By definition, Community Health Workers are unique and essential members of the health care team. A CHW is an individual who:

• Serves as a liaison/link between public health, health care, behavioral health services, social services, and the community to assist individuals and communities in adopting healthy behaviors
• Conducts outreach that promotes and improves individual and community health
• Facilitates access to services, decreases health disparities, and improves the quality and cultural competence of service delivery in Nebraska.

A CHW is a trusted member of, or has a good understanding of, the community they serve.They are able to build trusting relationships and are able to link individuals with the systems of care in the communities they serve.As recognized members of the communities they serve creates a unique and powerful bond of affinity and capability to communicate effectively with individuals and families seeking health care.

A CHW 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.

Nebraska SHIP Priority 4: Nebraska has improved integration among public health, behavioral health and healthcare services.

For this SHIP goal, several activities were planned for implementation:

• Develop reports documenting the recommended roles, core competencies, curriculum and systems for Nebraska community health workers.
• Provide support to the PHAN Community Health Worker Association to implement system goals.

There has been a longstanding interest in Community Health Workers (CHWs) in Nebraska since the 1990s. While meetings about the CHW workforce were conducted by local health department leadership in 2012 – 2013, momentum to move forward and establish a CHW coalition in the state was solidified in May 2012 during the annual Nebraska Department of Health and Human Services (DHHS) Minority Health conference. Interested participants attended a session facilitated by Carl Rush, a national consultant for the American Public Health Association on CHW workforce development. Carl included review of national trends and CHW models as well as consideration of a CHW initiative for the state. Subsequently, an informal Nebraska Community Health Worker Coalition was launched that included a Steering Committee and four workgroups (Association, Standards, Education, Sustainability) that would explore issues associated with successful development of the workforce.

Momentum for more structured consideration of elevating a CHW workforce in the state was further accelerated by efforts across the nation to promote CHWs as essential members of continuity of care teams in patient centered medical home models (PCMH). PCMH is widely promoted by the Centers for Medicaid and Medicare Services as a means of achieving the Triple AIM:improving population health and health outcomes; reducing health care costs; and improving patient satisfaction with care. Coupled with national dialogues regarding the potential to have third party billing for CHW services has been a strong incentive to position states for readiness to deploy the CHW workforce.

The Nebraska Community Health Worker Coalition Steering Committee was comprised of stakeholders engaged in varied aspects of CHW workforce development: funders, state and local health departments who employed CHWs, hospitals that employed CHWs, college or university staff involved with CHW training and “curriculum development, private sector CHW employers, state health department program staff, Public Health Association of Nebraska, state and local level policy advocates, a tribal health director, etc.

The Nebraska CHW Steering Committee reviewed national literature extensively in itsefforts to capitalize on lessons learned from Massachusetts, Minnesota, New York, Texas, Oregon; collective initiatives coordinated by the American Public Health Association (APHA), and the Indian Health Service. At the heart of workforce development was a sense creating a successful process for Nebraska that gives particular consideration to the concern for the unique needs of CHWs and CHW employers.

Two Nebraska models are in place in which hospitals are using CHWs in Clinical Integrated Networks to establish measures that demonstrate improved patient outcomes and savings.

In Kearney, NE Sentinel Health has partnered with Good Samaritan Hospital and a local clinic to create a network that uses CHWs. In its third year, the program has shown a61% reduction in Emergency Room visits from 313 visits to 123 visits. For clients enrolled in the program for one complete year), there was a 46% reduction in the total Emergency Room cost ($498,293 to $268,922).

In Grand Island, NE. Saint Francis Medical Center has just started a network in partnership with the privately funded Third City Community Clinic and federally funded Heartland Health Center and is using grant dollars to fund Community Health Workers. The program proposes to decrease Saint Francis Medical Center hospitalizations by at least 25% (4,622 or fewer hospital admissions); lower the rate of patient readmissions within 30 to 6.5%; reduce charity costs by 20% (annual reduction from $4.45 million to $3.56 million); and to establish 30% improvements in AC1 readings, cholesterol readings and blood pressure readings.

