Indiana community health workers: challenges and opportunities for workforce development

The research team and steering committee collaborated to identify objectives pertaining to data collection instrument development (i.e., survey, focus group questionnaire). Both quantitative and qualitative data collection instruments were framed by 13 pre-defined overarching topics (see Appendix).

An initial survey was created by the research team, with feedback from the steering committee and INCHWA to ensure appropriate content and consistent language leading to minor modifications (e.g., providing additional response options and language clarity for intended audience and adding questions for additional contact-related information from participants) and four items added. The final 59-item survey sought to establish a demographic profile of Indiana CHWs, identifying CHW job titles, roles, employment sectors, and activities, as well as to capture CHW certification and training prevalence, and collect demographic information of communities and populations that Indiana CHWs serve.

Concurrent with survey development, focus group data collection instruments followed a similar process as that of the survey. With the goals of receiving CHW and employer input related to the CHW workforce and gaining a greater understanding of strengths and challenges of the workforce and CHW roles, two semi-structured focus group guides (Appendix) were developed. Specifically, one guide was developed for CHWs and a separate guide for employers of CHWs.

In November 2020, an online survey of Indiana CHWs was conducted through use of an anonymous Qualtrics survey link distributed through INCHWA. Respondents could forward the link to additional CHWs. The survey remained open for 4 weeks. Only CHW respondents that indicated that they were based in Indiana were included in data analysis. Additionally, to eliminate potentially duplicative and fraudulent responses, researchers excluded responses from identical internet protocol (IP) addresses and email stems, that took 5 minutes or less to complete (minimum survey completion time of 10 min based on the estimated time to complete the survey), and that were less than 50% complete. SPSS software (Version 26) was used to descriptively analyze data (i.e., frequencies, counts). All eligible survey participants received a $10 e-gift card.

Focus group participants were recruited through INCHWA’s mailing lists, with all interested participants able to engage via Zoom videoconferencing software. Focus groups were facilitated by members of the research team over a four-week period in November–December 2020, with each focus group lasting between 75 and 105 min. All participants received a $45 e-gift card as compensation for their time. All focus groups were recorded verbatim and transcribed using Otter.ai software. Research assistants completed a quality check of each transcript to ensure accuracy prior to data analysis.

NVivo 12, a qualitative software, [13] was used to deductively and inductively analyze data to identify emergent topics [14, 15]. First, using the focus group guide a codebook with 13 pre-defined topics was developed and deductive coding was carried out. Next, an inductive analysis was conducted to further refine the pre-defined topics as well as add new topics to the qualitative codebook [15, 16]. Throughout the deductive and inductive analysis, coding consisted of identifying direct quotes that represented each topic and organizing these quotes, or raw data, into findings by topic while succinctly combining quotes into broader topics [6, 14]. Researchers met to review and discuss findings and any discrepancies were resolved through discussion [17].

To identify areas of concordance among data sources, survey and focus group data were triangulated using a data consolidation analytic approach [18, 19]. This approach blends qualitative and quantitative data to investigate a phenomenon, thus corroborating internal validity of findings [20]. Microsoft Word and Nvivo 12® [13] software were used to compare and consolidate findings via cross-tabulation of quantitative and qualitative findings by each of the pre-defined and inductively derived topics.

Quantitative analysis of survey results revealed that Indiana CHWs are highly diverse with 43 countries and 14 languages represented (Table 1). CHWs are employed under various titles (Table 3) and in various employment sectors and settings, including Social and Community Services (24%), County Health Departments (15%), and Private health sectors (13%) (Table 4). CHW services are provided throughout Indiana’s 92 counties and triangulated data supported existing literature [21, 22] that CHWs serve clients who face a myriad of economic, social, physical, and environmental challenges (Tables 2 and 5).

CHWs and employers both described key CHW attributes, characteristics, roles, and responsibilities, six of which aligned with the national CHW Core Consensus (C3) Project, which aims to increase visibility and a greater understanding of CHWs [23]. Following a post-hoc qualitative analysis, these nationally recognized C3 qualities, roles, and skills were mapped to our Topic 2 findings in Table 2. CHWs are often motivated by their “want to work with a lot of people [from] different backgrounds” and from the community they serve, or they leverage their own lived experience to connect and relate with clients. CHWs view themselves as trusted members of the community who actively work to create and keep this trust, “…it’s usually just a matter of them [clients] getting to know and trust you.” CHWs acknowledged that trust could be difficult to build but described qualities they possess that allow them to effectively develop this between themselves and their clients such as having patience, the ability to create a safe space, and the need for “compassion and passion for what you are doing.” Additionally, CHWs understand the importance of “meeting [clients] where they are” and of being creative and flexible. Being adaptable also helps CHWs overcome obstacles when carrying out their work as they, “come up against… a lot of barriers, and you’ve got to be very creative at how you address… those issues. You don’t want to burn any bridges.”

