Community Health Worker Certification and Licensure

Good afternoon everyone, my name is Kristen
Rego and I am the Director of Health Transformation at the Association of State and Territorial
Health Officials. I would like to welcome you to today’s webinar of Community Health
Worker Certification and Licensure. Integrating CHW into the healthcare work force is a growing
strategy for increasing access and improving population health while decreasing costs.
Today’s webinar is the first webinar in a Community Health Worker series that is supported
by the Health Resources and Services Administration. The objective for today’s webinar are to describe
the current landscape of CHW certification and training across the country; to identify
common content and methodology that can be included when developing CHW certification
programs; and to describe the opportunities, challenges, and barriers associated with establishing
certification for CHW. We have an esteemed panel of experts that
will be speaking with you today. Following my introductions, we will have two presentations
followed by an interactive panel discussion with our experts. If you have a question,
you are welcome to post it in the chat box on your screen at any time during the webinar.
These questions will be used during the Q&A after today’s presentation. At the conclusion
of the webinar, you will be directed to an evaluation survey. Please take a few minutes
to inform us about the work that you are doing related to Community Health Workers and to
provide us with feedback on today’s webinar. We look forward to hearing about your efforts. Now I would like to introduce today’s speakers,
KT Kramer and Carl Rush. KT Kramer is the Director of State Health Policy at ASTHO where
she supports a peer network of state legislative liaisons, and tracks and analyzes public health
legislation, regulation, and executive orders across the states and territories. Prior to
joining ASTHO, KT worked as a Winston Health Policy Fellow at the Senate Health Committee. Carl Rush has worked full time for and with
CHW for the past 19 years. He serves as a core team member of the policy center on CHW
at the University of Texas, Houston School of Public Health and has supported studies
on CHW employment policy for the states of Arizona, Texas, and Indiana, and for public
health Seattle King County. Our panelists today are Gail Hirsch, Katie
Mitchell, and Sergio Matos. Gail Hirsch is the Co-director of the Office of Community
Health Workers at the Massachusetts Department of Public Health. As a longtime leader in
CHW organizing efforts in the state, she has served as an advisor to other states, federal
agencies, and national organizations on CHW work force development. Katie Mitchell is the Project Director of
the Michigan Community Health Worker Alliance. The Michigan Community Health Worker Alliance
is a partner-driven coalition. Its mission is to promote and sustain the integration
of CHW’s into Michigan’s Health and Human Services system. Sergio Matos is the Co-Founder and Executive
Director of the Community Health Worker Network of New York City. The Network is a professional
association of CHW’s with over 700 members that work to advance the CHW work force while
preserving its integrity. With that, I will now turn it over to KT Kramer. Thanks, Kristen, welcome everybody to the
webinar. As Kristen mentioned, I am the Director of State Health Policy at ASTHO and part of
my role is to track emerging trends and issues. One of the ones that we have been following
closely is the emergence of Community Health Workers, CHW, and the certification and training
process that states and state health agencies and territorial health agencies are undertaking.
My presentation is going to be short with hopefully more time for some of the panelists
to discuss more of the issues on the ground as they saw these programs and processes unfold. So what you are seeing now is a map of the
national landscape for community health worker training and certification standards. We have
seen in the past couple of years 20 states have considered or enacted or created processes
and frameworks for community health workers to hit certification standards and training.
They have done this in a variety of ways. I think that is sort of an important thing
to mention. There is no uniform policy. I think the states have conversations with their
stakeholders about what the role of the community health worker is in their particular system.
You wind up with different results. There are some commonalities. What you see with
the states that are in green are ones where the state legislature has taken a role in
creating a statutory program for certification. Again, I will touch on it a little more later,
even within these state laws and regulations, there is variation in sort of how raw definitions
are and how much structure the law puts in versus regulation. Legislatures have also
been active in states like Illinois and Maryland in creating advisory boards and passports
for work groups to look at the issue of whether and how community health worker certification
should take place in their states. This may be a precursor to legislative activity or
to allowing it to happen more organically at a level below legislation and regulation. The states that are in blue are states where
the state health agency has taken a lead in creating community health worker certification
standards within the authority they already have in their health agencies. Minnesota has
sort of a unique position in that they have gone to the Department of Health and Human
Services and were able to get a waiver so that they could fund the community health
workers through their Medicaid program. The two states are in yellow are ones that legislation
that we are currently following. You have in Florida, florid has existing third party
certification program that operates. What the legislation would do is essentially codify
that program. Then the bill that is pending in New Jersey would create an advisory board
to look at certification standards, but interestingly also tying it to looking at financing and
how do you fund the work of community health workers through Medicaid and through private
insurance. That is sort of where we are right now. I
think the panelists will be able to talk a lot more about what the different approaches
might look like in a given state and what some of the benefits and drawbacks are as
they move forward. The final slide in my presentation is one
where we sort of broke down what the different state policies and programs contain. I think
the main take away that I would have from this slide is really to sort of reiterate
that there is a lot of variety and a lot of flexibility and how different states structure
these training and certification programs. I think we kind of see from the dots that
in Massachusetts and New Mexico, the legislative process was a lot more structured through
their laws and regulations. I think some of the states maybe just have advisory bodies.
I am very excited to hear the rest of the panelists kind of go through again how to
approach the conversation and engage the stakeholders. With that, I will turn it over to Carl. Thank you, KT. Hello, everybody. I am really
delighted that you all could join us. I was asked by ASTHO to comment before we get to
the – oops. Lost the screen there. Okay, I was asked to comment briefly on a project
called the CHW Core Consensus or C3 project. This is really an adjunct to the consideration
of certification. As KT was saying that the states are highly varied in their approach
to this. Part of the thinking behind the C3 project is that the deliberations in each
state regardless of who is leading it should be informed by some common understanding of
the pattern of the roles and skills that community health workers play in various states around
the country. Next slide please. So the purpose is to develop contemporary
recommendations around the country. Each state will take its own lead and follow its own
best likes in terms of how to use it, but we are talking about core roles, which often
translate into scope of practice and core skills that are required to perform those
roles. There is also a very important notion here of some core qualities. Most of you have
probably heard the term, the phrasing that a community health worker should be a member
of the community whom they serve. That is kind of shorthand for complicated set of issues
mainly related to shared life experience. That part of the unique capabilities of the
community health worker in working particularly in low-income communities and communities
of color is that they relate to the members of those communities, having lived through
the same kinds of experiences that those community members have had. Next slide please. I will add to that, by the way, in finishing
that last thought, that roles and skills are relatively easy to define. We were talking
about definitions here, not so much regulation. But the core qualities are very challenging
to embody in policy. So how those get handled because they really are of the essence of
the practice of the community health worker, how those poor qualities get recognized in
terms of making sure that the right people are hired for the work is a challenge in every
state. Why are we doing this now? There was a seminal study published in 1998, a National
Community Health Advisor study which was the first real national look at these issues of
the common roles and skills of community health workers. The findings of that study have been
used in a number of states, both for the initial consideration certification and also for the
creation of educational programs of CHW’s. We have seen in the last what is now 18 years
that times have changed. There is a lot more interest in the healthcare field and in embedding
community health workers in clinical organizations. That is going to change the picture in terms
of roles and skills. I think almost every state in the union now is at least investigating
standards and potentially certification for CHW’s. So having some common basis for at
least starting consideration in your state is, we think, a valuable thing. There has
been some pressure from national organizations and even inquiries from federal agencies.
