This section describes core activities for MCPs to consider in building or expanding the CHW/P workforce in programs for Medi-Cal enrollees. These activities include defining CHW/P roles, developing CHW/P position structure and supports, and recruiting CHW/Ps.

For the full “Key Implementation Approaches” (PDF) section on establishing roles and recruiting CHW/Ps, access the Resource Guide.

Define CHW/P Roles

CHW/P roles will depend on the needs of the prioritized population, program goals, and roles of other interdisciplinary team members. As MCPs look to design and implement CHW/P programs, organizations need to identify the competencies and responsibilities (PDF) required to successfully fulfill the job description. For more information, see this section in the Resource Guide (PDF).

To provide input on potential CHW/P roles, MCPs can engage a diverse array of staff, including organizational leadership, CHW/Ps within their organizations, CHW/Ps employed at external organizations, and staff who will work with CHW/Ps (e.g., social workers, nurses, primary care providers, substance use disorder counselors, and others). Clear identification of CHW/P roles maximizes the unique strengths of this workforce and prevents duplication with other positions. It is very difficult for MCPs to incorporate the CHW/P workforce into programs without a precise understanding of CHW/Ps’ roles and skills. Identifying CHW/P roles — and communicating what those roles are across organizational staff and leaders — can prevent CHW/Ps from becoming “just another cog in the clinical wheel: scheduling appointments, pinging patients to take their meds, or even performing menial tasks. CHWs can do so much more.” Absent a clear definition of the CHW/P role, it may become overmedicalized, which does not allow for the dynamic and person-centered work that CHW/Ps can effectively manage. MCPs and their partners should ensure that CHW/Ps are equal and integral parts of their larger team so they can perform roles at the top of their capacity.

The Community Health Worker Core Consensus Project (C3 Project) produced a framework (PDF) to support the development of CHW/P policies and standards. Informed by CHW/P associations and networks across the country, the C3 Project identified 10 core roles for CHW/Ps across diverse medical, behavioral, and public health settings, including care coordination, case management, and systems navigation, as well as advocacy for and engagement with individuals and communities.

Another potential role for CHW/Ps is helping patients transition upon discharge from medical or psychiatric hospitals. By coordinating with hospital discharge planning, MCPs can determine the roles for CHW/Ps in supporting care transitions. Arranging for the CHW/P to work either within the hospital or to connect with patients before they are released can start the relationship building that is important for CHW/Ps’ success in patient engagement (see the Savas Health spotlight below). Other potential CHW/P tasks ― such as navigating housing, routinely revisiting the care plan, and supporting members in attending follow-up appointments ― are often integral activities that are tracked, measured, and reported as key program outcomes. CHW/Ps may also play key roles in crisis response teams that provide community-based alternatives to justice involvement.

I would hire a CHW/P who is able to communicate with the patients, community, or people they are helping. They should have good communication skills, such as motivational interviewing, active listening skills, and not jumping into ‘fixing people.’

^{—Nubia Armenta, Community Health Specialist}

Develop CHW/P Position Structure and Supports

Once CHW/P roles have been established, MCPs can design the structure of the role, which includes establishing supervisory models, determining case workloads, and developing supports for interdisciplinary team integration. For more information, see the Resource Guide (PDF).

