16 organizations may require steps that preclude hiring individuals otherwise well-suited for a CHW/P job. One solution some health care entities have used is to contract with CBOs for CHW/P programs to avoid the constraints large health care systems have related to these challenges. Implementation guidance and policy changes also need to be championed in order to decrease the barriers to hiring individuals to perform the role of a CHW/P. Integrating a New Role into Interdisciplinary Teams Challenges exist around incorporating a new team member, roles, and responsibilities into an existing interdisciplinary team with already defined roles and responsibilities. The task of reexamining and redistributing job duties can be an arduous and sometimes contentious task given “turf issues” related to interdisciplinary team roles. Further, any new program — such as CalAIM’s ECM program — will likely not come with detailed requirements on key infrastructure such as roles, scope of work, and supervision requirements, nor provide a standardized statewide needs assessment tool and outcome measures to measure program effectiveness and return on investment of CHW/Ps. This level of definition of the interdisciplinary team ultimately needs to come out of discussion among partners to the CHW/P program. Other infrastructure barriers, especially those related to training, data collection and outcomes measurement, and financing and sustainability, will be addressed in future resource packages of the Community Health Workers & Promotores in the Future of Medi-Cal initiative. “CHWs can really make that relationship with the members so much more fruitful, and they do the hard work with members to help support them. Having CHWs as part of the interdisciplinary team helps shift the focus from checking the boxes to really thinking about what we are doing to best serve our members and help them move forward.” — Managed Care Plan A Project of the California Health Care Foundation 17 Insights from CHW/Ps One of the most important roles of CHW/Ps is to increase patient confidence in the services or program to support their wellness. Because many individuals may have experienced repeated traumatic experiences, including discriminatory behavior from service providers, they may be afraid of going to the doctor or seeking out support. CHW/Ps engage with patients in a nonjudgmental and culturally attuned matter that builds trust. Without a clear understanding regarding CHW/Ps skills and strengths, it is very difficult for a MCP, clinic, community-based organization, and the team members in those organizations to incorporate the CHW/P workforce into programs. For example, CHW/Ps should not be used as language interpreters and transportation providers. Therefore, it is valuable to have the workforce involved in the MCP’s planning efforts from the beginning in order to include CHW/Ps as an equal and integral part of the larger team. Expert Insights on CHW/P Roles: Desert Pain Clinic in Riverside County Deiter Crawford has worked in both community-based and clinical settings as a CHW for over a decade. He is currently a CHW at Desert Pain Clinic in Riverside County for the health homes program. He noted that one of the most important roles that CHW/Ps play is that of a liaison. In the community, the CHW/P can listen to community members and advocate for them across the larger community, such as working with government agencies to change or create new policy. In the clinical setting, CHW/Ps also build rapport with both patients and the medical team. This can be accomplished by taking the time to listen and help individuals, and then relaying back to the team. In his experience, one of the biggest challenges for CHWs is educating others about what the CHW/P brings to the team and what he or she can do. Although CHW/Ps have a responsibility in educating others, it is also helpful when employers, supervisors specifically, can help clearly translate to others what the CHW/P roles are and expectations for others within the organization who are collaborating with the CHW/P. Mr. Crawford shared that it is important to emphasize lived experience when hiring CHW/Ps. “I grew up living in and going through some of the same situations that our patients may be going through. It’s hard to talk to a patient about homelessness or food resources without this firsthand knowledge. The strength of the CHW/P is in our lived experiences.” A Project of the California Health Care Foundation 18 Lessons from Whole Person Care and Health Homes This section describes lessons from organizations participating in the HHP or WPC pilots. As CalAIM — through the ECM and ILOS proposals — prepares to serve as the vehicle for care management (via ECM) and innovative service provision (through ILOS), it is valuable to understand the experiences from these predecessor programs at both the state, local, and MCP level. Key