A key CHW role is the ability to “serve as a resource for people that I come in contact with.” As such, they often become a point person for their clients or “that one consistent face and voice that [clients] could contact.” They view “knowing the resources that we have in the community [as] very important” as it strengthens their capacity to connect clients to needed medical and social services. As trusted resources, CHWs often advocate for change, “I’m a health advocate, here at the hospital we have all kinds of projects. Our goal is to break those barriers [experiences by clients, such as] why people sit in the ER forever, you know, constantly, they can’t afford their medications, utilities…just can’t get to the doctors…the transportation.” In addition to linking clients to resources, CHW responsibilities involve providing case management, offering health programming, and working with clients to set health and wellness goals. Survey results revealed that CHWs work within a wide breadth of health-related topics with chronic disease management being a key focus (13%) (Table 6).

Employers shared ways that hired CHWs enhanced their organizational work as “there was so much that our registered nurses and dietitians and registered respiratory therapists couldn’t complete…so CHWs were hired to help us close those gaps.” When hiring future CHWs, employers looked for professionalism, flexibility, and organizational and communication skills. Employers also expressed a preference for bilingual candidates with an existing connection to the focus community, “We really try to hire from within that community. So we’re getting people who know the community, they know the resources, they know people coming into the clinic.” During the hiring process, employers reported turning to organizational leadership, community partners, and currently employed CHWs. Successful CHW hiring strategies included drafting clear job descriptions, recruiting directly from client populations, hiring CHW cohorts for group training and onboarding, and providing employee benefits.

After analysis, among the CHWs surveyed, over 80% (n = 526) reported being certified, more than 50% (n = 368) found CHW employment as a result of certification, 12% (n = 75) had a CHW position before becoming certified, 5% (n = 35) did not find CHW employment, and 6% (n = 40) did not seek CHW employment. Participants shared that certification provided CHW work with legitimacy and validation, “being certified as a CHW, just kind of gives us that little bit of …, I guess, upper level, you know what I mean?” Certification also seemed to offer CHWs an opportunity to strengthen overall skills, knowledge, and training, “…it’s just good to have that [training] knowledge and background and experience to add to what we do every day.”

Surveyed CHWs shared an unawareness of certification when they entered the workforce but were asked to complete certification by their employer. Most (n = 492; 76%) CHWs reported employers paying for the CHW certification; employers use state-funded training and workforce development reimbursement programs to do so. However, employers shared inconsistencies in terms of sponsors, certification type (e.g., combined CHW/Certified Recovery Specialist [CRS], stand-alone CHW certification), and cost, “… it [certification] was kind of expensive… it was even more money than just doing the whole CRS/CHW program. So I think that could deter some people from becoming CHWs.”

Making a difference in people’s lives was described as a rewarding aspect of CHW work when “you can see how you affected them or how, you know, you’re even able to make them believe in themselves, which is huge.” Being recognized by the medical team was also seen as rewarding: “I feel like the medical team really recognize after, you know, they definitely are thankful and appreciative of the help that we provide.” Despite the rewards, CHWs continue to face challenges due to a general lack of awareness of who the CHW workforce is and what they do, which “...a lot of the time with CHWs, I think that what we do is not valued. So we don’t really get paid that amount that we should get paid.” CHWs also described barriers such as a lack of resources to help the vulnerable people they serve, which can exact heavy physical and emotional costs. CHWs discussed ways to address these challenges including creating “more acceptance of what we do and being more respected as a profession because this is a profession.”

Being relatable, supportive, and familiar with CHW work were identified as characteristics of an ideal supervisor, “I need a supervisor who does this job... And I want someone who has done the work to be able to ‘train up’ others and also be that lead...” Related to professional development, CHWs expressed wanting access to supervisor encouraged and funded trainings and certifications that go beyond initial CHW certification, but shared that professional development opportunities are not readily available and costs fall upon the CHWs themselves. CHWs shared interest in on-the-job training in particular areas (e.g., home visits, and going into homes), and access to annual conference or annual/quarterly trainings in order to stay current in the field and learn from peers. CHWs also expressed concern over lack of career advancement pathways, “so within the organization, there are not too many [promotions].” Despite the absence of professional advancement, CHWs expressed a desire to expand their current position to include supervision and training of other CHWs, “I would like to teach the classes as well as even after going through the course, inquired about how to become an instructor.”