Are there national standards for CHW’s? I don’t know that we will ever actually get
there. States, in general, would prefer to reserve these decisions for the state level.
It is still not clear at this point, how much states will agree with each other about such
standards. Many of you have probably asked the question or have been asked the question,
what is a good community health worker training program? There is no real way authoritatively
to say what the answer to that is. Next slide. Another core value and this has really been
embodied in policy by the American Public Health Association. It’s very important, regardless
of who is leading the process or driving the process that the process of defining community
health workers, who they are and what they do, be led by community health workers themselves.
This is something that almost goes without saying in other professions. Yet, we have
seen a pattern in many places of people feeling that they can speak for or make decisions
for community health workers. This is an important core value that we have tried to bring into
the C3 project itself. Next slide. There was some precursor activity to C3, which
was funded by the Amgen Foundation in which one of the area health education centers in
Texas solicited information on over 40 training programs around the country and has conducted
an informal analysis of that. In the next stage of some others of us that became involved
in it, that we started to take a look at a review of roles and competencies from six
what we are calling benchmarked states. These are states where there has been a serious
effort to align the training requirements for CHW’s with the content of the job, the
scope and practice. A cross walk was performed between the scope
of practice and skill requirements in those six states with the original findings from
the National Community Health Advisor study from 1998 and also the National Scope of Practice
definition for community health representatives, which are part of a program for the Indian
Health service and really the only national program of community health workers. That
process has largely been completed. This past summer and into the fall, some 20 odd state
networks of community health workers and some local networks were asked to review and comment
before their modification was made to this kind of consensus, emerging consensus statement
of roles and skills. The report from that process should be coming out in early April.
It is now in the final editing and lay out process. That report will, of course, describe
the process and give the final recommendations from 2015 about roles and skill and will also
include in an appendix, all of the comments and dissenting opinions and concerns that
were raised by the various reviewers up to this point. Next slide, please. Beginning in the middle of this year and for
about a year to follow, we are going to be changing gears. There will be outreach to
additional community health worker groups, but also consensus building with other stakeholder
groups. We have already established contact, for example, with the American Hospital Association
and the American Nurses’ Association. We will be looking, certainly for input from them,
but eventually some form of endorsement in the sense that that organization representing
its constituency believes that this statement of roles and skills is a fair depiction nationally
of what community health workers should do. That outreach is obviously crucial, not only
to further broaden the consensus, but even basic education of some constituency groups
about understanding who and what community health workers are and what they do. The second major task, which has been an ongoing
issue, discussion, for some years, now that more community health workers are working
in clinical settings, is there a difference between the roles and the skill sets that
community health workers require in that setting and those required for folks who work exclusively
in a community setting. That, I think is going to be a very rich conversation and will be
helpful to folks in setting standards. For example, in New Mexico, they have a core certification
and then a special level one specialization certification that they call “Clinical Support
Skills.” That is optional. The third major task will be coming up with
recommendations on methods of assessing proficiency in these skills. We don’t really have time
at the moment to go into this, but it seems clear that many conventional methods of skill
assessment through exams and that sort of thing are not appropriate to the skill set
of community health workers. Something more like performance based assessment, looking
at actual measures and methods for assessing skills using such methods will be helpful
both in an educational setting and in an employment setting for performance assessment. Also,
assessing those core qualities, the sense of community connectedness is so difficult
to do with conventional means. It is important at least to provide tools to employers to
find ways of assuring that they are, in effect, hiring the right people. People have the right
degree of connectedness and credibility and commitment to the community to make a good
community health worker. Next slide, please. These are the states. I am not going to go
into detail on this, but these are the states that we looked at and the sources of information
about scope of practice. We were not able from the Indian Health Service to get a national
statement of core competencies. They are still working on that. Various regions and tribal
governments have their own standards for skills. The states involved are in different stages
in developing standards, certainly, but these are all states in which they have given a
very serious look at understanding the roles and skills of the community health worker
and the congruence between the skills and the roles that they serve. Next slide, please. We are going to make available through ASTHO
that a number of resource documents, obviously, the publication from 2015 recommendations
from C3, but also a number of the other very relevant source documents. This is not necessarily
a complete list. There also should be in 2017, a national policy study sponsored by CDC on
certification. That study is not going to begin until probably July this year. That
will also be very valuable, we think, to the states. Next slide, please. You will be able to download this information
when the slide deck from this webinar is published. For more information, you can send us an email.
There is also a link to join our mailing list. Next slide, please. Transition to our panel. I wanted to just
go over some basics about certifications. This is really not about regulation of an
occupation. We need to make that clear at the outset. Certification in general, the
sort of dictionary definition, has to do with some issuing authority declaring that the
individual has certain qualifications. It may or may not, but it’s generally not the
same as an educational certificate of completion. Some states may choose to make that equivalent.
That is really up to you. It is important. We are seeing some examples of this already.
The issuing authority, per se, does not have to be the state government. It could be an
educational certificate issued by an association or even an employer based group issuing the
certification. I also want to say that licensing at this point is probably off the table, even
though that is part of the title of the webinar. We need to say that what we are looking at
here is not prohibiting what people do because there are an awful lot of volunteers doing
this kind of work now and have been for decades. There is no particular issue of potential
harm to the public, if the scope of practice of the CHW is properly understood. The CHW
is, first and foremost, not a provider of clinical care. The issues of licensing in
several states, they have specifically said, “We are not going to license these folks.
It’s not appropriate for our licensing authority.” Next slide, please. Then lastly, there are folks who have misgivings
about certification. There are many pitfalls that can happen along the way. What we are
seeing from the pattern of mistakes made in the early states and the reservations that
people have, certification in general, there should be multiple paths for entry, including
based on experience. The process should be user friendly without unnecessary barriers.