• Establish CHW/P supervisory models. Developing a supervisory framework that leverages the strengths of CHW/Ps is critically important to the success of CHW/P programs. Poor supervision of CHW/Ps can result in low morale and poor productivity. Strategies for effective supervision include coaching, peer-to-peer support, “supportive supervision,” and integration of CHW/Ps within interdisciplinary teams, which can lead to improved productivity (PDF) and workflow across the whole team. Some organizations employ senior CHW/Ps to provide mentorship and support or direct supervision to CHW/Ps. Factors affecting the ratio of CHW/Ps to supervisors will include the number of CHW/Ps employed, activities implemented by CHW/Ps, and roles and responsibilities of existing staff. For example, the American Hospital Association recommends a CHW/P-to-supervisor ratio of 6:1.
• Determine appropriate CHW/P caseloads. When assessing the number of members assigned to each CHW/P, employers should consider the complexity of member health and social needs, the number of program focus areas, available tools to assist CHW/Ps in their work, documentation requirements, and the distance and time needed for travel between clients. Many programs prioritize a low CHW/P-to-member ratio, which creates more flexibility for meaningful member engagement and education and reduces burnout. As one example, Los Angeles County Department of Health Services employs over 200 CHWs, who each has a caseload of between 10 and 35 people. Medi-Cal members prioritized for this program include people with high risk related to homelessness, reentry status for formerly incarcerated people, and physical and behavioral health conditions.
• Develop supports for interdisciplinary team integration. CHW/Ps generally sit outside the traditional health care delivery system and will need support integrating into an interdisciplinary team. It is important to have both leadership involvement and clinical/provider support at the MCP, CBO, and provider level to achieve integration. MCPs will need to closely engage staff at all levels to integrate CHW/Ps into their workforce structure, requiring a focus on capacity building and careful planning. It is critical to develop a communication plan or strategy during initial program planning to keep internal and external stakeholders informed regarding program goals, to build organizational buy-in, and to communicate the value and lessons from the CHW/P program. CHW/P programs should develop clear protocols and job aids to support CHW/Ps in being effective in their work, such as risk screening protocols and tracking tools to document interventions. Programs will also need to clearly identify protocols and pathways so CHW/Ps understand when an issue should be escalated to other team members.

Health care is usually this vertical hierarchy — you’ve got the doctors, nurses, and all the additional staff. We throw it on its side and make it horizontal. The nurse is equal to the care coordinator is equal to the community health worker is equal to the behavioral health care manager . . . they all have a voice and are expected to speak and advocate and share their expertise.

^{—Catherine Knox, Inland Empire Health Plan}

Establish Strategies to Recruit and Retain CHW/Ps

MCPs and their partners that have not previously employed CHW/Ps will often need to use new strategies for employee recruitment and selection when hiring for these positions. Identifying and hiring the right candidates who can build trusted relationships with members is critically important for the success of this position. For more information, see the Resource Guide (PDF).

• Create job descriptions that align with CHW/P roles. Employers should develop job descriptions that clearly define CHW/P roles and specific tasks, both independent and within the team and employer organization, and CHW/P competencies and qualifications, including interpersonal traits, technical skills, language requirements, and educational requirements if applicable. Many CHW/P job descriptions cite the importance of lived experience. Employers should define the specific nature of lived experience most relevant for the given program and position and state this within the qualifications. CHW/Ps have valuable knowledge and skills gained through life experience, which should be reflected in an appropriate salary scale.

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RELATED RESOURCE: There are a range of sample job description for CHW/P roles available in the “Resources and Tools” section.

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• Use effective recruiting strategies. Both traditional and nontraditional recruiting tools may support health plans and their partners in recruiting high-quality candidates. Methods to reach candidates trusted in their communities may include conducting outreach or posting flyers at CHW associations, health clinics, CBOs, and houses of worship. Because CHW/P work depends on effective one-on-one interactions, the interview process should be designed to identify candidates with strong interpersonal traits. Supervisors can use direct questions, as well as role-playing and problem-solving scenarios that can provide a more nuanced understanding of applicants’ qualities. Clear assessment criteria to support the hiring process will help leadership make informed choices about hiring and about identifying potential training needs for newly hired CHW/Ps. Organizations should consider including CHW/Ps on hiring panels to help identify strong candidates.
• Establish competitive salaries. CHW/P programs should also develop a salary scale that considers market rates, level of education, lived experience, and skills, and have opportunities for full-time positions with salary increases over time. The low rate of pay and short-term funding streams are significant challenges for the recruitment and retention of the CHW/P workforce. MCPs can work with providers, CBOs, and CHW/Ps to ensure that salaries and benefits are aligned with living wages and comparable to local standards (e.g., consider salaries within public health departments and clinics doing comparable work).