lessons around developing roles for CHW/Ps from the MCPs, their partner community-based care management entities (CB-CMEs) participating in the HHP, and county pilots participating in WPC include the following: ► Acknowledge the “Heavy Lift” of Outreach and Engagement. Program impact is heavily dependent on the degree to which individuals participate in the program. A CHW/P’s skill set of trust building and relatability is extremely valuable in connecting with individuals who meet the criteria for the program and effectively engaging them, so it is important for MCPs or the CB-CMEs to provide the resources to support this valuable, up-front work of engagement. ► Craft Interdisciplinary Teams. MCPs should thoughtfully design any requirements around team composition and roles to best address the needs of prioritized populations. A team intended to focus on people experiencing homelessness may need a different composition and duties than a team focusing on other populations (e.g., top five percent of utilization, previously incarcerated, behavior health-focus). CHW/Ps are well-suited to perform various roles needed as part of HHP core requirements, including care coordination, health education and promotion, and patient navigation. ► Create Career Opportunities. MCPs and counties can identify opportunities to expand the career ladder for CHW/Ps, including levels for new staff, staff with program experience, and supervisors. Creating a career ladder can support the longevity of CHW/Ps within the organization. In addition to a career ladder, other incentives such as ongoing training, self-care resources, and providing input on program design, workflow, and improvements can also create a positive work environment for CHW/Ps. ► Focus on Critical Tasks. CHW/Ps often engage with patients during critical transitions in care. Staffing the CHW/P to work either within the hospital or to connect with patients before they are released to go home can start the trust and relationship building that is important for CHW/Ps success in engaging patients (see Health Homes spotlight below). Other specific tasks such as navigating housing or routinely revisiting the plan of care, may be such an integral activity that they are tracked, measured and, reported as key outcomes of a program. For more examples of CHW/P programs within the HHP and WPC pilots, see Examples of CHW/P Programs and Roles in California in the Resources and Tools section of this package. A Project of the California Health Care Foundation 19 Health Homes Program Spotlight: Inland Empire Health Plan Inland Empire Health Plan (IEHP) hires CHWs both directly and through contracts with providers. The health plan understands that members who were recently hospitalized are often more motivated to engage in care and thus that CHWs can play a critical role in care transitions. Consequently, IEHP CHWs coordinate directly with the assigned care team to visit members during their hospitalization and post-discharge and to enroll new eligible members who receive a visit in the hospital. IEHP’s health homes–eligible members who receive a CHW visit in the hospital have a 38% engagement rate, which is significantly higher than the plan’s traditional telephonic outreach.32 By defining the CHW role to support transitions of care, IEHP is able to increase connections with members. Whole Person Care Spotlight: Los Angeles Department of Health Services Los Angeles Department of Health Services (LADHS) incorporates CHWs into its WPC program, which serves eligible Medi-Cal member populations including homeless high-risk, reentry high-risk, mental health high-risk, substance use disorder high-risk, perinatal high-risk, and medically high-risk. In LADHS’ WPC model, the CHW role includes outreach, engagement, assessment, peer support, accompaniment to appointments, and other care coordination activities. The CHW works with the patient’s primary care team as well as with hospital case management for transitions and community organizations for referrals. LADHS employs over 200 CHWs who each serve anywhere from 10 to 35 patients. LADHS worked with human resources to identify ideal CHW candidates through a process that includes (1) traditional interviews to identify a candidate’s specific motivation for the program and position, awareness of the challenges faced by folks from the populations of focus, and experiences working with community members from the populations of focus; and (2) discussion of case scenarios to help LADHS learn about an interviewee’s ability to build trust, receive and respond to feedback, and capacity for empathy. A Project of the California Health Care Foundation 20 Resources and Tools This section of the resource package contains practical resources and tools provided by project contributors or collected from subject matter experts in the field and across other states. Please note that this is not inclusive