Commentary: Sustaining Community Health Workers—The Importance of Professional Self-Governance and Self-Determination

HOW ARE WE STILL SEEING COMMUNITY HEALTH WORKER ROLES BOTH RECOGNIZED AND REDEFINED? While the community health worker (CHW) field is over 60 years old in the United States (Rosenthal et al., 2024), the profession has experienced enormous growth and interest in the last 15 years—advanced by the Affordable Care Act in 2010 (Islam et al., 2015) and more recently, during the COVID-19 pandemic. CHWs’ successes and efficacy in both clinical and community settings have brought CHWs high visibility and new funding avenues through Medicaid and Medicare. Though these sources have some notable limitations and are only a component of braided funding strategies, they have jumpstarted organizations’ ability to integrate CHWs into service delivery and begin to build infrastructure to support and sustain the workforce. As CHWs and allies make strides toward sustainability, the CHW field also faces headwinds that threaten to upend the progress made through the field’s decades-long commitment to self-determination in policy and practice. Self-determination, or self-governance, means CHWs’ rights and responsibilities to define and set standards for their professional practice. The CHW movement has long held to “nothing about us, without us,” and is committed to CHW leadership and majority representation in policy development or credentialing affecting the workforce (American Public Health Association, 2014). The authors of this commentary, along with other CHW and ally leaders, have invested decades of work with state and federal agencies and other governmental offices to secure the recognition CHWs deserve. This has been done through furthering the use of the self-determined CHW definition and scope of practice, which has supported the development of a long-standing workforce, profession, and practice throughout the United States. However, with each new leader of varied federal agencies, changes in state and local leadership and power dynamics, and changes in staff at health centers, CHWs often lose hard-won recognition and support. Institutional knowledge is lost, relationship-building must begin anew, and CHWs and allies must fight the case again. Through unsynchronized governmental interventions as well as varied private sector funding initiatives intended to build the CHW workforce, there is a risk of undercutting the standards put forth by the field by overlooking the widely nationally accepted CHW definition developed by the American Public Health Association CHW Section (https://www.apha.org/apha-communities/member-sections/community-health-workers), as well as the CHW roles and competencies put forth by the C3 Project, recently renamed the National Council on CHW Core Consensus Standards (National C3 Council). For example, the recent 22-124 funding opportunity from the Health Resource and Services Administration (HRSA) disregarded existing workforce infrastructure and standards in favor of newly invented terms and scopes of practice (HRSA, 2022). This discrepancy was outlined in a response to HRSA’s Bureau of Health Workforce by the National Association of Community Health Workers (NACHW) (https://nachw.org/) (Octavia Smith, 2022). A recent 2024 memo released by HRSA in relation to the 22-124 funding (HRSA, 2024) includes a definition that does not reflect the workforce or the nationally recognized definition, and states that a CHW is a community member “not licensed to practice as a fully qualified health care professional.” This redefining of the CHW workforce is not limited to government. With increased funding and visibility, efforts are emerging for accreditation of CHWs, CHW trainings, and CHW programs. We are concerned that some actors, especially those new to the field, are not engaging in consensus building with local and national CHW workforce leaders in their standards development processes. Standards and accreditations developed and adopted too quickly, with limited CHW involvement and buy-in, will result in fracturing the field and diluting the hard-won power and recognition of CHWs (Covert et al., 2019; Matos et al., 2019). We fear that these continuous incursions on CHWs’ self-determination may lead to disintegration in the CHW field, as job titles and scope of practice standards bifurcate, leading to a “divided and conquered” workforce. This trend, after years of CHWs working to establish a professional identity under one umbrella term and one set of core roles and competencies, is detrimental to the sustainability of CHWs who practice daily under varied job titles, including CHW, patient liaison, promotor(a), Community Health Representative, and more. The National C3 Council has decades of documented experience (Rosenthal et al., 1998,2016,2018) of equitable partnership with the CHW workforce, identifying the CHW core roles and competencies (qualities and skills) that define the profession and scope of practice across clinical and community settings. These roles and competencies are acknowledged by NACHW and incorporated by many states into guidelines, policies, and programs (National Association of Community Health Workers, n.d.). This commentary by the National C3 Council team responds to growing discordance that undercuts the decades of investments made by CHW leaders and allies, including some government agencies and other funders, to define and position CHWs as an essential public health workforce. Recent well-intentioned but poorly informed funding and workforce development efforts are, in some cases, weakening years of progress and introducing confusion that can damage the CHW workforce and overall health equity efforts. Through this commentary, the National C3 Council’s objective is to promote CHW workforce self-determination efforts and prevent regression of progress made in developing and unifying the workforce. WHAT DEFINES A PROFESSION? The Cambridge Dictionary defines a profession as “any type of work that needs special training or a particular skill, often one that is respected because it involves a high level of education.” CHWs are trained in dedicated educational programs and receive on the job training, but, additionally, their lived experience uniquely positions them to bring value-added expertise to their practice. The competence that comes from their connection to the communities they serve position them to bring skills to their work that go beyond what training programs alone can offer. In their article, “Regulating health professional scopes of practice: comparing institutional arrangements and approaches in the US, Canada, Australia, and the UK,” Leslie et al. (2021) indicate that federal governments have an important role in influencing state-by-state variation in how professions are defined and regulated. Within the United States, “A critical challenge associated with the regulation of health professions is state-to-state variation in scope of practice, which is limited by the location of the professional rather than by their skills and competencies (Leslie et al., 2021, p. 9).” They indicate that of the countries studied, the United States is particularly good at “efficiency,” creating flexibility in its regulatory systems, such as licensure, so they can cross local and state jurisdictions. At this time of unprecedented growth and development, the CHW field needs federal entities to take a proactive role and support their self-determined national scope of practice. Studies reveal that workforce members themselves should be at the heart of workforce governance. According to Lim and Lin (2021), we need to improve our understanding of stakeholder-driven network governance. Their findings reveal how important it is to include the workforce’s own established organizations in any effort to strengthen a workforce. The medical profession gives a valuable example of how self-governance can look after years of development (Frogner et al., 2020). In Bauchner et al. (2015), a discussion of self-regulation in medicine is featured in a themed issue of the Journal of the American Medical Association on physician governance. They point out that there are numerous physician leadership organizations that have strategic roles in supporting the workforce but only a few are formally endorsed by governmental entities. This indicates there are only select roles that government should play in defining and monitoring a profession’s own training and practice. WHAT DOES THE CHW FIELD NEED FROM THE FEDERAL GOVERNMENT TO SUPPORT SUSTAINABILITY? In this time of rapid growth in the CHW field, recognition by governmental entities is critical, as well as steady leadership and support of CHW’s self-determination from the federal government. CHWs have been a force contributing to frontline public health in the United States for many decades, and CHWs are here to stay. Creating new career ladders and categories within the workforce must come from CHWs and their allies, as is the case in other health-related professions. Federal actors and agencies must recognize the well-established nature of the CHW field and resist acting as if they have newly discovered CHWs. Health and Human Services (HHS) entities must work together to coordinate their support of CHWs. Ideally, CHW self-governance must be supported and coordinated with federal leaders—not steered by them. Federal agencies must consult the organizations that anchor the field, such as NACHW, and the CHW Section of APHA. To further support CHW self-determination, a new national collaboration is emerging between NACHW, APHA, the National C3 Council, the CHW Center for Research and Evaluation (https://www.chwcre.org/) (Rodela et al., 2021) and Envision Equity https://envisionequity.org/). This collaboration grew out of a now regular annual session at APHA known as the “CHW State of the Union” (American Public Health Association, Community Health Worker Section Business Meeting, Annual Meeting (2023, October 27)). The goals of this collaboration are still being forged, but one clear goal is to ensure CHW self-determination. IS THERE CONSENSUS ON A CHW DEFINITION AND CHW SCOPE OF PRACTICE? As noted previously, CHWs have organized nationally to define their own workforce for many years in an effort to connect and unify CHWs and the many titles CHWs work under across the country (Barbero et al., 2021). In 2009, national CHW and ally leaders developed a formal definition of CHWs, which was adopted by the American Public Health Association (American Public Health Association, 2009) (see Table 1). The APHA CHW Section, alongside hundreds of CHWs and allies, advocated for the national CHW definition to be acknowledged by the U.S. Department of Labor through the development of a CHW Standard Occupational Classification (SOC) which was successful in 2010 with the creation of the CHW SOC (21-1094). In 2023, efforts were further advanced with the separation of Health Educators from CHWs as outlined in the Outlook Occupational Handbook released by the Bureau of Labor Statistics (Bureau of Labor Statistics, U.S. Department of Labor, 2023) that pulled heavily from the APHA CHW Section definition and National C3 Council guidance on roles and competencies. Table 1. - Defining Our Workforce: The Community Health Worker Section of the American Public Health Association Definition (2009) The CHW Section adopted the following definition of a community health worker:A community health worker is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. Source: https://www.apha.org/APHA-Communities/Member-Sections/Community-Health-Workers.Reprinted with permission from the CHW Section, APHA. In 2016, the National C3 Council released a set of CHW roles and competencies (qualities and skills) (see Table 2) (Rosenthal et al., 2016). These efforts to define the CHW scope of practice were community-based, participatory, workforce-driven, CHW-led, and included many allies. Their creation through consensus building is fundamental to their successful adoption by the field. Many individual states have adopted variations on the C3 roles and competencies for their certification programs and the C3 list of roles is the accepted common language used to describe the unified national workforce (Malcarney et al., 2017). Table 2. - The National Council for Community Health Worker Core Consensus Standards: Core Roles and Sub-Roles that Define a Scope of Practice (2016) Core CHW Roles Description/Sub-Roles 1. Cultural Mediation Among Individuals, Communities, and Health Social Service Systems a. Educating individuals and communities about how to use health and social service systems (including understanding how systems operate) b. Building health literacy and cross-cultural communication c. Educating systems about community perspectives and cultural norms 2. Providing Culturally Appropriate Health Education and Information a. Conducting health promotion and disease prevention education that matches linguistic and cultural needs of participants/community b. Providing necessary information to understand and prevent diseases and to help people manage health conditions (including chronic