By Jacqueline (Jackie) Miller, Senior Research Data Analyst, Healthforce Center at UCSF

In California, one of the most culturally diverse states in the country, health care must bridge cultural and linguistic divides to serve all communities equitably. As trusted community members with lived experience, community health workers and promotores de salud (CHW/Ps) are increasingly recognized as a valuable part of the health care workforce. These frontline public health workers have a long history of connecting those not well served by the traditional health care system with culturally competent health and social services. However, payment for their services is sporadic.

Recent changes are reenergizing this workforce through new payment streams: California added certain CHW/P services as a reimbursable Medi-Cal benefit in 2022, and the CalAIM waiver to transform and strengthen Medi-Cal will also boost funding for CHW/P services. These new funding sources will improve sustainability of the field and potentially help grow this workforce.

The Roots of Community Health Workers and Promotores

With international roots in the 1920s, CHW/Ps’ presence in the US started growing in the 1960s and ‘70s. CHW/Ps act as liaisons, or links, between their clients and health and social services. They are uniquely qualified to serve this role because their shared language, culture, ethnicity, and/or experiences creates trust between them and their community members.

As demonstrated in Healthforce Center's recent surveys of CHW/Ps and their health care employers, CHW/Ps work in a variety of settings and perform various jobs, such as case management, care coordination, systems navigation, advocacy, and referral and direct services. CHW/Ps care for diverse populations such as unhoused individuals, formerly incarcerated individuals, and youth and families with a multiplicity of ailments, including chronic conditions such as diabetes, asthma, and heart disease and mental and behavioral health disorders.

Although CHW/Ps provide many services to many people, challenges remain in hiring practices and potential for career growth in this field. Historically, most CHW/P positions have been supported by grants without a clear path toward long-term funding. To receive sustained funding for CHW/Ps, hospital and clinic executives often ask for evidence of financial and/or clinical return on investment (ROI) of the CHW/P contribution. Demonstrating ROI takes time as well as resources and may be impossible, especially if CHW/Ps work in care teams.

Growth and Recognition Boosts Funding

Despite funding challenges, the workforce has continued to grow as this role gains recognition as a valuable part of the health care team. In 2019, the California Future Health Workforce Commission recommended scaling up the CHW/P workforce to broaden access to preventive and social support services as well as team-based integrated primary and behavioral health care.

Since then, the designation of CHW/Ps as health care team members has become clearer as providers continue to acknowledge and emphasize the significance of social drivers of health and financing shifts toward global/capitated and pay-for-performance approaches. Furthermore, the COVID-19 pandemic highlighted their value and created additional demand for CHW/Ps, who were well positioned to combat disinformation, assist with testing, and advocate for vaccinations within communities where they had previously established trust.

While COVID created additional need, it also generated more funding for CHW/Ps. During the pandemic, many local and national efforts were designed to increase CHW/Ps in the workforce as well as arm them with more information and resources. However, as the federal COVID-19 public health emergency has ended, many grants for CHW/Ps services have also ended.

The Road to Funding Sustainability: SPA and CalAIM

Given these funding sustainability challenges, there is growing excitement in California about the newly approved State Plan Amendment (SPA), often referred to as the “CHW benefit” or the “DHCS benefit” (a reference to the California Department of Health Care Services). The SPA provides direct reimbursement for CHW/Ps services to prevent disease and disability progression, prolong life, and promote physical and mental health to address:

• Control and prevention of chronic conditions or infectious diseases
• Mental health conditions and substance use disorders
• Perinatal health conditions
• Sexual and reproductive health
• Environmental and climate-sensitive health issues
• Child health and development
• Oral health
• Aging
• Injury
• Domestic violence
• Violence prevention

Recent research shows that CHW/P employers are excited about the potential for the SPA to improve access to preventive care and mitigate the need to demonstrate ROI for the role. One employer explained how the SPA could also contribute to professional recognition, something that CHW/Ps continually fight for: “If people do [hire] more [CHW/Ps] because there’s now a reimbursement stream for this, then hopefully over time more and more people recognize the value.”

In addition to the SPA, CalAIM, a Medicaid waiver designed to shift Medi-Cal to a population health approach, may also be a reimbursement channel for some CHW/P services. Components of CalAIM called Enhanced Care Management (ECM) and Community Supports could enable reimbursement of CHW/P activities such as case management.

One employer expressed excitement about the reimbursement opportunities offered by both the SPA and CalAIM, including the potential to establish more clearly defined career ladders and respect for the profession, but also voiced potential concerns given their novelty: “We'd love to see [CHW/Ps] gain more skills to become supervisors as they do the work and supervise others. We see that in some of our sites where people are able to move on to be supervisors. That's not always possible in many of the sites. We're hoping that with CalAIM and the SPA people can grow the community health worker programs, but it's unclear how this is going to play out.”

As the first full year of SPA implementation nears and CalAIM continues to be implemented, there are more funding opportunities for CHW/Ps in California than ever before. These opportunities are steps toward more sustainable funding that could foster supplemental funding streams. In addition to improving funding stability, they also promote the importance and value of the profession. It is an exciting time for the CHW/P workforce, which is almost certain to grow given these financing reforms and additional investments across the state and the nation.

With support from the California Health Care Foundation, Healthforce Center at UCSF conducted a series of surveys and interviews with CHW/Ps, health care employers, and training institutions. Miller presented the findings at a CHCF event on April 28, 2023.

For More Information

• CHW/Ps Research from Healthforce Center
• CHWs Offer Critical Supports for Patients with Complex Health and Social Needs (Milbank Memorial Fund)
• Community Health Worker & Promotor Workforce Development Resource Library (Health Leads)