The State of Texas, we don’t have any of these requirements as part of certification. If
there is going to be education required, it needs to be in familiar accessible settings
using appropriate methods. We have one of our panelists today, one of
the national experts on popular education for CHW’s in Sergio Matos. It is about the
congruence of the educational methods to the skills and the characteristics of the candidates
for this work that is specified that these methods are appropriate. If you are going
to have continuing education requirements, than there needs to be adequate access to
those opportunities. In many cases, especially with rural populations, distance learning
is going to need to be an option. Lastly, I would say we have tens of thousands
probably of volunteer CHW’s around the country. The last thing we want to do is impeded them
in their work. As you are considering the issue of certification, remember the dictum
of the medical profession, which is first do no harm. We don’t want to do anything to
impede volunteer CHW’s and their honorable and very successful work. With that, we are going to turn to our panel.
I am going to pose a series of questions. We are going to ask each of the panelists
to respond to this one question at a time. We have randomized the order of their responses.
You won’t always be hearing from the same person first on each question. The first question
is what process was followed in considering certification in your state? By that, we are
saying in part who or what has been driving the process up to this point? What stakeholders
or other factors seem to be most influential in the outcome thus far? If we go to the next
slide, please, we will start with our first responder from Gail Hirsh. Hi, hello everyone. You can advance to the
next slide, if you would. In Massachusetts, I answered this question. I would say that
this has grown out of a long-term partnership between the Mass Association of Community
Health Workers, the Department of Public Health, the Massachusetts Public Health Association,
and CHW Training Programs. This has been going on for close to 20 years as far as moving
from being against certification towards supporting certification. The development of this partnership
happened through the late ’90s and early 2000s in synergy with some national efforts to define
and study the workforce. I would say it’s been a process of convening key partners,
building consensus. There have been multiple legislative and advocacy initiatives, and
then collaborative implementation of laws that have been passed. There has been a dedication
of resources to support community health worker leadership and engagement along the way. The
next slide, please. Brief overview, there was a statewide advisory
council that grew out of our health reform law, that wound up recommending certification
amongst its 34 recommendations, which actually set the stage for MACHW, which again is the
Mass Association of Community Health Workers, to track and advocate for rapid passage of
Chapter 322 in 2010. That established the Board of Certification at the Department of
Public Health. There was a decision made at that point that the state would be the issuing
authority. We went back and forth on this a lot. As Carl mentioned, this is a very important
decision. We don’t know, really, how this is going to go. We know how it has gone so
far. I would just sort of overlay all my comments by saying this is an experiment. We are doing
an evaluation, which is really important. We decided to house this at the Department
of Public Health because it had capacity. Also, we thought that it would give credibility
to the certification. The board is comprised of strong CHW representation. It’s a voluntary
certification. It’s a title act, not a practice act. That means in order to call yourself
a certified community health worker, you need to go through the process, but you not need
it in order to practice as a community health worker. Also, the law requires the board to
set standards for core training programs. Thank you. Okay, next slide, please. Good afternoon, this is Katie Mitchell with
the Michigan Community Health Worker Alliance. I am going to show you a little bit our process
in Michigan. So MICHW was founded in 2011. We have been in process in tackling the question
of certifications since our founding. It was identified really early on as an essential
discussion item and that very much fit under our mission of promoting and sustaining the
workforce of CHW’s. Since 2011, we have had significant discussions with stakeholders
and other groups of CHW’s, employers, and others even broader, to really tackle this
question of what does certification mean. The way that MICHW is structured is that we
have working groups, a steering committee. We also host a lot of conferences and events
to bring others in, to make sure that we are being as collaborative as possible in this
process. We spent a good part of 2012 doing a lot of research. We hosted some CHW only
discussion forums at the beginning of 2013. We presented a lot of that research and provided
CHW’s an opportunity to really get together with each and hash out different thoughts
and opinions and feelings about all of that work that had been done. We issued a policy
brief in 2013 indicating our support for recertification system, keeping in mind that for our purposes
it is called certification is voluntary. It is not something that would be mandated. It
would be an option. Then we continued our journey into this by doing more research. A big part of it is that with certification,
there are a lot of elements. Gail alluded to many of them as part of the process in
Massachusetts. We are still tackling a lot of those in Michigan. When you think about
what goes into certification that includes things like time frames and standards, and
curricula and all of that. We have spent the last couple of years doing additional research.
We have also looked at the processes in other states, as well as for other professions to
find good models. At the end of 2014, we determined that MICHW would manage the certification
process versus a different type of authority such as the state government. In 2015, we
were able to take all of this information back to our larger stakeholder group, including
CHW, health plans, health systems, employers, and gather additional support. We have also used a lot of tools to support
this discussion. These are two pictures during some of our forums in 2013 with our CHW’s.
We have done a lot of this work over conference calls. We have done surveys. We had a statewide
survey in 2014. We do a lot of polling. We are doing polling right now, actually, on
the grand parenting provision of this part of certification. The process is iterative
and ongoing. It takes a lot to engage various types of stakeholders and a lot to educate.
We really focused on making sure that at all times, we were engaging people and making
sure that people are aware of what is happening. Some of the challenges to the process though,
are making sure that all of those people are included and that all of those voices are
respected. That is part of our corporate focus is to really make sure that that collaboration
is participatory. We really do work hard at making sure that all voices are brought in
as much as possible. It also takes a lot in terms of challenges to get people up to speed
on what decisions are being considered and why. Even giving overviews on a webinar like
this can be really helpful in moving the process forward by giving an overview of what some
of the options in considering some of those what ifs. What if certification was in place?
