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Penn Center for Community Health Workers.
Cheryl Garfield Lead CHW
Cheryl Garfield, is a lead Community Health Worker with the Penn Center for Community Health Workers. Along with several of her CHW colleagues and allies, they have worked over the past year to develop national policy recommendations for how to expand and support our workforce. These collaborators include
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October 1, 2020
The Honorable Alex M. Azar
Secretary Department of Health and Human Services
200 Independence Avenue,
SW Washington, DC 20201
Dear Secretary Azar,
Thank you for your leadership and ongoing efforts to address the COVID-19 pandemic. Tragically, over 175,000 of our fellow Americans have lost their lives to this virus, and outbreaks are growing in several parts of the country with a disproportionate impact on communities of color. As we grapple with the unfathomable toll on Americans’ health and cascading economic impacts across our country, we are committed to supporting response efforts that will help our nation progress through a period of recovery, which will restore our physical, mental, and financial health. We write today to express our support for an essential part of this recovery: community health workers. Community health workers are trusted individuals from local communities who improve the health of their neighbors every day. We encourage you to expand programs that increase the utilization of these essential frontline health care workers.
Community health workers can play many critical roles in a pandemic response, long-term improvement of public health, and lasting economic recovery. In the short term, they can form the backbone of successful contact tracing efforts, address the social determinants of health, and help address non-medical needs that too often fall on overwhelmed frontline clinicians. Beyond the immediate pandemic health crisis, they can mediate the impacts of stress, social isolation, financial strain on health, hospitalizations, and health care spending.
In addition, employment of community health workers creates economic opportunities for some of the nation’s hardest hit communities, where many Americans are underemployed. Even before COVID-19, organizations across the country were hiring and training community health workers as evidence of their effectiveness grew. Randomized clinical trials have shown that community health workers improve health while reducing costly hospitalizations and readmissions, saving Medicaid $4,200 per beneficiary. If scaled to even fifteen percent of U.S. Medicaid beneficiaries, community health workers would save taxpayers $47 billion annually. National evidence-informed and community-centered standards for hiring, training, supervision, and work practice for community health workers can help ensure that a national scale-up of this workforce achieves these same high-quality outcomes.
Unfortunately, current federal support for community health workers does not leverage the full value of this workforce. Historically, the Centers for Disease Control and Prevention (CDC) has been a key funder of community health workers; yet much of their funding has been disease-specific. For example, many CDC programs focus only on heart disease or stroke. Yet, the evidence suggests that community health workers make the biggest impact when they are part of a comprehensive approach to public health that addresses social determinants of health across a range of health conditions and settings. The Centers for Medicare and Medicaid Services (CMS) also has provided some funding for community health workers; yet this has been a patchwork through State Plan Amendments (SPAs) or 1115 waivers, which are hamstrung by a narrow definition of the preventive services that community health workers are able to deliver.
Given their potential to contribute to all aspects of a successful national recovery, we urge you to expand the utilization of community health workers within existing programs at the Department of Health and Human Services to fully leverage their expertise and skills. To facilitate that effort, we kindly request that you consider the following actions to improve the health and overall wellness of our constituents and the communities where they live: Centers for Disease
Control and Prevention
1.Utilize existing COVID-19 response funds, including through the Public Health Emergency Preparedness (PHEP) Cooperative Agreement and the Epidemiology and Laboratory Capacity for Prevention and Control of Emerging Infectious Diseases (ELC) Cooperative Agreement, to provide guidance to states on the ways that community health workers can strengthen response and recovery efforts, including recommendations to the states regarding the availability of funds to hire, train and deploy community health workers based on scientific evidence. We encourage the CDC to use these funds for the recruitment, training, and hiring of
CHWs for public health response work, particularly contact tracing.
2.Provide guidance to the states to help them expand beyond disease-specific programs for community health workers toward a comprehensive approach that aligns with the best available evidence and standards.