Additionally, the Indian Health Service (IHS) infrastructure for its community health representative (CHR) workforce has been in place since the 1960s and provides opportunities for the state to learn how IHS has addressed challenges successfully in building and implementing this profession.There are four tribes located in Nebraska (Winnebago Tribe of Nebraska, Ponca Tribe of Nebraska, Santee Sioux Nation, and Omaha Tribe of Nebraska) that have a combination of IHS and tribally owned health care facilities.IHS has also had in place for a number of years the Improving Patient Care (IPC) model which is built on a foundation of the Patient Centered Medical Home Model (PCMH) in development nationally.

Stakeholders on the Nebraska CHW Coalition Steering Committee worked collectively as a task force more than as a coalition so that one of the workgroups, the Association, could mature and assume leadership for a single statewide CHW organization led, in majority, by CHW members.The transition in leadership from the Steering Committee to the Public Health Association of Nebraska (PHAN) CHW Association section began in December 2014.In accordance with the SHIP objective, the Steering Committee delivered recommendations for core competencies and skills, a scope of practice, and certification process.Four existing training programs were evaluated for commonalities, alignment of curricula with skills base and scope of practice, differences, strengths,and costs in terms of time and fees.The Steering Committee provided a “living will” to the PHAN CHW Association that included key items to carry forward from the Steering Committee action plan.

Click here to learn more about the PHAN Community Health Worker Association: http://publichealthne.org/phan-sections/community-...

Check out these videos to learn more about Community Health Workers:

Am I a Community Health Worker?

Employing a Community Health Worker

How Community Health Workers Help Community Members: Maria & Belen’s Story.

Roles (functions/responsibilities/activities) of Community Health Workers most commonly include:

• Ability to work within the Nebraska CHW Association code of ethics
• Serve as a Cultural Health Liaison or Facilitator
• Empower clients through advocacy and education
• Conduct outreach activities
• Raise awareness of health and wellness needs
• Provide disease prevention education
• Provide social support
• Build community capacity
• Community resources navigation

Community health workers have been utilized within the state for more than 20 years.They have been carrying out the roles of community health workers under the title of promotoras, lay health ambassadors, outreach workers, community health representatives in tribal communities, and interventionists to just name a few.They have been used throughout the state serving communities based on needs of service providers, including state, local, and tribal governments, community based service organizations, faith-based organizations, as well as clinics serving disparate populations such as Federally Qualified Health Centers.

The most stable path to sustainability for Community Health Workers is to create value for Nebraska healthcare providers. However, the assumption must be made that the employers of healthcare – hospitals, clinics and physicians – are not yet convinced that the hiring of Community Health Workers will provide them with a desired return on investment, in terms of patient outcomes and cost savings.

While hospitals and physicians may be willing to invest in Community Health Workers as a best practice toward improving healthcare outcomes, they will seek documentation of its success. It is incumbent upon Community Healthcare Worker programs to carefully document improvement in patient outcomes and hospital/clinic savings to establish a cause and effect relationship between the hiring of Community Healthcare Workers and better patient outcomes. Strategies and methodologies used in reaching these outcomes also will become very important in decision-making by healthcare providers before deciding whether to invest in Community Healthcare Workers.

For the four American Indian tribes and nations located in Nebraska, it will be critical for tribal leadership to assess the value of the statewide initiative to promote the CHW workforce to each tribe as well as the PCMH model in light of the long-standing health care infrastructure provided by IHS.

As supporters of Community Health Workers in Nebraska move forward to help fulfill the Triple Aim Vision, important issues need to be considered:

• Certification as opposed to licensure and credentialing. Based on lessons learned from other states, certification appears to be the right fit to provide CHWs with a defined role in healthcare but also flexibility to meet the needs across the state.
• In the development of payer Sources, it is important to consider the role of Behavioral Health Specialists in working with CHWs to develop successful client and patient outcomes. A significant individuals fail at self-care because of anxiety and depression.
• Community Health Worker standards should be kept separate from Workforce development to protect the integrity of the CHW role and position within the overall healthcare picture.
• Integrated care opportunities will exist for CHWs. It will become important for CHWs to understand their specific responsibilities and how they fit within the healthcare system. CHWs will be able to specialize in certain types of care but will also need to remain within their own scope of skill sets and responsibilities.