of the resources cited throughout this resource package, which can be found in the endnotes. This section contains links to publicly available resources as well as internal documents (e.g., job descriptions, workflows, presentations, etc.) that provide practical examples to inform other programs. The materials were shared by a variety of stakeholders; please cite materials appropriately if you use these tools in your own programs. Toolkits RESOURCE BRIEF DESCRIPTION Building a Community Health Worker Program: This toolkit, developed by the American Health Association and the The Key to Better Care, Better Outcomes, & Lower National Urban League, is intended to help administrative and clinical Costs leaders across the United States implement successful and sustainable CHW programs. Rural Health Information Hub: CHW Toolkit This resource, supported by the US Department of Health and Human Services, describes the role of CHWs in a rural setting. State Community Health Worker Models This map, produced by the National Academy for State Health Policy, highlights state activity to integrate CHWs into evolving health care systems in key areas such as financing; education and training; certification; and state definitions, roles, and scope of practice. Integrating Community Health Workers into This toolkit, supported by the US Department of Health and Human Primary Care Practice: CHWs and Health Care for Services, discusses the roles of CHWs for members experiencing the Homeless homelessness, includes hiring, training, and integration tips. Addressing Social Determinants of Health through This list, created by the Hispanic Health Council and its expert policy Community Health Workers: A Call to Action research panel, contains 20 recommendations in seven broad CHW policy categories. CHW Role Competencies and Training Passport for This resource, used for CommunityConnect in Contra Costa County, CommunityConnect outlines the role competencies for CHWs and details the schedule for their training program. Whole Person Care: The Essential Role of This presentation, from the California Association of Public Hospitals Community Health Workers & Peers and Health Systems and California Health Care Safety Net Institute, discusses hiring and workforce development on slides 10–39. Community Health Worker Orientation Toolkit This comprehensive toolkit for CHW onboarding, developed by the Kennedy Community Health Center, includes policies and procedures, job descriptions, and basic education guidelines. A Project of the California Health Care Foundation 21 Job Descriptions RESOURCE BRIEF DESCRIPTION Complete Job Description of a Community Health For CHWs from MPHonline, an online resource for public health Worker students. The University of New Mexico: CHW For CHWs working in both clinical and community-based settings. Texas Department of State Health Services: CHW For CHW/Ps from Texas’ Medicaid program. Certification Requirements Tiburcio Vasquez Health Center: Promotora For a promotora position. Contra Costa County: CHW I For an entry level CHW position. Contra Costa County: Mental Health Community For an entry level CHW in a behavioral health setting. Support Worker I Homeless Health Care Los Angeles: Care For a care coordinator case manager, whose role is similar to a CHW. Coordinator Case Manager Riverside County: Community Service Assistant For a community service assistant — a CHW in Riverside County. Riverside Health: Health Coach Job Description For health coaches — a CHW with a college education at Riverside Health. CHW/P Program Design RESOURCE BRIEF DESCRIPTION Managing Community Health Worker Contracts This resource, created by two researchers from the Harvard Business School, highlights the importance of contract design in the development of the CHW workforce. Diffusion of Community Health Workers Within This case study, published in Health Affairs, delves into how New Medicaid Managed Care: A Strategy to Address Mexico Medicaid implemented a CHW/P program for their managed Social Determinants of Health care members. Including Community Health Workers (CHWs) in This checklist, produced by the Centers for Disease Control and Health Care Settings: A Checklist for Public Health Prevention, presents a general framework for public health Practitioners practitioners to lead or assist in including CHWs and integrating the CHW scope of practice in health care settings. Asian Health Services: Innovative Services This resource, from the Asian Health Services (AHS), offers recommendations to coordinate with AHS for the recruitment of CHWs and offers tips for CHWs to engage with Asian American clients. Integrating the Promotores Model to Strengthen This issue brief, by the Center for the Study of Social Policy, is meant Community Partnerships to provide organizations with a deeper understanding of the Promotor Model — including its purpose, history, and contributions