Centers for Medicare and Medicaid Services
1.Work with states to promote utilization of community health workers to provide a comprehensive range of social, behavioral and economic supports as allowable preventive services. CMS should build on the 2013 final rule entitled, “Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment” (CMS-2334-F) to expand the scope of Medicaid-reimbursable services that can be provided by community health workers and listing CHWs as a qualified provider type for a suite of discrete services.
2.On June 5, 2020, the Centers for Medicare and Medicaid Services (CMS) indicated that the agency is developing “additional guidance on the use of social determinants of health in state Medicaid programs.” We strongly encourage you to include specific guidance to affirm that Medicaid funding is available for community health worker services that address social determinants of health.
Indian Health Service
1. Support community health representatives (IHS-funded community health workers serving tribal nations) in efforts to combat COVID-19 and address longstanding disparities in chronic disease, infant mortality, and other causes of premature death and disability.
Thank you for your leadership throughout this crisis. We hope that the Department of Health and Human Services works quickly to identify additional opportunities to amplify the important role community health workers can play in the response to the COVID-19 pandemic and improving the health of all Americans.
Thank you for your attention to this request.
MEMBERs OF CONGRESS
Eliot L. Engel
Alcee L. Hastings
Eleanor Holmes Norton
Yvette D. Clarke
Val B. Demings
Sean Patrick Maloney
James P. McGovern
Marcia L. Fudge
David N. Cicilline
September 30, 2020
The Honorable Alex M. Azar,
Secretary Department of Health and Human Services
200 Independence Avenue Southwest Washington,
Dear Secretary Azar
We write to call your attention to a frontline workforce that has the potential to address health disparities, assist with elements of the COVID-19 pandemic response and provide cost savings to the federal government: community health workers. Community health workers, promotores and community health representatives are trusted individuals from their local communities who partner with health care and social service providers to improve the health of their neighbors every day.
Brea Burke from Bristol, Tennessee exemplifies the effectiveness of community health workers. Born and raised in Bristol, Brea is a trusted member of her community, working within a local health system as a community health worker. She has always been involved in her community, taking care of people and helping them when she can. Now, as a part of her community’s response to the pandemic, Brea is ramping up her regular checks on elderly neighbors, who are at higher risk of COVID-19 complications, organizing donations of masks to the local food pantry and reinforcing COVID-19 prevention tips.
The COVID-19 pandemic has disproportionately impacted our Nation’s most at risk, including seniors and people of color. While incomplete data make it impossible to calculate the precise impact of COVID-19 on communities of color, one analysis found that, for every 100,000 people, 72 Black individuals died from COVID-19 (when adjusted for age) between February and June 2020, while the death rate for white individuals during the same period was 20 per 100,000. The age-adjusted rate of death for Hispanics/Latinos was 50 per 100,000. Further, according to the Centers for Disease Control and Prevention (CDC), the COVID-19 incidence rate for American Indians/Alaska Natives is 3.5 times higher than that of non-Hispanic white individuals.
Community health workers respond to the collective impacts of historic and institutional racism, health disparities and lack of trust in the health care system. They do this by meeting people where they are, building relationships within the community and providing culturally appropriate care. In Texas, for example, community health worker and Promotora de Salud networks, such as Dia de la Mujer Latina, are partnering with the Texas Department of State Health Services to develop and implement culturally and linguistically appropriate COVID-19 contact tracing training and interventions. During this public health crisis, providing culturally appropriate services and care is essential to effectively addressing the needs of marginalized groups; community health workers can enhance those efforts.
Even before COVID-19, organizations across the country were hiring and training community health workers, as the body of evidence of their effectiveness has continued to grow. Numerous studies indicate that community health workers can help improve mental health and chronic disease control, serve rural populations, mitigate risks associated with the social determinants of health5 and generate cost savings. Randomized clinical trials have shown that community health worker scan improve health while reducing costly hospitalization sand readmissions, saving Medicaid $4,200 per beneficiary. If scaled to even 15 percent of Medicaid beneficiaries, community health workers could save taxpayers $47 billion annually. Research findings confirm community health workers’ services are a cost-effective means to address racial and ethnic health disparities and produce better health outcomes for individuals at high risk. National, evidence-informed standards for hiring, training, supervision and work practice for community health workers can ensure that a scale-up of this workforce achieves these same high-quality outcomes.