What if there are volunteers? Things like that. We also are still in process of getting caught
up in all of the details versus the big picture. That is something that is very common, thinking
about the bigger reality that would be created by certification. Sometimes those details
can bog things down. Really, it’s a collaborative process. In Michigan, we have worked really
hard to counter beliefs that stakeholders can only be reactive versus proactive. That
certification ultimately is something that community health workers really need to have
the true say on in the end. MICHW can serve as a place to foster all of those voices and
really support all of the community health worker, employer, and other stakeholder voices
throughout this process. I will turn it over from there to Sergio. Thank you, Katie, and everyone. Welcome everyone
to this webinar and thank you for joining us. I am Sergio Matos. I am the cofounder
and executive director of the Community Health Network of New York City. You see before you
on the slide there our mission. I give you a second to read that. I just wanted to say
that all of the comments that I make, I make within the context of my position as a leader
of a workforce and a professional association of that workforce. The process that we followed started I guess
about seven years ago. Having worked for about 15 years to advance the CHW work force, we
knew that this was going to be a long, an extended effort. The very first thing we did
was secure funding to support a staff, a small staff of people for what we anticipated would
be a two-year effort. We wanted to have a dedicated staff that would be able to work
full time on this effort for at least two years. The other big thing we do with our process
is that we committed to a stakeholder led process, in which case I will talk to you
a little bit about that in a minute. That whole state led process would be under CHW
leadership in agreement with a lot of the national policy positions that were emerging
at the time, including APHA. The other big thing we do with our processes is that from
the very beginning, we secured academic partners. We sort of had a suspicion that this was going
to take some original research and we wanted to publish our results. We had a vision to
be able to publish our results. We aligned some academic partners. You see some of them
here, although there were five or six others. Then lastly, in determining our process, we
felt it important to develop a leadership group. We wanted that leadership group to
be representative of pretty much all stakeholder sectors that had an interest in the CHW workforce.
Secondarily, we sort of had the sense that at the end of the road, we were going to need
to have to change systems and policies. We wanted these leadership advisory group members
to consist of really top leaders, leaders from across the state that might be capable,
and if engaged, to be able to realize change down the road when we were able to make our
recommendations. We wanted to have statewide representation. Very similar to the way Gail
and Katie expressed their efforts, we were very focused on supporting regional CHW organizing
to participate in this statewide effort. Actually, in some cases, it took where we had to go
to parts of the state and beat the bushes and find people who were wanting to organize
CHW and to really help them really develop local or regional network associations to
support our statewide efforts. Then we did support CHW’s to participate and lead this
effort throughout the entire period. Next slide, please. The other thing about our process is that
once we convened our leadership advisory group, it was about 60 people. Remember, these were
all top leaders of their sectors. For example, when we sought out regulators, we didn�t
go to every elected official in our Chambers of Congress, but rather we went to the chairs
of the health committees in those chambers. When we were looking for hospital representatives,
we didn’t go to every executive director of every hospital, but the executive director
of the statewide association of hospitals. We followed that approach in all of the sectors.
So anyway, we established that leadership advisory group. They, very early, decided
that their priority was going to be financing because their goal was to sustain the CHW
practice. They very quickly focused on financing. However, they realized that in order to consider
financing, they needed to have some kind of training or credentialing sorts in mind so
they would know what they were paying for. Then, in order to have training or credentialing
processes in mind, they realized they had to have a scope of practice to figure out
what it was they were training. They established these three working groups
to do that work. Each working group was co-chaired by a CHW and a stakeholder. The work group
efforts were staggered because the leadership advisory group also quickly realized that
they needed the work of the scope of practice work group in order to do their own work.
So the scope of practice work was done at a quicker pace and before the other two work
groups really started their work. The very first thing that the scope of practice told
us was that they needed some rigorous market analysis to be done in order for them to understand
what were the CHW’s scope of practice including roles. We had to go out through our academic components
and actually conduct that rigorous and original scientific research and the enormous data
analysis that was associated with that. So it was lucky that had established these academic
components beforehand, anticipating that we might have that need. The academic partners
did all of that work and through the CHW network conducted a lot of CDPR surveys. I think we
interviewed a couple of hundred CHW’s and almost 100 employers, payers, regulators,
and labor representatives. Next slide, please. So the results of if I fast forward two years,
the results of our work�this was a statewide CHW effort. We adopted the American Public
Health Association in our own CHW definition, which is published and we will be happy to
share with you. We established a statewide evidenced based CHW scope of practice. Again,
that’s on our website, which was on my introductory set of slides. That scope of practice articulates
the CHW roles, the CHW task, and the CHW skills that all significant stakeholder sectors look
for. We analyzed the results of that rigorous scientific research using a number of analytical
methodologies and they were done through our academic partners. Then at the suggestion
of Carl, who was one of our national leaders on our leadership advisory group, we applied
a labor functional task analysis, which really is a very rigorous analysis of data. There were two very interesting things that
emerged out of the findings that we did not expect, in spite of our extended experience
in advancing the workforce. One was that employers of CHW’s identified a number of priorities
that they utilize in assessing and hiring CHW’s. You see those listed. They include
shared life experience, a recognized set of personal attributes that Carl referred to.
These are personal qualities. These are like, well, personal attributes that employers very
specifically look for in employing CHW’s. That makes this workforce a little different
from others and has ramifications when you consider certification because these are really
not things that can be certified, but yet they are very critically important to employers. Employers also look for previous employment
as a CHW. Then lastly, and actually ironically, least importantly, employers look for previous
training. Many, many, many employers reported to us that previous training often gets in
the way, actually. They have to retrain CHW’s to not implement a lot of the stuff that they
come with from previous training. Most importantly, we found that actually credentialing,
employers didn’t care that much about it. It did not influence their decision of whether
or not to employ somebody. It just was not a primary element in their considerations.
Next slide, please. Lastly, I want to say that these statewide
efforts that we made to advance the CHW workforce, also besides the scope of work, once we had
that established the other two workers were able to get to work. The training and credentialing
group published a set of recommendations. The most important thing that this group of
leaders decided was to put certification considerations on hold, primarily driven by the fact that
there was an employer indifference about certification. The group itself expressed the desire to be
thoughtfully deliberate about this. The other driving force behind this decision
to put the brakes on this whole credentialing process was an examination of the national
experience with CHW certification that was emerging, which was really providing more
cautionary tales than best practices. A lot of the experience coming out of the state
that was certifying was not really serving to advance the CHW workforce, although it
was certainly regulating it. The training and credentialing workgroup also made very
specific recommendations around training content and pedagogy and methodology about the development
of the training and how that should be done and that CHW’s be co-trainers, they made recommendations
about citing and the delivery of the training. They made very specific recommendations about
training institutions, requirements for those training institutions and some thoughts around
what might be a possible credentialing process. Then lastly, the financing work group made
very specific recommendations to a variety of pairs about how to go about funding for
CHW’s. I will say that New York since the publication of these recommendations, New
York has become a _____ state and so these recommendations have been really integrated
into the work of our Medicaid redesign team and our district design teams. I will turn
it back over to our moderator, Carl Harrison Rush. Thank you, there you go. Okay, great stuff
about the process. Now, we have heard some things about reservations and in one of our
presenters about initial opposition to certification and things like that. So we decided to ask
a little bit about, first of all, what are the pros, in other words, the value. Who defines
the value of certification? What is it based on? Who really initially introduced this kind
of value proposition? Next slide, please. Katie. In terms of value, I am going to talk a little
bit about potential positive impact. So just to start, I wanted to be transparent about
what MICHW’s current recommendations are. When I say that these are MICHW’s recommendations,
it means that they have been approved by our steering committee, which is a body made up
of community health workers, as well as other individuals, who formally applied to be a
part of the committee and serve a two-year term. Individuals represent various types
of organizations all across the state. In 2013, the recommendation came up from our
working groups, both our community health worker network, as well as our education workforce
group that Michigan should adopt this generalized competency based training and certification
system for community health workers. That concurrently, Michigan should support policies
for community health worker reimbursements through Medicaid, managed care, and other
payers. So from there, we started embarking on our journey toward where we are at now,
which is we have a standardized curriculum in place. We are actively training CHW’s through
it. We are looking to scale it in the next year so that it is acceptable throughout the
state versus in some kind of isolated geographic areas right now based on capacity. But from there, we also move to really getting
more consensus over what that means. We talk about certification and the question of value
really does come up. Is there value to it? Will someone pay a CHW more or will there
be more reimbursement opportunities for an employer because someone is certified or not.
