1. Community Health Worker (CHW): A New Profession in the Health Care Workforce? Bita A. Kash, MBA, FACHE Marlynn L. May, PhD, MDiv Ming Tai-Seale, PhD, MPH Southwest Rural Health Research Center School of Rural Public Health, Texas A&M University Health Science Center TAMU 1266 College Station, Texas 77843-1266 (979) 458-0653 www.srph.tamushsc.edu/srhrc

2. Project Support - Acknowledgement Projects funded by a grant (5-UIC- RH00033) through …  Federal Office of Rural Health Policy (ORHP)  Health Resources and Services Administration (HRSA)  Data collection through the Southwest Rural Health Research Center (SRHRC)  Catherine Hawes, PhD, Senior Investigator and Director of SRHRC

3. Community Health Workers  Community Health Advisors  Promotoras  Indigenous Workers  Lay Health Workers  Community Health Aides  Family Service Workers

4. Research Objective 1.To apply economic perspective of market failure (Arrow, 1963), and human capital theory (Becker, 1962) to study the history and development of certification programs for CHWs in the United States. 2.To explore potential workforce implications.

5. Background Classical models of the process of professionalization rooted in sociology: Schein (1972) Caplow (1954) Sociologists have been increasingly incorporating economic models and literature to expand sociological sub-fields such as labor markets and human capital since the 1970s (Baron and Hannan, 1994).

6. Background Why economic models can be an alternative approach in examining emerging allied health professions: 1.These occupations developed largely as a result of an unmet need in the healthcare market, and 2.They are less likely to pursue autonomy, which is the problematic component of the professionalization models based in sociology.

7. Framework of Analysis Results of a national survey of CHW programs are presented based on: 1.The framework of “market failure” (Arrow, 1963) when analyzing the history and initiation of CHW programs in the U.S., and 2. The “human capital theory” (Becker, 1962) when discussing goals and impact of the CHW programs.

8. Research Hypothesis 1.States are moving towards standardization of training and certification of CHWs in order to increase and improve CHW utilization and income potential. 2.CHWs are an emerging new class of professionals in the healthcare workforce market, and therefore will experience an increase in earnings potential.

9. National Study: Data Sources 1.Informants: public health officials, healthcare associations, CHW networks, community colleges, and service providers. 2. Internet Resources: state legislative websites, and CHW program websites.

10. National Study: Methodology Initial Screening 50 States In-depth Interviews 19 States Typology of CHW Programs Selection Criteria Atlas.ti Snowball Process Qualitative Analysis

11. Summary of Results 19 states have existing CHW certification and/or training programs.19 states have existing CHW certification and/or training programs. Most of these states have training programs at community colleges and direct service agencies. Most of these states have training programs at community colleges and direct service agencies. Only 9 of these programs are supported by the state either financially or through other means. Only 9 of these programs are supported by the state either financially or through other means. AK, and TX are the only states administering a certification program for CHWs. AK, and TX are the only states administering a certification program for CHWs.

12. Summary of Results AZ, CA, NM, KY, and MA are considering state-level certification for CHWs.AZ, CA, NM, KY, and MA are considering state-level certification for CHWs. OH, NC, and NV have established standards for training of CHWs at the state level, but do not administer certification programs. OH, NC, and NV have established standards for training of CHWs at the state level, but do not administer certification programs. Agency level training appears to be most prevalent in “special case” states that utilize specialized lay health workers in areas such as prenatal care, heart disease, cancer, mental health, and AIDS prevention. Agency level training appears to be most prevalent in “special case” states that utilize specialized lay health workers in areas such as prenatal care, heart disease, cancer, mental health, and AIDS prevention.

13. Level of Support for CHW Programs OH NC NV AK IN AZ CA HI KY TX NM OR FL CT MA MS WV VA MD State Legislated/Required by State Supported by StateNo State Support/Agency Based

14. Typology of CHW Programs CertificationTrainingSpecial Cases State Legislated or Required AK, TXOH, NC, NV IN Supported by State (financial or other) AZ, CA, HI, KY, MA, NM, VA CT, FL Not Supported by State ORMS, MD, WV States in Bold: Program Impact is Larger than Regional

15. Conclusions: Emergence of CHW Programs  Initiatives can be described as society taking steps to correct dissatisfaction with the competitive equilibrium achieved in the market (Arrow, 1963).  All programs reported a common theme in the history of their programs, and the initial creation of the CHW occupation: unmet need and lack of access to healthcare services in culturally, economically and geographically difficult to reach communities. unmet need and lack of access to healthcare services in culturally, economically and geographically difficult to reach communities.

16. Conclusions: Goals and Impact of Programs Three prevalent themes on training and certification: Schooling at the community college level: provides career advancement opportunities into nursing and social work. Schooling at the community college level: provides career advancement opportunities into nursing and social work. On-the-job training at the agency level: improves standards of care, outcomes, secures CHW income, and improves retention of CHWs. On-the-job training at the agency level: improves standards of care, outcomes, secures CHW income, and improves retention of CHWs. Certification at the state level: recognizes the value of CHWs, enhances reimburseability of CHWs, and improves self-esteem and self worth of CHWs. Certification at the state level: recognizes the value of CHWs, enhances reimburseability of CHWs, and improves self-esteem and self worth of CHWs.

17. What CHWs are saying about Certification “What is power? Health is power. Money is power. This is why I am participating in the certification program. If you wish to be a volunteer, that’s fine. I’ve been a volunteer, too. This certification will help us get paid for out work. I am told that I am one of the best paid promotoras, but I don’t think I earn that much…” Lorenza Zuniga, Promotora, El Paso, TX “I’ve been a migrant farmworker since I was nine-years-old. Promotoras are from the community, they help the community because they want to do this and love to help. As a volunteer, I did not think about compensation or recognition. But now things have changed. We all need to survive in this world…” Graciela Camarena, Promotora, Mercedes, TX

18. Policy Implications  Improve the vertical mobility and career advancement of CHWs by subsidizing education (community college approach).  Provide stable jobs and incomes for CHWs by supporting the reimbursement of trained and certified CHWs (on-the-job training and state certification approach). Depending on what a state department of health or federal health agency attempts to achieve in the healthcare workforce supply.

20. References: Arrow, K. J. (1963). "Uncertainty and the Welfare Economics of Medical Care." American Economic Review 53(5): 941-973. Baron, J. N. and M. T. Hannan (1994). "The Impact of Economics on Contemporary Sociology." Journal of Economic Literature 32: 1111-1146. Becker, G. S. (1962). "Investment in Human Capital: A Theoretical Analysis." The Journal of Political Economy 70(5): 9-49. Caplow, T. (1954). The Sociology of Work. New York, McGraw-Hill Book Co. Rosenthal, E. L. (1998). A Summary of National Community Health Advisor Study. Baltimore, MD, Annie E. Casey Foundation. Schein, E. H. (1972). Professional Education: Some New Directions. New York, McGraw-Hill Books Co.

21. Thank You! Southwest Rural Health Research Center School of Rural Public Health, Texas A&M University Health Science Center TAMU 1266 College Station, Texas 77843-1266 (979) 458-0653 www.srph.tamushsc.edu/srhrc