Unfortunately, current federal support for community health workers is minimal and fails to leverage the full potential of this workforce. The CDC has been a key funder of community health workers for providing services for patients with specific diseases, such as heart disease or stroke. Yet the evidence suggests that community health workers make the biggest impact when they are part of cross-cutting efforts that address the social determinants of health, including helping to mitigate negative social determinants of health.
The Centers for Medicare and Medicaid Services (CMS) have also approved a number of State Plan Amendments (SPAs) and 1115 waivers that have allowed some states to incorporate community health workers into their Medicaid programs. Even though there is broad statutory authority for diagnostic, screening, preventive and rehabilitative services, these efforts have been limited by a narrow definition of preventive services that restrict how community health workers are able to serve their patients. Despite this patchwork of funding mechanisms, states are innovating to the extent they can. For example, Medi-Cal (California’s Medicaid program) encourages employing community health workers in the state’s Medicaid Health Homes for patients with complex medical needs. These workers can serve as the “eyes and ears” for care teams to make sure patients get the care they need. And in Minnesota’s Medicaid program, community health workers provide care coordination and diagnosis-specific patient education. The Agency for Healthcare Research and Quality has also recognized the value of community health workers in tackling the social determinants of health, improving quality of care and reducing health expenditures.
Community health workers have the potential to contribute to all aspects of a successful national recovery—particularly for communities who have been historically underserved and hardest hit by the current pandemic. We urge you to expand the integration of community health workers within existing programs at the Department of Health and Human Services to more fully leverage their expertise and skills. To facilitate that effort, we respectfully request that you consider the following actions to improve the health and overall wellness of our constituents and the communities where they live:
Centers for Disease Control and Prevention
1.The CDC should provide guidance to state, local, Tribal and territorial entities to help public health departments and other relevant stakeholders build cross-cutting, comprehensive community health worker programs that align with the best available evidence, standards and community practice. The CDC should work with the Indian Health Service (IHS) to coordinate the work of community health representatives, who are IHS-funded community health workers serving Tribal nations.
2.In addition to recommending that health care delivery systems work with community health workers,16 the CDC should provide guidance on the ways that community health workers can strengthen COVID-19 response and recovery efforts under programs, such as the Public Health Crisis Cooperative Agreement and the Epidemiology and Laboratory Cooperative Agreement. This includes providing recommendations to state, local, Tribal and territorial entities regarding the availability of funds to hire, train and deploy community health workers based in a variety of venues.
Centers for Medicare and Medicaid Services
1. CMS should work with states to promote integration of community health workers in programs to provide a comprehensive range of social, behavioral and economic supports. CMS should clarify that diagnostic, screening, preventive and rehabilitative services are allowable under Medicaid.
2. On June 5, 2020, CMS indicated that the agency is developing “additional guidance on the use of social determinants of health in state Medicaid programs.”17 CMS should include specific guidance to clarify the availability of Medicaid funding for community health worker services that help address social determinants of health. CMS should encourage states to incorporate these workers into the Medicaid programs. We hope that the Department will work quickly to identify additional opportunities to amplify the important role community health workers can play in the response to the COVID-19 pandemic and to improve the health of all Americans.
Thank you for your attention to this request.
Robert P. Casey, Jr. United States Senator
Tina Smith United States Senator
Cory A. Booker United States Senator
Sherrod Brown United States Senator
Michael F. Bennet United States Senator
Debbie Stabenow United States Senator
Margaret Wood Hassan United States Senator
Bernard Sanders United States Senator
Richard Blumenthal United States Senator
Christopher A. Coons United States Senator
Cc: Ms. Seema Verma, Administrator, Centers for Medicare and Medicaid Services Dr. and Robert R. Redfield, Director, Centers for Disease Control and Prevention
Shreya Kangovi and Uché Blackstock, The Washington Post, “Community Health Workers are Essential in This Crisis. We Need More of Them.” (July 3, 2020), https://www.washingtonpost.com/opinions/2020/07/03/community-health-workers-are-essential-this-crisis-we-need-more-them/
Tiffany Ford, Sarah Reber, Richard V. Reeves, Brookings Institution, “Race Gaps in COVID-19 Deaths are Even Bigger than They Appear” (June 16, 2020), https://www.brookings.edu/blog/up-front/2020/06/16/race-gaps-in-covid-19-deaths-are-even-bigger-than-they-appear/.