So in 2015, MICHW hosted a series of stakeholder forums specifically with our payers to help
address that question to an extent. One of the action items from that would be that MICHW
should develop and implement standard sets for CHW certification in Michigan. The potential positives that we’ve identified
over the course of time include the fact that right now, the CHW role is still a little
bit hazy. Having something like a certification would really provide a lot of definition to
the CHW’s role. That’s not to say that a definition or a scope of practice, or a listing of core
roles and skills couldn’t do that as well. We have moved towards certification because
our CHW’s have really called for that and have supported that. This is one method through
which a community health worker can be recognized. It’s also an acknowledgement that a minimum
standard of competency and skills have been met. To earn a certification, whether it’s
through training or through some type of grandparenting process, which we are still figuring out right
now, it’s kind of a stamp of approval that yes, we acknowledged that you have met this
minimum standard of education and training within your profession as a community health
worker. There is also an element of establishing the
CHW profession as a profession versus a paraprofessional or unprofessional role. That is still a battle
that a lot of community health workers face is making sure that in conversations about
care, about working communities, that the CHW isn’t ignored or thought of as this lesser
professional because they don’t have a license or because they don’t provide direct clinical
care. Certification is one method through which we can acknowledge or recognize the
CHW as a professional. It’s not the only method, but one of them. It’s also validation of the
CHW’s investment in training and skill development. There is also impact from multiple stakeholders,
which is a point I just really want to emphasize. There has been in other places, conversation
about really what this value is to the CHW, as well as the employer. So for the CHW, we
care a lot that there is a personal value. From a CHW perspective, there is a value in
being able to say, “I am certified. I have met this particular standard.” Or “I would
like to be certified so that I can say that I have met this particular standard.” Then
there is also professional value in acknowledging and validating where that particular person
is in their professional career. There is also value to the employer in acknowledging
that “yes, my individuals are certified. Therefore, they have met these particulars standards.
Again, in Michigan, this is not in place right now, but these are potential positive impacts
that have been cited. There is also a lot of positive impact that
we are not quite sure about yet. For the CHW, one of the most common questions that I get
is will my pay go up if I am certified? The answer is that we don�t know. We don’t know
if a wage increase will follow. We also don�t know whether or not we will have defined gateways
to new education opportunities. The intent with our standardized curriculum, which we
delivered in partnership with community colleges, is that at some point, because of our connection
to the education system, there will be opportunities for that CHW to move through that system in
another way if they would elect to. We also anticipate that there will be increased
personal and professional efficiency for that CHW that they will themselves, would be empowered,
and feel like that they have more agency over their profession and their activities. Again,
that is a potential positive impact. There is a lot of CHW’s right now. I am not one
of them. I am not a CHW. There are a lot of CHW’s who are very, very confident in what
they do and who they are as a community health worker. Certification may or may not increase
that confidence or impact them in that way. We are not quite sure. For the employer, there is also potential
opportunities for new funding streams, but we don’t quite know what those are yet. There
is a lot of educated guesses being made as _____ about whether or not a certified CHW
would be eligible for reimbursement or not, whether it’s through Medicaid or through other
mechanisms or whether or not health plans or others would acknowledged the certification
as a minimum standard that they could get behind with some type of increased payment.
We also anticipate that certification would create some type of workforce standard that
you could kind of more generalize where people are and who they are and what they do, especially
when you have so many people under different titles. You have such varying roles within
their different agencies that all fall under the CHW umbrella. That could be a way to really
honor the diversity of the workforce, but still set the standard of competency or skill
that people could align with in some way. Again, that is something that we anticipate,
but is not guaranteed in any way. Sergio. Are you on mute, Sergio? I am so sorry, I was on mute. So thank you,
Katie. In considering the pros of certification, and in part of conducting our statewide CVPR
work, original research, we actually asked people and groups of people, what is it that
you are looking for in a credential? Many of the issues that were raised were the ones
that Katie just itemized. The question of increased funding was usually central to most
people’s consideration of this issue. In particular, because so many community health worker programs
are grant funded or were at the time. So people were concerned and were wanting a certification
to give them more funding availability and sustainability. We are actually finding as
a result, that a more recent development in New York, especially with _____ that it is
actually the business case that is most effective to both CHW’s and payers and healthcare administrators
and designers. It is the evidence that exists improved outcomes, cost savings, return on
investment, and value added, that is driving funding of CHW’s, not so much the certification. The other big thing that CHW’s always told
us is that they expect better opportunities and wages, similar to what Katie said. In
fact, employers don’t care about that. So they are not asking for that certification.
I don’t know how much relativity there is to that. The other things is that people felt
that a certification would give them more prestige recognition and stability at their
work so they wouldn’t get fired every two years when the grant runs out. Again, we don’t
know that there is any existing evidence for that. In fact, a lot of the recognition or
prestige that might be associated with credentials depends very much on who the governing party
is for that credential. There are some states where other professional associations have
taken over governance of the CHW’s and have actually created less prestige and less recognition.