CHW positions are primarily funded through county, state, and federal grants or soft-monies and, to a lesser degree, by institutional or hard-money leading to concerns related to job security, “We work for a not for profit, so things change all the time. Funding could go at any moment...” Both employers and CHWs shared how soft-money funded programs place employees at risk for unexpected terminations: “…their [CHW] grant was from the Office of Minority Health, they really hated it because it got pulled in year three and they had made so much progress…I’m staying away from grants because you can’t trust them. The work they did was so valuable…so it was really sad they couldn’t finish.”

Participants expressed confusion and lacked understanding related to CHW billing for Medicaid reimbursement. They shared concern regarding the sustainability of a business model that relies on the current CHW reimbursement structure given that it does not allow for billing of clients with a diverse payer mix, does not provide payment for CHW services provided on the same day as other provider services, and fails to cover a broad spectrum of CHW services, “But I think that insurance companies like Medicaid and SSI would benefit in the long run, if they covered more of the services CHWs do because they’re all services that keep their patients, their customers in compliance.” Both CHWs and employers agreed that applying for CHW reimbursement through Medicaid is cumbersome, confusing, and complex, “…it would be nice to see more guidance on what’s considered appropriate within those ranges…it’s hard to get a concrete understanding of what’s a part of that CHW service definition.” Employers discussed the potential of Z code usage, and that more effective collaboration among doctors, providers, and CHWs would be needed to address these challenges, “…if our doctors or providers would work closer together, and they would look through the curriculum with me, we could work as a partner, and I could educate, educate the group and get reimbursed for his patients.”

Scaling and sustaining CHW positions is best facilitated through accessible information documenting the roles, responsibilities, and impact of CHWs. Clearly defining CHW roles to healthcare providers allows for better CHW integration into healthcare organizations, improving overall health outcomes [6, 25]. Maintaining an Indiana CHW registry will allow compilation of up-to-date statistics on workforce density, geography, certification levels, areas of work, employment, and income. With standardized data collection across employer organizations, it is possible to measure the full impact of CHW services and demonstrate ROI, as well as establish standardized and sector-specific metrics for CHW outputs and outcomes. Ingram et al. [4] described the use of electronic health records to examine the effect of CHW services on chronic disease outcomes. The Arizona Community Health Worker Association and the CHW Workforce Coalition spent 2 years gathering data from and about CHWs and community health representatives serving American Indian Tribes and communities via small group sessions and annual meetings. These data later informed a formalized assessment of CHW mastery of core competencies as well as a process to approve training programs throughout the state [26]. Our recommendation to build and maintain an up-to-date evidence based CHW registry and database could serve as a more efficient approach to collecting data, and meaningfully build upon the mounting evidence of positive health outcomes associated with the integration of CHWs into patient care across the country [3‐5, 27‐32]. These standardized data can be used to inform and catalyze advocacy and policy efforts towards creating and/or refining standardized state training programs, pathways for certification, employment, and sustainable funding for the CHW workforce.

Dissemination of evidence can be more easily achieved upon establishment of the evidence-based database (Recommendation 1), which could inform the development of dissemination products, such as informational materials and strategies, and can equip all applicable stakeholders with increased clarity and understanding of the CHW profession, associated roles, and impact on health outcomes. The National Association of Community Health Workers (NACHW) document resource center is one example of data dissemination, which is accessible on the NACHW website for free and includes study reports, policy briefs, fact sheets, and more from researchers and CHW organizations across the country [33]. In accordance with Sabo et al. [24], we recommend that evidence be distributed in lay language and accessible through a variety of outlets (e.g., social media, newsletters, workshops, interactive presentations at staff meetings), in the preferred language of the focus community. Communities who understand the role of CHWs will be more trusting of the profession and are better poised to leverage CHW services. Employers who know the demands of the job are also in a better position to take the steps to adequately support the workforce [34]. Yearly reviews and pre- and post-program implementation analyses are vital in promoting workforce development. Frequent data analysis and dissemination of organizational-level CHW impact metrics will support evidence-based advocacy for the workforce. Impact metrics can include the number of enrolled patients, client evaluation forms, follow-up rates, and community-specific indicators such as a reduction in emergency room use [2]. The C3 Project, which aims to increase visibility and a greater understanding of CHWs, created a publicly available CHW assessment toolkit. The toolkit allows for field-oriented, evidence-based recommendations and resources that aid in the holistic assessment of CHW impact [23]. Similarly, our recommendation supports creating and disseminating informational products that are readily accessible and can demonstrate the positive impact that CHWs have on their communities, thus, leading to opportunities for increased funding, expanded policy initiatives and resources for employing and retaining CHWs.