Sarah M. Hatcher, et al., CDC Morbidity and Mortality Weekly Report, “COVID-19 among American Indian and Alaska Native Persons — 23 States, January 31–July 3, 2020” (August 19, 2020), https://www.cdc.gov/mmwr/volumes/69/wr/mm6934e1.htm?s_cid=mm6934e1_e&deliveryName=USCDC_921-DM35683#T1_down
Dia de La Mujer Latina, Inc. press release, “As States Ramp-Up Contact Tracing to Address the Spike in COVID-19 – Community Health Workers/Promotores Answer the Call” (June 16, 2020), https://diadelamujerlatina.org/wp-content/uploads/2020/06/6-16-20-Press-Release-DML-Contact-Tracing-Training-Program-1.pdf
T.R. Goldman, Health Affairs, “Charting a Pathway to Better Health” (December 2018), https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05166.6
Association of State and Territorial Health Officials, National Association of Community Health Workers. “Community Health Workers, Evidence of their Effectiveness,” https://astho.org/Programs/Clinical-to-Community-Connections/Documents/CHW-Evidence-of-Effectiveness/
Accessed August 12, 2020
Shreya Kangovi, et al., Health Affairs, “Evidence-Based Community Health Worker Program Addresses Unmet Social Needs and Generates Positive Return on Investment” (February 2020), https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00981
Shannon Cosgrove, et al., “Community Health Workers as an Integral Strategy in the REACH U.S. Program to Eliminate Health Inequities,” Health Promot. Pract. 2014 Nov; 15(6): 795–802. doi: 10.1177/1524839914541442.
United States Centers for Disease Control and Prevention, “Community Health Worker Resources,” https://www.cdc.gov/publichealthgateway/chw/index.html
Accessed July 30, 2020.10 SSA Sec 1905(a)(13), available online at https://www.ssa.gov/OP_Home/ssact/title19/1905.htm
Calder Lynch, Deputy Administrator and Director Center for Medicaid and CHIP Services (CMCS), CMCS Informational Bulletin, “Medicaid Managed Care Frequently Asked Questions (FAQs) – Medical Loss Ratio” (June 5, 2020), https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/cib060520_new.pdf.Page 4/s/
Federal Register, “Medicaid and Children's Health Insurance Programs: Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing and Appeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment: A rule by the Centers for Medicare and Medicaid Services” (July 15, 2013), https://www.federalregister.gov/documents/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit.
Association of State and Territorial Health Officials, “Ever Changing Picture: State Approaches to CHW Certification” (February, 2020), https://astho.org/Programs/Clinical-to-Community-Connections/Documents/Map-of-State-Approaches-to-CHW-Certification/
Accessed August 12, 2020.
Jim Lloyd, Kathy Moses, Rachel Davis, Center for Health Care Strategies, Inc., “Recognizing and Sustaining the Value of Community Health Workers and Promotores” (January 2020), https://www.chcs.org/media/CHCS-CHCF-CHWP-Brief_010920_FINAL.pdf
Minnesota Department of Health, “Community Health Worker (CHW),” https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/index.html
Accessed July 30, 2020.15
Mary Applegate, et al., Community Care Coordination Learning Network and the Pathways Community HUB Certification Program (prepared for the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services), “Pathways Community HUB Manual: A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes” (January 2016), https://innovations.ahrq.gov/sites/default/files/Guides/CommunityHubManual.pdf
United States Centers for Disease Control and Prevention, “What Can We Do,” https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/what-we-can-do.html Accessed July 30, 2020.