That evidence is the jury is still out on that. Then lastly, there was a sense that a credential
might provide increased cooperation with the healthcare community. Again, we have found
that that doesn’t depend so much on the credential, but really on understanding the role and the
tasks and the skill set that CHW’s bring. That’s what makes them the most effective
member of the evolving healthcare teams that are coming out of these new innovations. When
we find out when providers, particularly medical providers and employers witness the success
that CHW’s bring and the cooperation with those communities increases. Thank you. Gail. This is Gail. I think Katie touched on a lot
of what I was going to touch on. I would emphasize that we see this as a piece of advancing,
not everything. I would just add that from various perspectives here, what some of the
potential benefits that were anticipated might be. I would say that the community health
workers, they see it as an opportunity to better define a practice. That is to create
awareness of and clarity around the scope and the skills, the competencies, and to build
professional identity. I will just add to that right now that I think what we have found
here in Massachusetts is that when we have some kind of legislatively mandated process
that is underway, it kind of gently encourages people to participate in it or forces people
to participate in it, as it were. I actually sort of makes people pay attention to community
health workers and to create consensus around it and buy in an ownership of advancing the
field. I would say that every legislative process we have has built consensus and grown
professional identity within Massachusetts. Other things, there are the things that Katie
mentioned around increased pay, benefits, supervision, training, and career letters.
We don’t know how that will play out yet, but it is certainly we are hopeful. We had
some providers and employers, we actually did have support for moving ahead with certification
to help them understand what a community health worker does compared to other workforces and
to establish what the training standards would be for that workforce. For us, as well, in
Massachusetts, with our public and private insurers, we really actually found that we
weren’t able to kind of move forward without thinking about certification. What we have
tried to do for perspective is create a process that would be led by community health workers
that is both our public and private insurers are paying much more attention to this, are
engaged in it, including our Medicaid agency because we are actually talking about defining
the qualities and qualifications are of the workforce. I think we can move on to the next
question. Thank you, the final question, as you might
imagine, a little symmetry here, the cons or potential negative impacts, and its inevitable
that there would be pushback, skepticism, even resistance, but in your experience, when
in the process were these negatives first articulated and how influential do you see
them having been on the outcome in your state? Next slide, please. Sergio? You are on mute
again. Thank you, Carl. As you can probably imagine,
I am more in this camp, than the previous camp. I have arrived there over many years
of experience. The concerns that people have raised around certification. The responses
that I get from people and that we got from people when we were doing our statewide research,
and some of the evidence that is emerging from the experience of other states is that
primarily certification could redefine the practice. In fact, we define it to the extent
that it would no longer even be recognizable. There might be a loss of identity and specifically
the power of CHW’s to determine their own practice. This has actually already happened
in a number of states. We talk about self-determination as sort of the silver bullet to try to address
this whole issue of redefining the practice. In fact, I know one state turned governance
of CHW’s over to a different profession. Now that different profession has imposed their
culture and standards and norms onto CHW practice to where they are not even really recognizable
anymore so there is that danger. The other thing is that a certification tends
to establish restrictions on a practice so that there is the potential that the scope
of work could become limited, especially if it is not informed by the evidence base. There
are other requirements generally for a certification, which would have to be addressed, like educational,
academic, higher education requirements that might not be relevant, immigration status
in some states might be an issue. Typically, I just finished publishing a book on how immigrants
improved their health and how CHW’s improved the health of immigrant communities. Those
CHW’s are generally immigrants. Immigration status might be an issue. English only states
might have an issue with establishing a credential. Of course, financial responsibility for the
training and credentialing might be a burden. The other big thing is these criminal background
checks. Like I said, CHW employers look for CHW’s because of their shared life experience.
Well, if you are looking for somebody to work with teenager prostitutes, than you are going
to probably want to find somebody who was a teenage prostitute. That person might very
well have a criminal record. People’s criminal history might interfere with a credentialing
process that uses that as a block. The other big thing is that it might not be
necessary. People in our processes, there is really no need for it. Nobody is asking
for it. The business case for CHW effectiveness is extensive and convincing. Employers are
really looking for personal qualities, not a credential. So people are asking well, and
actually one of the participants on this very webinar posted a question about that and I
hope we get to address that. Then the big thing is that from the national experience,
certification alone does not provide, is not showing to provide any of those things that
people are searching for in a credential. The other big warning point that our�this
came from our business community in the advisory group, is that if you pass a bill that requires
something, than that bill has to be funded. Any credentialing process that any state decides
to embark upon, there is some expense associated with it. Somebody is going to have to maintain
testing and evaluation. Somebody is going to have to maintain a registry of certified
people and keep that current. Somebody is going to have to enforce that credentialing
or regulation. That is going to cost money. In general, the political climate across most
states is that people are not looking to expand government or increase spending right now.
Taking a legislative agenda or establishing a process that’s going to require investment
isn’t really very attractive to many states. I will turn it over to Katie, I guess. Oh,
no, Gail. Yeah, it’s actually Gail. Definitely what
you said was true that your last point about the challenges of state government spending
money on a certification process. We are specifying and we are tightrope walking as well. I just
to get into some of the challenge that we talk about in terms of certification, we acknowledge
that it means different things to everybody, actually, probably of the hundreds of people
on this call, something different comes to their mind about what certification really
is. It can be different. It can be shaped differently and designed differently. That’s
really sort of the main take home here. If it is done well, at least you have a better
chance of having it be responsive to the needs of the workforce. Obviously, some of the potential
adverse impact which were already mentioned is that we do not want to erect barriers to
entering the workforce or practicing for effective community health workers that are already
practicing. We don’t want to diminish effectiveness of community health workers by distorting
the identity of community health workers or over medicalizing the practice. We don’t want
to restrict community health workers because they are very creative and respond to complex
needs. The other thing we also want to be careful about is creating separate classes
of community health workers. That is, those who were certified and those who are not.
That is tricky. Moving forward. Here is the next one. Can
somebody advance it to the next slide, please, there we go. Okay so thank you. What some
of the ways that we are addressing anticipated challenges is we are including a grandparenting
provision that recognizes work experience. It recognizes voluntary and part time work
experience. There will be flexible training program approval standards, that is the curriculum
needs to be based on adult learning principles, but it is not going to be proscribed. The
training programs will need to address the core competencies. We are creating a user
friendly application. There are no minimum educational requirements. We will not be requiring
proficiency in English. There will not be a test, but we will be doing along the lines
of a call test, some kind of performance competency based assessment. The fee will be affordable.
Can somebody move it to the next one? Thank you. Lastly, or almost lastly, some of the things
that we are doing on a broader level to address some of these challenges are to engage people
at every step of the way and create ownership. Somebody asked the question about actively
supporting CHW leadership with resources. I can try to get some more detail about that.