disease) 3. Care Coordination, Case Management, and System Navigation a. Participating in care coordination and/or case management b. Making referrals and providing follow-up c. Facilitating transportation and helping address barriers to services d. Documenting and tracking individual and population level data e. Informing people and systems about community assets and challenges 4. Providing Coaching and Social Support a. Providing individual support and coaching b. Motivating and encouraging people to obtain care and other services c. Supporting self-management of disease prevention and management of health conditions (including chronic disease) d. Planning and/or leading support groups 5. Advocating for Individuals and Communities a. Advocating for the needs and perspectives of communities b. Connecting to resources and advocating for basic needs (e.g., food, housing) c. Conducting policy advocacy 6. Building Individual and Community Capacity a. Building individual capacity b. Building community capacity c. Training and building individual capacity with peers and among CHW groups 7. Providing Direct Services a. Providing basic screening tests (e.g., height, weight, blood pressure) b. Providing basic services (e.g., first aid, diabetic foot checks) c. Meeting basic needs (e.g., direct provision of food and other resources) 8. Implementing Individual and Community Assessments a. Participating in design, implementation, and interpretation of individual-level assessments (e.g., home environmental assessment) b. Participating in design, implementation, and interpretation of community-level assessments 9. Conducting Outreach a. Case-finding/recruitment of individuals, families, and community groups to services and systems b. Follow-up on encounters with individuals, families, and community groups c. Home visiting to provide education, assessment, and social support d. Presenting at local agencies and community events 10. Participating in Evaluation and Research a. Engaging in evaluating CHW services and programs b. Identifying and engaging community members as research partners c. Participating in evaluation and research: a. Identification of priority issues and evaluation/research questions b. Development of evaluation/ research design and methods c. Data collection and interpretation d. Sharing results and findings e. Engaging stakeholders to act on findings Source: https://www.c3project.org/_files/ugd/7ec423_cb744c7b87284c75af7318614061c8ec.pdf.Reprinted with Permission from the National Council on Community Health Worker Core (C3) Consensus Standards. In 2024, in response to the growing threats to the field’s self-determination described above, the C3 Project team changed its name to the National Council for CHW Core Consensus Workforce Standards (https://www.c3Council.org/), in order to more clearly frame the C3 roles and competencies as national workforce standards. With this language and name change, we hope to more actively unify the workforce behind the use of the C3 standards and to push back against the proliferation of often incomplete descriptions of CHW scope of practice and the division of the workforce through funding opportunities relying on narrow definitions of CHW roles or scope of practice. We recognize that the C3 roles and competencies have been utilized as a starting point for state regulations and trainings without formally being called standards. We have now decided to call these field-driven guidelines what they have become: standards. An important example of this, in 2024, is that Medicare affirmed the C3 guidelines as the standards to be used in states without their own established standards (ASTHO, 2024). CALL TO ACTION: IDENTIFYING WAYS TO SUPPORT CHW SELF-DETERMINATION AND SELF-GOVERNANCE We call for national and state governmental agencies and non-governmental organizations to consistently acknowledge and wherever possible use the APHA CHW definition and the C3 roles and competency standards. We call for consistent identification of CHWs as a united workforce that is strengthened by its varied job titles that reflect the diversity of the populations CHWs serve. Continuity in governance through inevitable transitions in federal and state agencies is critical. The CHW profession cannot and must not be re-defined by each governmental entity as it seeks to work with CHWs—just as physicians and nurses would expect. We urge governmental agencies to seek out formal CHW representation by dedicating seats for CHWs in their working groups on CHW policy and practice. This mechanism provides a formal avenue for direct consultation with CHWs. We urge accountability in honoring and accepting CHW guidance and requests for support that come through such pathways. We applaud government actors, such as the Centers for Disease Control and Prevention that support CHW national, state, and local self-governance. We look to government agencies to play a responsive rather than a defining role. This strengthens CHW leaders, positioning them to lead and guide workforce development efforts. Finally, given the proliferation of emerging protocols and guidelines, we encourage governmental actors to actively partner with the National Association of CHWs and, as appropriate, state and local CHW associations and networks (https://nachw.org/generalresources/networks-and-training-programs/) to identify any needed refinements in CHW definitions and scope of practice standards for federal, state, and local CHW initiatives. Organizations leading new efforts for accreditation must recognize the standards and values already adopted by the CHW field and actively seek partnerships with leading CHW organizations in the field that have worked to unify the CHW workforce. WHERE DO WE GO FROM HERE? The CHW field has made great strides in recent decades towards recognition and sustainability. Partnerships between CHWs, CHW allies, and governmental and community-based organizations have played a key role in creating an increasingly sustainable environment for CHWs. With the integration of CHWs into many programs and settings, safeguards should ensure that CHWs—not those who employ or fund them—define, refine, and govern their professional identity and scope of practice. This commentary is a call to action to support the CHW workforce’s self-determination and self-governance while promoting the breadth and depth of CHWs’ core roles and competencies to facilitate CHWs’ optimal contributions to the health and well-being of the individuals, families, and communities they serve.

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