to community capacity building efforts. Supervision of Community Health Workers This excerpt from “Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide” — developed by United States Agency for International Development — discusses key strategies for implementing CHW supervision systems. Basic Description of CHW Program This resource, from the Worker Education and Resource Center, offers a high-level outline of its CHW Core Competency Program. A Project of the California Health Care Foundation 22 Examples of CHW/P Programs and Roles from California RESOURCE BRIEF DESCRIPTION Whole Person Care Improves Care Coordination These findings, from the University of California Los Angeles Center for Many Californians for Health Policy Research, highlight opportunities and challenges in implementing a cross-sector care coordination program for patients with complex health and social needs. Supporting the Integration of Community Health This resource, developed by the Healthforce Center at University of Workers in Whole Person Care Pilots California San Francisco, showcases lessons from counties that employed CHWs through WPC. Whole Person Care: The Essential Role of This resource, created by California Association of Public Hospitals Community Health Workers & Peers and Health Systems and California Health Care Safety Net Institute, provides a summary of the essential role that CHW/Ps play in the success of WPC pilots. Center for Human Development: Reducing Health An example from Contra Costa where CHW/Ps, navigators, and Disparities health conductors lead services in the Bay Area and partner with larger health organizations. Utilization of Community Health Workers in This resource brief, developed by the Healthforce Center at Emerging Care Coordination Models in California University of California San Francisco, discusses barriers and recommendations to better utilize CHW/Ps in various care settings in California. Integrating the Promotores Model to Strengthen This issue brief, produced by the Center for the Study of Social Policy, Community Partnerships is meant to provide community leaders and their partner organizations with a deeper understanding of the Promotor Model, based on lessons learned from Los Angeles. Examples of CHW/P Programs and Roles from Other States RESOURCE BRIEF DESCRIPTION How New Mexico’s Community Health Workers This case study, published by The Commonwealth Fund, describes Are Helping to Meet Patients’ Needs the many ways CHWs have been deployed in New Mexico to promote health and tackle social challenges including unemployment and criminal recidivism. Community Health Worker Employment and This fact sheet, from the Ohio CHW Statewide Assessment, explains Supervision in Ohio the roles and competencies for CHWs in Ohio. Integrating Community Health Workers in Ohio’s This report, produced by Universal Health Care Action Network Ohio, Health Care Teams provides an overview of CHWs in Ohio and offers examples of other states that have adopted innovative strategies around scope of practice, training, and sustainable financing. Community Health Worker (CHW) Toolkit: A This toolkit, from the Minnesota Department of Health, is designed to Guide for Employers provide employers and prospective employers with practical guidance for organizational and practice integration of CHWs, as well as how to understand the education and competencies of CHWs. Community Health Workers in Vermont This brief, produced by the Community Health Workers of Vermont, summarizes data from a May 2020 survey of CHWs and supervisors from across Vermont to collect information about the roles, scope of work, skills, and training of the CHW workforce in the state. A Project of the California Health Care Foundation 23 Acknowledgments We would like to acknowledge the individuals who contributed resources and/or who reviewed and commented on this resource package, including: Michael Anderson-Nathe (Health Management Associates); Heidi Arthur (Health Management Associates); Isabel Becerra (Coalition of Orange Community Clinics); Heidi Behforouz (Los Angeles County Department of Health Services); Rebecca Boyd Anderson (Partnership HealthPlan); Joe Calderon (Transitions Clinic Network); Cynthia Carmona (L.A. Care); Deiter Crawford (Desert Clinic Pain Institute); Doreen Crume (Partnership HealthPlan); Jacob Deme (Community Health Center Network); Lakshmi Dhanvanthari (Health Plan of San Joaquin); Alexander Fajardo (El Sol Neighborhood Educational Center); Jessica Finney (Central California Alliance for Health); Elia Gallardo (County Behavioral Health Directors Association of California); Iliana Gilman (Health Management Associates); Pamela Gomez (Contra Costa Health Plan); Angela Guerverra (Partnership HealthPlan); Kathreyn Horton (College of Marin); Jennifer Judge (Open Door Community Health Centers); Catherine Knox (Inland Empire Health Plan); Ashley Kokotaylo (Contra Costa Health Services); Lily Lee (Loma Linda University/San Manuel Gateway College, CHW/Promotores Academy); Rishi Manchanda (HealthBegins); Melissa McCartney (Partnership HealthPlan); Laura Miller (Community Health Center Network); Judi Nightingale (Riverside University Health System); Angela O'Brien, (Community Health Center Network); Leticia Rodriguez (LA County Department of Health Services Whole Person Care); Sandra A. Rodriguez (Tiburcio Vasquez Health Center); Amber Roth (Worker Education & Resource Center); Carl Rush (Community Resources); Chloe Schafer (Partnership HealthPlan); Shira Shavit (Transitions Clinic Network); Jessica Solares (AltaMed); Ashlen Strong (Health Management Associates); Mary Zavala (L.A. Care) We would also like to thank all Project Contributors for their guidance on the topic selection and for informing this package, including: Health Plan Council The Health Plan Council is composed of a subset of the Medi-Cal managed care plan CEOs who anticipate direct involvement in CalAIM or who have historically engaged in California’s Whole Person Care pilots or Health Homes Program. John Baackes (L.A. Care); Liz Gibboney (Partnership HealthPlan); Sharron Mackey (Contra Costa Health Plan); Jarrod McNaughton (Inland Empire Health Plan); Michael Schrader (Health Plan of San Joaquin); and Stephanie Sonnenshine (Central California Alliance for Health) Stakeholder Group The Stakeholder Group is composed of organizational representatives and CHW/Ps who anticipate direct involvement in the CalAIM initiative implementation or who have historically engaged in California’s Whole Person Care pilots or Health Homes Program. Bianca Alvarez (Ventura County Whole Person Care); Isabel Becerra (Coalition of Orange Community Clinics); Joe Calderon (Transitions Clinic Network); Cynthia Carmona (L.A. Care); Deiter Crawford (Desert Clinic Pain Institute); Lakshmi Dhanvanthari (Health Plan of San Joaquin); Valerie Edwards (Alameda County Whole Person Care); Jessica Finney (Central California Alliance for Health); Pamela Gomez (Contra Costa Health Plan); Lupe Gonzalez (Visión y Compromiso); Catherine Knox (Inland Empire Health Plan); Lily Lee (Loma Linda University, San Manuel A Project of the California Health Care Foundation 24 Gateway College, CHW/Promotores Academy); Laura Miller (Community Health Center Network); Judi Nightingale (Riverside University Health System); Leticia Rodriguez (LA County Department of Health Services Whole Person Care); Sandra A. Rodriguez (Tiburcio Vasquez Health Center); Chloe Schafer (Partnership HealthPlan); Shira Shavit (Transitions Clinic Network); and Jessica Solares (AltaMed) Advisory Council The Advisory Council is composed of representatives of California-based and national organizations and subject matter experts who have relevant knowledge or expertise in advancing the role of the CHW/P workforce in the Medicaid context. Mayra Alvarez (Children’s Partnership); Heidi Behforouz (Los Angeles County Department of Health Services); Tim Berthold (San Francisco City College); America Bracho (Latino Health Access); Amanda Clarke (California Association of Public Hospitals / California Health Care Safety Net Institute); Alexander Fajardo (El Sol Neighborhood Educational Center); Elia Gallardo (County Behavioral Health Directors Association of California); Brian Hansen (California Department of Health Care Services); Nancy Ibrahim (Esperanza Community Housing); Ashley Kokotaylo (Contra Costa Health Services); Denys Lau (National Committee for Quality Assurance); Maria Lemus (Visión y Compromiso); Brianna Lierman (Local Health Plans of California); Rishi Manchanda (HealthBegins); Andie Martinez (California Primary Care Association); Amber Roth (Worker Education & Resource Center); Carl Rush (Community Resources); Kiran Savage (California Pan-Ethnic Health Network); and Holly Webb (WellSpace Health) The Project Team for this initiative includes Carlina Hansen (Senior Program Officer), California Health Care Foundation; Shannon Mong (Project Lead), In-Sight Associates; Kathy Moses (Product Lead), Center for Health Care Strategies; Nayely Chavez (Project Coordinator), Health Management Associates; Logan Kelly (Product Manager), Center for Health Care Strategies; Audrey Nuamah (Product Coordinator), Center for Health Care Strategies; Ashlen Strong (Communications Lead), Health Management Associates; Melissa Schoen (Project Support), Schoen Consulting; and Neena Virk (Project Assistant), Health Management Associates 1 California Advancing and Innovating Medi-Cal, Department of Health Care Services, 2021, https://www.dhcs.ca.gov/calaim. 