In essence, the State Public Health Department is providing resources, financial resources
and technical support for CHW association to be engaging community health workers at
every step of the way. The whole time we are going through this, we are recognizing the
inherent tension of the work of formalizing a CHW profession while retaining and supporting
the grass roots nature of the profession. Then lastly, what we are always careful to
do is to include community health workers who work in community based settings as well,
not only in healthcare so that this doesn’t become a healthcare driven process that we
are really recognizing the broad spectrum of community health workers that are working
out there in the field now and who want to enter the field. I think we can move on. Great, so I am going to finish up here real
fast so we have time for some Q&A. one of the big things that has been touched on already
is just in terms of negative impact, the CHW role has really historically been grass roots,
community based, oftentimes an opportunity for entry into the work force, many times
for the first time, and really centered around this concept of life experience and/or unique
connection to community. There is always concern as to what certification may be do for that.
What’s been really interesting as we tackle the question about whether or not certification
dilutes the workforce by ignoring some of those things or whether it actually supports
those, is that in Michigan our conversation looked different. Some days, CHW have this
concern. Other days, it was employers have this concern. Because there is a perception
that when you have someone who is truly grass roots of the community, community based, that
that person getting the certification somehow is not that anymore. So that is a tension
that we are actually battling all the time and really trying to talk through and get
different people’s perspective. As a disclaimer, as I’ve already stated, Michigan
really is pursuing this because of our CHW’s and our employer stakeholders have supported
it. Some of the potential negatives otherwise that have been recorded during this process
include the cost of regulation and oversight, as well as decision making over the course
of time. These have all already been touched on by the potential exclusion of CHW’s, as
well as cost to the employer. It is cost to the CHW, if the employer is unwilling to pay
or if the community health worker is a volunteer. In terms of handling it, how do we handle
these potential negatives? We talk a lot. This is something very, very common for us.
We discuss pros and cons in conference calls and in person discussions. We make sure that
whoever is on this call is up to date as to what is going on. It’s a huge challenges sometimes.
We really are built on participatory principles, meaning that we really value all voices. We
make decisions by consensus, not voting, so we don’t take individual tallies, but we don’t
move forward unless we are really all on board or we are enough on board that we feel comfortable
in taking the next step forward. Next slide. Some additional concerns cited by CHW’s employers
have led us to pursue various aspects of certification over others. As a result, things that we are
pursuing now include MICHW managing certification versus an external party. MICHW was identified
as this potential third party versus someone else because we are the Community Health Worker
Alliance. We are not formally associated with a specific employer group or another association.
There was some general consensus that if MICHW was over it than community health worker voice
could be maintained and really be sought out and acknowledged as a part of the whole process.
We have also made sure to include a grandparenting provision, which we are talking through right
now. It’s a voluntary process, which is inherent as part of certification. We are also pursuing
employer paid certification when possible. We polled our employers and had fairly positive
responses for all of them. We are also launching a registry for community health workers that
you can enroll in as a CHW regardless of your certification status. There will be a method
on the registry to identify who is certified and who is not. That will be the method by
which MICHW certifies CHW’s, but any CHW has the freedom to register, which we are also
hoping will help reduce some barriers for CHW’s who may feel in a different class than
someone else as Gail stated. With that, we will move on to Q&A. Carl? Great, thank you. I want to thank all of our
panelists, a lot of important perspectives here for our participants. I am going to ask
Kristen to field or select the questions. Our main intent here is for the panel to be
able to respond to questions from the participants. We will be, since we are running a little
low on time, we will make the commitment to ask these panelists to respond in writing
to any of them that we are not able to handle verbally. Kristen, do you want to toss out
a question we have received by the chat box? Sure, the first question will be for Gail.
Could you speak more about the dedication of resources to support CHW leadership and
who from and how much? Sure, so this is an almost 20 year process
of ongoing support from the state for the Mass Association for Community Health Workers
that somebody else actually asked about as well around seeding the formation of it back
in 2000. But more recently, with the certification process, the Department of Public Health used
small pockets of resources for MACHW to convene town halls across Massachusetts to get community
health worker input on certification before the decision was made to go forward, to work
with the code of ethics and adapt that for Massachusetts to hold educational forums across
the state; to help community health workers understand what certification and what is
happening with certification; to gather input from them about the process to bring them
to certification board meetings; help them have an organized voice at certification meetings;
and to also develop materials that are friendly around application and around the process.
I am sure there are other things, too, but that those were the quick things I jotted
down in response to that question. In essence, we do not move forward on anything here without
significant community health worker input and also leadership around convening community
health workers to gain leadership skills as well. Okay, thanks, Gail. This next question is
for Carl. Can you define provider clinical care further and could you tell us more about
non-clinical tasks that are being set that may require a license to practice? Sure, well, I think the first thing to say
is that clinical license mean that someone who does not have a license, it is illegal
for them to perform the tasks that that licensed profession is allowed to perform. One of the
things that we run into is that particular in healthcare organizations, is that folks
have a hard time wrapping their heads around how someone can be effective in their organization
without significant clinical training. The point is that community health workers do
not diagnose or treat or dispense medications. They do not perform lab tests and so forth.
They may perform vital signs that an individual should be able to perform for himself or herself
like it doesn’t take a license to take your own blood pressure, that sort of thing. Those
are about as far as a community health worker might go in providing clinical care. That
is anything involved in actually diagnosing or treating illness. There is sometimes some confusion between
community health workers and direct care workers like personal care attendants or home health
aides. These are very different skill sets because those individuals are providing direct
services necessary for maintaining or improving the patient’s health. The community health
worker is much more in a mode of coaching, supporting, advocating for, teaching, supporting
adherence to treatment, things like that, helping people overcome barriers to keeping
appointments. These are not things that require clinical training. This can be very important
for the organization in terms of improving communication, increasing levels of trust
and relationship between provider and patient. These are all strength that community health
workers have that are not directly involved in the provision of clinical care. Lastly, one thing that has become extremely
important is assisting with the management of social determinance of health, both by
helping providers, clinical care providers, understand the life of the patient, but also
helping the patient to deal with micro issues like housing or family violence, things like
that that clearly affect people’s health, but they are not within the purview of the
clinical provider like a physician or nurse. It’s a very important distinction. It’s one
of the reasons why it’s not necessary for CHW’s to be licensed. It’s also not necessary
for them to have professional liability or malpractice coverage because they are not
conducting activities that are subject to those kinds of standards. Okay, thank you. I think this next question
is for Katie, but if others have anything to share, feel free to chime in after Katie.
