A marathon, not a sprint
Our five-year campaign to evaluate impact and ensure sustainability of CHWs in Kansas
This post originally appeared in Grant Makers in Health on Aug. 19, 2024.
David Jordan, President and CEO, United Methodist Health Ministry Fund
Katie Schoenhoff, Vice President of Programs, United Methodist Health Ministry Fund
McClain Bryant Macklin, Vice President, Policy and Impact, Health Forward Foundation
Nathan Madden, Policy Impact Strategist, Health Forward Foundation
Community Health Workers (CHWs), also referred to as health navigators, advocates, or promotor(a)s, are trusted community members trained to work with local health care and social services to help clients navigate often complex systems of care, while also improving the quality and cultural competence of service delivery.
The United Methodist Health Ministry Fund (Health Fund) and Health Forward Foundation have long supported CHWs in Kansas and Missouri, providing grants to organizations to support CHWs in a variety of settings – clinical and community-based – as well as supporting coalition-building, training, research and advocacy efforts.
As helpful as our work has been in piloting and demonstrating the value of CHWs, short-term funding mechanisms like grants do not ensure the long-term viability of CHWs. Both organizations have long advocated that Medicaid needs to reimburse employers for CHW services to help ensure a stable workforce. In addition, to achieve the status necessary for reimbursement, CHWs need to be certified.
In the summer of 2019, our two foundations began working with the Kansas Department of Health and Environment (KDHE) and the Kansas Community Health Worker Coalition (KSCHWC) to achieve our two goals: certification and reimbursement.
Using multiple strategies—research and evaluation, convening, administrative and legislative advocacy, and communications—we made steady progress toward achieving our long-term vision to cement CHWs in the healthcare system in Kansas.
Today, five years after our original meeting, we celebrate the Kansas Medicaid office’s recent decision to more than double reimbursement rates for our CHWs, who the state now recognizes as professionals. Still, there’s more work to be done, focusing on implementation.
Research
During our initial 2019 meeting, KDHE leadership concluded that while they saw substantial evidence CHWs were becoming integral to the health care system, they needed to better understand the state’s CHW landscape before instituting policy changes.
Following that meeting, the Health Fund contracted with Wichita State University, which houses the KSCHWC, to conduct focus groups with CHWs and their employers to elucidate the current system’s strengths and weaknesses. The research also included a literature review and comprehensive mapping of the state’s existing CHWs.
The Wichita State team found that integrating CHWs into care teams results in better access to care, improved health outcomes, and reduced health care inequities. The research team also found that CHWs helped health organizations achieve savings and efficiencies, thus providing a healthy return on investment.
Convening A CHW Work Group to Advance Certification and Payment Policy
Armed with that research demonstrating the value of CHWs, our two foundations asked KDHE to form a workgroup to develop recommendations on CHW certification and payment, specifically Medicaid reimbursement.
KDHE agreed and together we began the first critical step – developing a diverse workgroup of stakeholders. Ultimately, we found broad support and interest in the group, which included state agency partners, the KSCHWC, the two foundations, the state’s hospital association, the state’s primary care association, managed care organizations, health educators, hospitals, clinics, doctors, community-based organizations, and others who employ and supervise CHWs.
The group, facilitated by the Health Fund and KDHE, and supported by health policy consultants Erika Saleski and Donna Cohen Ross, launched in the fall of 2020 and met monthly through the summer of 2021.
In the fall of 2021, the workgroup announced the following recommendations:
- KDHE should support a CHW certification process maintained by a non-governmental agency.
- The KSCHWC should be designated as the certification organization.
- KDHE should take the necessary steps in the short term to authorize Medicaid payment for CHWs and develop financing strategies that incentivize the Medicaid managed care providers to support CHWs.