2 Len Finocchio, Matthew Newman, and Eunice Roh, Medi-Cal Facts and Figures: Crucial Support for Low-Income Californians, California Health Care Foundation, 2019, chcf.org. 3 Health Homes Program, Department of Health Care Services, 2021, https://www.dhcs.ca.gov/services/Pages/HealthHomesProgram.aspx. 4 Whole Person Care Pilots, Department of Health Care Services, 2021, https://www.dhcs.ca.gov/services/Pages/WholePersonCarePilots.aspx. 5 Policy Evidence Assessment Report: Community Health Worker Policy Components, Centers for Disease Control, 2014, www.cdc.gov (PDF). Aditi Vasan et al., “Effects of a Standardized Community Health Worker Intervention on Hospitalization among Disadvantaged Patients with Multiple Chronic Conditions: A Pooled Analysis of Three Clinical Trials,” Health Services Research, 55, supplement 2 (2020): 894–901, doi:10.1111/1475-6773.13321. Diane Johnson et al., “Community Health Workers and Medicaid Managed Care in New Mexico,”Journal of Community Health 37 (2012): 563–571, doi:10.1007/s10900- 011-9484-1. Shreya Kangovi et al., “Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment,” Health Affairs 39, no. 2 (2020): 207–213, doi:10.1377/hlthaff.2019.00981. 6 “Community Health Workers,” American Public Health Association, accessed January 18, 2021, apha.org. 7 “Promotores and Promotoras de Salud,” MHP Salud, 2017, https://mhpsalud.org/our-chw-initiatives/promotoras-de-salud/. 8 “Key Workforce Priorities for the Community Transformation Model,” Visión y Compromiso, 2017, visionycompromiso.org (PDF). A Project of the California Health Care Foundation 25 9 Jim Lloyd, Rachel Davis, and Kathy Moses, Recognizing and Sustaining the Value of Community Health Workers and Promotores, 2020, https://www.chcs.org/media/CHCS-CHCF-CHWP-Brief_010920_FINAL.pdf (PDF). 10 “Community Health Representative,” Indian Health Service, accessed January 18, 2021, ihs.gov. 11 Understanding Scope and Competencies, The Community Health Worker Core Consensus Project, 2016, c3project.org (PDF). 12 Understanding Scope and Competencies, The Community Health Worker Core Consensus Project. 13 Advancing Health Equity Through Community Health Workers and Peer Providers: Mounting Evidence and Policy Recommendations, Families USA, 2019, familiesusa.org (PDF). 14 Beth Brooks et al., Building a Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs, American Hospital Association, 2018, aha.org (PDF). 15 Cheryl Garfield and Shreya Kangovi, “Integrating Community Health Workers Into Health Care Teams Without Coopting Them,” Health Affairs Blog, 2019, doi:10.1377/hblog20190507.746358. 16 Understanding Scope and Competencies, The Community Health Worker Core Consensus Project. 17 Taking Innovation to Scale: Community Health Workers, Promotores, and the Triple Aim, California Health Care Workforce Alliance, 2013, blueshieldcafoundation.org. 18 Wanda Jaskiewicz and Kate Tulenko, “Increasing Community Health Worker Productivity and Effectiveness: A Review of the Influence of the Work Environment,” Human Resources for Health 10, no. 38 (2012), doi:10.1186/1478-4491-10-38. 19 Community Health Worker Toolkit: A Guide for Employers, Minnesota Department of Health, 2016, health.state.mn.us (PDF). 20 Orson Brown, Shreya Kangovi, Noelle Wiggins, and Carla S. Alvarado, Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings. 21 Beth Brooks et al., Building a Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs. 22 Community Health Worker Toolkit: A Guide for Employers, Minnesota Department of Health. 23 Community Health Worker Toolkit: A Guide for Employers, Minnesota Department of Health. 24 Beth Brooks et al., Building a Community Health Worker Program: The Key to Better Care, Better Outcomes, & Lower Costs. 25 Wanda Jaskiewicz and Kate Tulenko, “Increasing Community Health Worker Productivity and Effectiveness: A Review of the Influence of the Work Environment.” 26 Orson Brown, Shreya Kangovi, Noelle Wiggins, and Carla S. Alvarado, Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings. 27 Community Health Worker Toolkit: A Guide for Employers, Minnesota Department of Health. 28 Understanding Scope and Competencies, The Community Health Worker Core Consensus Project. 29 “Key Workforce Priorities for the Community Transformation Model,” Visión y Compromiso. 30 Orson Brown, Shreya Kangovi, Noelle Wiggins, and Carla S. Alvarado, Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings. 31 Justice-involved individuals include anyone who is currently or has been involved with the criminal justice system. This includes individuals who are awaiting trial, convicted of a crime, on probation, under home confinement, incarcerated in jail or prison, under community residential supervision, or on parole. Source: Jhamirah Howard and colleagues. “The Importance of Medicaid Coverage for Criminal Justice Involved Individuals Reentering Their Communities.” U.S. Department of Health and Human Services. 2016. (PDF). 32 Jim Lloyd, Rachel Davis, and Kathy Moses, Recognizing and Sustaining the Value of Community Health Workers and Promotores, 2020, https://www.chcs.org/media/CHCS-CHCF-CHWP-Brief_010920_FINAL.pdf (PDF). A Project of the California Health Care Foundation 26