An underutilized and misunderstood billing framework for reimbursement of CHW services leads to a lack of sustainable funding for permanent CHW positions. Inconsistent funding jeopardizes CHW recruitment and retention, as well as program implementation. Ensuring sufficient funds through extensive cost analyses that consider expenses associated with continued training, sufficient supervision, and integration of CHWs into healthcare systems is vital [34]. There are various CHW funding strategies to be explored, including reimbursement for non-clinic based CHWs, and leveraging existing state workforce development programs. Our study findings suggest that the existing Medicaid reimbursement policies in Indiana require improved clarity and employer education to increase appropriate utilization [2]. Ibe et al. [35] concluded that more research needs to be conducted to gain a better understanding of CHW certification and its’ impact on patient health outcomes. Similarly, further research on the role of CHW certification in supporting the financial sustainability and workforce development of CHWs in the US is warranted.

A well-maintained evidenced-based CHW database (Recommendation 1) could facilitate advocacy efforts regarding reimbursement rates to be commensurate with the impact of CHWs and better alignment with similar position policies (i.e., Certified Recovery Specialists). Furthermore, the current public health climate due to the Coronavirus Disease 2019 (COVID-19) pandemic has generated additional federal funding mechanisms for CHW career paths. A more recent avenue of federal funding is the increased public health workforce funding through the Centers for Disease Control and Prevention (CDC). As of March 2021, the CDC planned to provide $300 million towards CHW services to support COVID-19 control and prevention and an additional $32 million towards training, technical assistance, and evaluation of CHWs [36]. President Biden’s plan included increasing the CHW workforce by 150,000 nationally and pledged to provide direct grant funding, as well as add CHW services as an optional benefit for states through Medicaid [37]. States can better maximize the sustainability of the workforce as funding opportunities arise to revise existing regulations around CHW reimbursement.

Fragmented CHW employment pathways and lack of career development opportunities can lead to missed opportunities, stagnant wages, job dissatisfaction, and high turnover rates. These can be mitigated by the creation of standardized, sector-specific guidance for optimal recruitment, integration, training, and ongoing education, certification, supervision, career development, and funding of CHWs for employers in Indiana. The National Committee for Quality Assurance (NCQA), in partnership with the Penn Center for Community Health Workers, is a multi-stakeholder effort to create such standards nationally. The goal of the NCQA standards is less about dictating CHW training methods or scope of practice and more about providing evidence-governed guidelines for the systems in which CHWs work [38]. Involving CHWs at all levels of decision-making related to the workforce will streamline communication across CHW employer organizations, state agency partners, and other stakeholders to align state-wide efforts. Yearly reviews of national CHW models and standards should be conducted to remain aligned with best practices outside of Indiana and coordinate with efforts already underway (e.g., APHA–CHW section, NACHW). Demonstration projects can allow for the development of context-specific guidance to help integrate CHWs and scale up workforce models into organizational strategic plans, teams, and workflows across the state.

There were several limitations to this study. While our steering committee guided our work, participants of the focus groups did not capture all potential stakeholders (e.g., unemployed CHWs, policy makers, and national organizations who work with CHWs). A disproportionate percentage of CHWs selected “American Indian or Alaska Native” as their race/ethnicity which is inconsistent with the known demographics of Indiana. Future surveys should be created to more clearly delineate the race/ethnicity of all respondents in order to avoid this classification error. Methods taken to eliminate potentially duplicative and fraudulent survey responses as described above may have inadvertently eliminated legitimate responses. Future online surveys should utilize software features, such as prevention of “ballot stuffing”. Lastly, the findings presented here are specific to Indiana and may not be generalizable to all states; thus, each state should identify unique nuances of the CHW workforce in their geographic region.