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The California Health Care Foundation is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need.
This section explores important considerations for developing and financing new CHW/P programs or refining existing programs to incorporate CHW/Ps. Topics covered include assessing member needs and designing program goals, identifying ECM and ILOS roles in coverage and financing for CHW/Ps, contracting with partner organizations to serve Medi-Cal members, and developing financially sustainable programs and partnerships.
Before designing a CHW/P program, MCPs should assess the needs of the communities they serve and define the priority populations that would benefit from these programs. Identifying program goals and designing the scope of the program are also important initial steps to take before developing a CHW/P program. For more information, see the Resource Guide (PDF).
Assess needs and determine priority populations. The health needs of a community or a priority population should drive the development and scope of CHW/P programs. As MCPs develop goals for CHW/P programs, they should carefully balance input from health care leaders and community members to establish a shared set of principles and program goals. MCPs can evaluate data indicators across different systems and conduct a community health needs assessment to help identify these needs. This quantitative and qualitative data will help identify which CHW/P services will be most beneficial for members.
Identify program goals and design program scope. CHW/P programs are designed to achieve different goals and outcomes with distinct populations. Once an MCP clarifies program goals, it can tailor a program to meet these needs by considering which staff roles are best positioned to serve the population and in which setting services should be delivered (e.g., community or clinic). Then MCPs can establish the responsibilities of the interdisciplinary team and clearly identify specific roles for the CHW/P position. When considering potential care management partners and CHW/P programs, MCPs should evaluate their own priorities, including quality improvement, member engagement in services, broader population health goals, and cost containment, and identify opportunities for CHW/Ps to help address these goals.
“Measures of engagement are really important from the perspective of MCPs, and CHW/Ps can really improve the engagement of our members. Because if members are not engaged, they’re not going to get the services, and MCPs are never going to be able to demonstrate ROI.”
—Cynthia Carmona, L.A. Care Health Plan
Partnerships Between MCPs and CHW/P Programs
Designing and implementing a CHW/P program often requires MCPs to collaborate with multiple partners. MCPs can leverage the skills and assets of external organizations such as providers, health systems, CBOs, and state and county authorities. For more information, see the Resource Guide (PDF).
Assess partnership opportunities. MCPs can decide to hire CHW/Ps directly or contract with another organization to employ CHW/Ps. Exhibit 7 in the Resource Guide (PDF) outlines examples of pros and cons for MCPs to consider in determining whether to hire CHW/Ps directly at the plan level or to contract with another organization to hire, support, and manage this workforce. If MCPs decide to partner with an external organization that employs CHW/Ps, they should consider which organizations are best suited as partners, based on the program goals and expertise and community connections of the respective partner organizations. Below are suggested steps for MCPs to undertake in engaging potential CHW/P program partners.
Checklist: Engaging Program Partners
Conduct a crosswalk or assessment of the potential priority populations, needed services, existing partnerships, and allowable financing arrangements.
Research and engage partners based on MCP needs, eligible populations, and required expertise.
Assess the expertise and outcomes of available CHW/P programs.
Determine financial controls, billing, and contract capacity.
Determine the size and scale of the contracting arrangement.
Determine capacity to integrate CHW/Ps successfully into MCP and partner workflows.
Develop strong contractual partnerships. When MCPs decide to partner with external organizations that employ CHW/Ps, they will need to develop contracts that support sustainable and effective programs. MCPs, providers, and CBOs must consider equitable roles for each partner at each stage in partnership development. It is important for MCPs to work in partnership with provider and CBO partners to ensure that contracting and programmatic agreements represent aligned goals and eliminate potential barriers for CHW/Ps to do their work.
“CHW/Ps should already know or be eager to learn about community resources and have experience networking with other agencies. You have to be someone who can adapt to the populations you work with ― comfortable doing the handholding and coaching.”
—Elma Prieto, Community Health Worker
Program Financial Sustainability
MCPs can promote financial sustainability by adopting alternative payment models that support enhanced care delivery and improved outcomes. While not a requirement from California’s Department of Health Care Services (DHCS), MCPs can consider developing risk-based financial incentive structures within their CBO or provider care management contracts that promote integration of CHW/Ps to improve outcomes and to reduce costs related to unnecessary care. These payment models would reward quality among partners and address the direct and indirect cost of CHW/P programs. For more information, see the Resource Guide (PDF).
Under CalAIM, DHCS is proposing a variety of funding changes and alternative payment models to promote the expansion of CHW/Ps:
MCP incentives linked to quality and performance improvements. These payments could potentially support pilot integration of CHW/Ps for specific priority areas, populations, or quality improvement goals that involve ECM and ILOS (PDF). Incentives can be passed down to CHW/P programs and staff meeting these quality objectives and can support critical investments in the workforce, such as fair pay, sufficient supports and training, and career pathways.
Shared savings and incentive methodologies that will involve MCP and other stakeholder engagement. These models can be a mechanism to reward partner organizations in achieving benchmarks and quality goals. One way that MCPs can use shared savings models is to pay for potential career pathways and opportunities for CHW/P advancement.
RELATED RESOURCE: To learn more about payment models for integrating community health worker services, explore the Community Health Worker Payment Model Guide (PDF) developed by the Oregon Community Health Workers Association.
“The MCP has a role not just in assessing but building capacity in their provider networks for CHW/Ps in the workforce. CalAIM incentive dollars for investments in care management capabilities, including investing in building CHW/P capacity and the recognition of CHW as a Medi-Cal provider type, are steps toward supporting MCPs’ CHW capacity building efforts.”
—Jessica Finney, Central Coast Alliance for Health (managed care plan)
