Here are some contemporary questions confronting the CHW field. For each we have given some background and in most cases a link or two for further research:

A. Definitional issues
B. Scope of practice and other professions
C. Professionalization and Credentialing
D. Organizing (associations of CHWs)
E. Funding/financing/sustainability
F. Roles in major programs
G. Career opportunities
H. Welfare to work as a secondary purpose of creating CHW jobs

Definition of a CHW

As more organizations have come to recognize the effectiveness of CHWs, they have begun to "stretch" the historic definition of the term. Who decides whether someone is a CHW or not?

Are grassroots volunteers the only "true" CHWs? Can someone with a graduate degree be a CHW? Can a worker "earn" credibility in a community other than their own? Can a hospital or HMO employee be a CHW? Are CHWs in danger of losing their identity if the receive college training?

For some thoughts on these and other questions, click here for an essay on this topic.

Scope of practice

CHW functions can resemble those of other professionals, including nurses, social workers, case managers and health educators. As the field becomes more widely accepted, and CHWs take on more duties, those other professional groups may resist what they perceive as (a) taking over that group's responsibilities (usually at lower wage levels) and/or (b) beyond the CHWs' training and capabilities. These kinds of "scope of practice" disputes have taken place for many years between physicians, nurses and allied health professions.

This is largely a problem of definition: it's important to clarify definitions, and to point out to these other groups that CHWs rely for their effectiveness primarily on their ability to communicate with target communities and to gain their trust, rather than on the kinds of professional (clinical) expertise on which the other professions rely.

CHWs can do things the other professions cannot do, and can collaborate effectively with them. The other professions can be trained to supervise CHWs and to serve as backup and resources to CHWs.

CHWs, program developers and advocates will need to deal with this question openly in the near future.

Professionalization and credentialing

CHWs appear to be divided, at both local and national levels, on the desirability of (or need for) credentialing. This is a major subject of our page on legislation and regulation.

Texas is the first State to mandate credentialing of CHWs. In New Mexico, the state CHW association does not favor direct state legislative action on this issue. Some CHWs argue that CHWs themselves should set the standards for their profession, as other professional groups have done.

As other local and national associations of CHWs develop, this question will be at the top of their agendas.

CHW Organizing/
associations

A number of local and statewide associations are active in various states, including California, New York, Texas (Lower Rio Grande Valley and El Paso), Oregon (under the Health Promotion Section of the Oregon Public Health Association) Massachusetts, Arizona, New Mexico and New Jersey.

There is a CHW Special Interest Group within the American Public Health Association (click here to view the CHW SPIG newsletter; click here to find the current SPIG contact person). The Spring 2003 newsletter has an article on strategies for a national association.

The Community Health Advisor Network (CHAN) program acts as a network for a number of programs, largely in the Southeast. The Lay Health Worker/Promotora National Network also has a large number of members, many from the Southwest. There has been discussion of a state CHW association for Texas at recent statewide training workshops; contact HETCAT for the current status of this process.

CHW associations exist for a number of reasons, notably advocacy for a larger role for CHWs and establishment of professional standards. Still to be resolved are issues such as eligibility, again related to problems of definition.

Sustainability

Most CHW programs operate at a small scale for a limited period of time. There are a few exceptions, such as the Indian Health Service's Community Health Representatives and the Kentucky Homeplace program, which have legislated appropriations.

This topic is closely related to the potential CHW role in major programs (see next column). See also comments on our Startup Issues page.

Major federal agencies, notably HRSA, have taken an interest in stabilizing the CHW field, initially by trying to establish a sound basis of research on the cost-effectiveness of CHWs. Private funders such as the Kellogg Foundation are also interested. This is considered to be a vital first step. The Kellogg Foundation is also backing a project to inventory all existing programs involving CHWs.

The next step is likely to be convincing potential funders and purchasers of services of the value of short-term investment for the potential long-term return of reduced costs and improved health outcomes. Leadership on this issue has not yet solidified.

Roles in major programs

Many observers feel that CHWs will only "enter the mainstream" by becoming an accepted part of programs such as Medicaid. In Texas, Senate Bill 751 (2001) mandated that the State use certified CHWs "to the extent possible" in Medicaid and CHIP.

In January 2001, a group of federal and state officials met for a working conference to discuss this set of issues, and there was strong consensus that CHWs could strengthen Medicaid, CHIP, Food Stamps, WIC, Immunizations and many other programs. Unfortunately, a changing fiscal/policy climate at the state and federal levels has made it difficult to pursue these ideas since that time.

When Texas issued its RFP for Medicaid claims administration and primary care case management services in 2002, for the first time the vendor was required to use certified CHWs in outreach and education activities (see Section 8.5.5.6).

Again, leadership at the state and federal levels are necessary to advance this issue in the future.

For further references, see our Legislation page.

Career opportunities

Early CHW programs often made no attempt to prepare the workers for other career opportunities. With many experienced CHWs being lost to better-paying jobs, more programs are considering how to (a) keep good people by offering advancement and/or (b) help skilled workers who desire to move on.

The skills and attitudes which prompt individuals to become CHWs are adaptable to other careers. If they so desire, they can also be successful in nursing, social work, member services, health education and health care administration.

Clearly there are education and training resources available to CHWs who wish to change careers. This discussion does not presume that a CHW should or should not want to find other work, but low wages and poor job security lead many to do so.

This is an area where a great deal of research and dialogue will be needed in the future.

Job creation and welfare to work

Because of the unique qualities required of CHWs, the life experience of many low-income individuals can be an asset in entering the workforce rather than a hindrance. This has made the CHW attractive to developers of jobs programs. As the theory goes, success as a CHW can improve the individual's sense of self-esteem and self-efficacy, as well as providing exposure to the expectations of the world of work.

CHW jobs programs have met with modest success. Project HOPE in New Jersey produced an evaluation report which, while positive, does not provide strong enough evidence of success.

The Annie E. Casey Foundation, through the economic development group Seedco, funded two studies on job opportunities in health, concluding that CHW jobs had potential for a "win-win," producing value for the health care system as well as rewarding jobs. (See citation on our Bibliography page.) Seedco also funded two planning projects, including one in San Antonio.

The Arkansas Center for Health Improvement is now pursuing a similar project in the Delta region of the state.