Demonstration Projects, Training and Federal Grants
Simultaneous to our convening of the policy group, we recognized the need to demonstrate how CHWs were already improving care across the state. The Health Fund supported five pilot projects, housed in rural hospitals, Federally Qualified Health Centers (FQHCs), and health departments in both urban and rural communities. We worked with a safety-net clinic with deep expertise in CHW programs, long supported by Health Forward, to provide technical assistance to the sites. We also used a shared data system and developed a robust evaluation protocol to capture both the importance of CHWs to improving patient experiences and the return on investment they delivered. Health Forward continued funding existing CHW programs, adding to research from their successful pilots which showed that including CHWs on health care teams reduced health disparities, improved health outcomes and reduced emergency department visits.
Between our foundation-supported demonstrations and two large, federally-supported CHW programs, we added nearly one hundred CHWs statewide, increasing the profession’s ranks by 20 percent. With these grants ending by 2024, there was increasing urgency to develop an adequate CHW funding strategy.
Certification and Recognition of the Profession
In the spring of 2022, KDHE established the CHW certification process, while also creating a CHW section within its Bureau of Family Health, recognizing an increasing momentum for the profession.
A news release from KDHE said the certification recognizes the valuable role of CHW as a link between health and social services and communities. It noted CHWs facilitate access to services and improve the quality and cultural competency of service delivery.
As recommended by the workgroup, the certification process would be managed by the KSCHWC.
Ongoing Payment Policy Advocacy
While CHW certification was a big win, we faced a setback in the summer of 2022 when new leadership at KDHE raised issues we thought were long settled—specifically, were CHWs a sound investment, and was Medicaid reimbursement needed?
We pressed our case with data from previous and ongoing pilots and a 2020 Penn Medicine study that found each dollar invested in CHWs yielded a $2.47 return on investment.
Satisfied by data provided, Medicaid leadership agreed to pursue a state plan amendment (SPA), the first step in securing reimbursements. Initially elated, we soon learned they were modeling it on Indiana’s SPA, which had lower reimbursement rates than we sought and problematic eligibility restrictions.
We proposed several ways to improve the SPA, grounded in our Kansas experience as well as that of other states, such as Rhode Island. Medicaid was willing to include some of our changes, but the reimbursement rates they proposed were far too low, and their language excluded rural health clinics (RHCs), FQHCs, and Indian Health Clinics (IHCs) from any reimbursement. The exclusion was highly problematic because many of our most vulnerable Kansans rely on these providers for services.
Despite our best efforts, including detailed comment letters signed by over 20 organizations, the SPA, went into effect on July 1, 2023.
Improving a Flawed Policy
Disappointed but unbowed, we redoubled our efforts to improve the flawed policy. Just weeks after Medicaid’s decision, we met with a newly appointed Kansas Medicaid director, who agreed to immediately clarify that FQHCs, RHCs, and IHCs were indeed eligible for reimbursement.
Even more important, the agency agreed to conduct a rate review, opening the door for renewed advocacy for the higher reimbursements. The foundations supported the agency’s review process, providing Medicaid with critical information for its analysis.
In the spring of 2024, Kansas Medicaid made its decision: the reimbursement rate for CHWs was increased by more than 100 percent, ensuring that Kansas would finally have a robust CHW reimbursement policy.
The increase was implemented in June, and in July, the foundations organized a sign-on letter of 30+ organizations thanking KDHE and Medicaid for their leadership and commitment to CHWs.
Also, the state’s new managed care contracts integrate CHWs into the state’s privatized Medicaid program, as originally recommended.
In the five years since our original meeting, Kansas has gone from an under-resourced network of CHWs to a recognized, growing and recognized profession that will receive Medicaid reimbursement, and thanks to federal advocacy, Medicare reimbursement.
What lessons do we draw? These processes can be long and arduous, and perseverance is critical. When we achieved less progress than we sought, we embraced the half-loaf and redoubled our efforts to secure the rest. When we ran into bureaucratic roadblocks, we were mindful that such barriers are not uncommon—nor insurmountable. It’s often a marathon, not a sprint.
Final Thoughts
Today, we continue to work with the state and Medicaid to implement the payment policy, help organizations integrate CHWs into their operations, develop employer reimbursement strategies, and pursue communications strategies to recruit CHWs and make providers and patients aware of how to engage them and leverage their value. The work is far from done, but we are grateful for the support we’ve received and proud of the progress we’ve made.