For individuals who are now taking CHW training, whether online or in a classroom setting,
will certification be available as an option for them? Is it available statewide or is
it only available to MICHW and has it been decided or is it in discussion for now? Is
it up to providers and employers to decide? It’s a long question. I can chime in a little bit on that, but I
welcome the other panelists to also share. Currently, in Michigan, certification does
not formally exist yet. MICHW will lunch our certification process later this year, but
it’s not up and running yet. Right now, options for community health worker training in Michigan
include our core competency based curriculum, which is being implemented across the state
in various parts. To date, we have over 75 CHW’s who have completed with several more
in process. We also have a history of training in this state. There will be several dozen,
if not hundreds of CHW’s who will be eligible for grandparenting. We have not finalized
those criteria yet, but there will CHW’s who have previous training experience whether
it be electronic or in person, as long as it hits on some of our core competencies.
As part of grandparenting, there will be a provision where the CHW will have to verify
that they have met those core competencies and that we are still figuring out the details
of the extent to which an employer can sign off on that versus previous training experience
and documentation needing to be provided for that. This is Gail and I will jump in for Massachusetts.
The way it will work here, we believe, it hasn’t been finalized yet, is that any community
health worker in Massachusetts can apply to become certified. If they are going through
the training and work experience pathway, they will need to submit evidence that they
have successfully completed an approved training program. otherwise, as they go through the
work experience pathway, they won’t. All CHW applicants will need to submit three references
attesting to their proficiency in the core competencies. Again, as Katie says, the devil
is in the details. How we are going to do that? Again, we are trying to adhere to the
principles of not creating barriers to community health workers who are successfully working
now. I think that probably answers the question from our perspective. Yeah, if I could just add very quickly, in
New York, our recommendations are really centered around credentialing training programs rather
than credentialing individuals. A number of reasons for that there were many members of
our leadership advisory group that were either academic training institutions or proprietary
training institutions. This whole, in New York, at least, these concepts of either credit
for life experience or college credit bearing training programs, are very, very complex
issues. Evaluating life experience for credit is really, really difficult and complex according
to these educational experts and institutions. Rather than put that onus on the individual,
we chose to credential training programs that were responsible to the scope of practice
and that applied appropriate pedagogies. Okay, thank you. So this next question isn’t
directed towards any of our speakers, but maybe we can start with Carl and then if other
speakers could chime in. Is there any realistic chance of moving beyond grant based funding
for CHW, EG and integrated care teams without CHW certification in the context of changing
payments models under ACA? Sure, and I will say that’s a very important
question, maybe a little beyond the scope of this particular webinar. I am hoping we
will get back to one later. I will just say very briefly that while as Sergio said that
the financing question is not dependent on certification, certainly. That some agreement
on qualifications is going to be important. There are a lot of different pathways to sustainable
funding. Grant funding, by definition is pretty much out of the question as a sustainable
strategy. I will just saw a couple of things. One is that, of course, we are talking mainly
about Medicaid since the major area of effectiveness of community health workers is with low income
populations, but that there are plenty of things in those states which have a managed
care model that health plans have a lot of latitude to do things with CHW’s now with
no additional authorization from the state. Secondly, that a lot of states are moving
towards some form of value based payment for healthcare and that the opportunity to persuade
them to integrate community health workers into those strategies can really make a lot
of sense. I think that is really where the strategies like that make the most sense rather
than pursuing dedicated funding streams for CHW’s as a workforce. I would say that the answer to that question
at least from New York is absolutely, yes. CHW’s are being built into district models
and integrated into healthcare teams quite extensively across all of our district recipients.
Some of these district models are really quite extensive. Some of them are even called medical
villages. So yeah, CHW’s are being integrated as part of those teams without credentialing. Gail or Katie, do you want to weigh in on
that? Okay, I am mindful of our time. We are about five minutes before our planned ending
time, so maybe this next one may be the last question. It’s up to you, Kristen, but it’s
looking that way. Yeah, I think that sounds great, Carl. This question will be for Sergio
and also for Gail, if you both have remarks. In terms of the CHW advisory boards, what
were lessons learned, if any, in terms of maintaining self-determination and making
sure that voice of CHW’s is heard in the process? You want to go with that, Gail? Sure, it’s sort of to the effect of what I
was saying before. I mean I think that we have dedicated resources and staff time to
actually ensuring that there be a community health worker association with voice at the
table and with support to speak up. I think people need to be mindful of that. They need
to understand what the specific challenges are that community health workers face in
participating in these conversations and actually make active attempts to get past them so that
community health workers feel ownership and otherwise there is no point in doing this.
I guess I would just leave it at that. Yeah, I would say that it was really labor
intensive for us. We really had to go throughout the state and beat the bushes and find small
groups of people that wanted to organize and then really worked to help them not only become
organized, but to become literate and intelligent about the salient issues so that people were
really able to consider what are their potentials and consequences of certification, not just
to meet just the hopes or the dreams , but what is the reality and what is the national
experience today so they can be, like I said, deliberately intelligent about it. That was
not an easy thing to do. It took us quite a bit of time traveling across the state doing
that, but I will say that it’s CHW’s are typically not in a position of power in their work experience.
So bringing them to a table to leaders and asking them to contribute to that needs support.
That is not a normal posture or position for them to be in. They really need a lot of encouragement
and support in order to be able to contribute their wisdom to a discussion of a group in
which there are power dynamics that are working against us. Kristen, you have some comments to make in
wrap up? Yes, so thank you so much to our panel and
our speakers today for the engaging discussion. I just wanted to mention that we have a couple
of slides here with different references and also resources that will be available to everyone
when the slide deck is posted on ASTHO’s web page. I just wanted to thank everyone for
joining us today and as mentioned earlier, you will be immediately directed to an evaluation
at the conclusion of today’s webinar. So please take a few minutes to complete our survey
that provides with useful information for our future projects. It also has questions
related to the work you are doing around community health workers in your state. We really want
to hear about the work that you are doing and how it may inform our future projects.
I would like to thank HRSA for sponsoring this webinar and I would also like to thank
our speakers, KT Kramer, Carl Rush, Gail Hirsh, Katie Miller, and Sergio Matos. A recording
of today’s webinar will be available on our website within the next few days and the web
address is on your screen now. As Carl mentioned, we will also post the answers to some of the
Q&A questions that we weren’t able to get to during the discussion this afternoon. We
hope that you will be able to use this webinar as a resource and will share the link with
others once it is available. Also, please visit ASTHO’s website to access the number
of CHW resources, along with the other resources that our presenters shared with us today.
Information about the next webinar in this Community Health Worker call series will be
available soon. If you have any questions about today’s webinar, please feel free to
contact me at [email protected] Thank you so much and enjoy the rest of your day. [End of Audio]


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