Clear CHW Roles Essential for Program Success

Case studies throughout this site are replete with examples of large institutions initially experiencing costly high turnover, team frustration and  failed outcomes because CHW roles were not developed in accordance with best practice. In every case, HR Departments have found it important to create a specific job category for community health workers, documenting the CHW role in moving between community settings and institutional settings, and highlighting the significant time spent in the community. A well-developed job description helps define the parameters of the role for the community health worker, their supervisor, and all the health care professionals who refer to and collaborate with the CHW.  When shared with the team, a well-developed job description can serve as a guidepost for how to maximize the benefit of the CHW in the workplace.  

Community Health Worker Scope of Practice

The Community Health Worker Scope of Practice provides a framework for understanding the broad scope of activities that CHWs carry out day to day in many different settings and should guide the development of CHW job descriptions. Ten major roles together constitute contemporary Community Health Worker Scope of Practice, according to the C3 nationwide assessment of Community Health Worker roles. While not all CHWs will have all 10 roles, they may take on any combination of these roles, depending on the needs of their community.

1) Cultural Mediation among Individuals, Communities, and Health and Social Service Systems

• Educating individuals and communities about how to use health and social service systems (including understanding how systems operate)

• Educating systems about community perspectives and cultural norms (including supporting implementation of Culturally and Linguistically Appropriate Services [CLAS] standards)
• Building health literacy and cross-cultural communication

2) Providing Culturally Appropriate Health Education and Information

• Conducting health promotion and disease prevention education in a manner that matches linguistic and cultural needs of participants or community

• 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

• Participating in care coordination and/or case management

• Making referrals and providing follow-up

• Facilitating transportation to services and helping to address other barriers to services
• Documenting and tracking individual and population level data

• Informing people and systems about community assets and challenges

4) Providing Coaching and Social Support

• Providing individual support and coaching

• Motivating and encouraging people to obtain care and other services

• Supporting self-management of disease prevention and management of health conditions (including chronic disease)

• Planning and/or leading support groups

5) Advocating for Individuals and Communities

• Advocating for the needs and perspectives of communities

• Connecting to resources and advocating for basic needs (e.g. food and housing)
• Conducting policy advocacy

6) Building Individual and Community Capacity

• Building individual capacity

• Building community capacity

• Training and building individual capacity with CHW peers and among groups of CHWs

7) Providing Direct Service

• Providing basic screening tests (e.g. heights & weights, blood pressure)
• Providing basic services (e.g. first aid, diabetic foot checks)

• Meeting basic needs (e.g., direct provision of food and other resources)

8) Implementing Individual and Community Assessments

• Participating in design, implementation, and interpretation of individual-level assessments (e.g. home environmental assessment)

• Participating in design, implementation, and interpretation of community-level assessments (e.g. windshield survey of community assets and challenges, community asset mapping)

9) Conducting Outreach

• Case-finding/recruitment of individuals, families, and community groups to services and systems
• Follow-up on health and social service encounters with individuals, families, and community groups

• Home visiting to provide education, assessment, and social support
• Presenting at local agencies and community events

10) Participating in Evaluation and Research

• Engaging in evaluating CHW services and programs
• Identifying and engaging community members as research partners, including community consent processes

• Participating in evaluation and research: i) Identification of priority issues and evaluation/research questions ii) Development of evaluation/research design and methods
iii) Data collection and interpretation
iv) Sharing results and findings v) Engaging stakeholders to take action on findings

Job Descriptions

CHW job descriptions are very diverse and dependent on organizational needs. The Minnesota Community Health Worker Toolkit identifies these key considerations for developing a job description:

• Primary duties (e.g. home visiting, patient education);
• Personal skills (e.g. empathy, ability to develop trusting relationships, interest in helping the community)
• Prior health and other related work experience (including knowledge of community)
• Language requirements (e.g. both oral and written, English, other languages)
• Physical requirements (e.g. transporting education materials, walking and stair-climbing to visit patient homes)
• Special skills (e.g. computer skills, EHR experience, phone calling skills, driver’s license)
• Educational requirements  

Sample Job Descriptions:

• Penn Center for Community Health Workers Job Description
• Making the Connection: The Role of Community Health Workers in Health Homes, NY Health Foundation

Code of Ethics

View MA Community Workers Code of Ethics. 

A CHW’s background and personality traits should weigh more heavily in the hiring decision than their level of education. General consensus within the field is that the skills and traits which make CHWs successful are inherent or gained through work and life experience. The technical skills and specific health knowledge needed for a CHW position can be learned through sufficient on-the-job training. Employers should hire CHWs with positive communication skills, adaptability, reliability, strength, and both passion for and sensitivity to community issues. (1)

The process of hiring CHWs should be well thought out and structured to ensure the program hires the right candidate for the job and that the employer is clear with the CHW about the expectations of the position. Interviews should cover:

• Logistical questions (i.e., schedule flexibility, etc)
• Ask about the CHW’s relationship with and knowledge of the community (including any formal and informal experience with community work)
• Passion for the job
• Comfort with the position requirements
• Overall work experience. (1)  

Key Skills & Traits

The following describes key skills and traits that can help guide the selection of CHWs and also inform employers of the training needs of their workforce, drawn from a nationwide assessment of CHWs. (2)

Communication Skills

• Ability to use language confidently

• Ability to use language in ways that engage and motivate

• Ability to communicate using plain and clear language

• Ability to communicate with empathy

• Ability to listen actively

• Ability to prepare written communication including electronic communication (e.g., email, tele- communication device for the deaf)

• Ability to document work
h. Ability to communicate with the community served (may not be fluent in language of all com- munities served)

Interpersonal and Relationship-Building Skills

• Ability to provide coaching and social support

• Ability to conduct self-management coaching

• Ability to use interviewing techniques (e.g. motivational interviewing)
• Ability to work as a team member
• Ability to manage conflict

• Ability to practice cultural humility

Service Coordination and Navigation Skills

• Ability to coordinate care (including identifying and accessing resources and overcoming barriers)
• Ability to make appropriate referrals

• Ability to facilitate development of an individual and/or group action plan and goal attainment
• Ability to coordinate CHW activities with clinical and other community services
• Ability to follow-up and track care and referral outcomes

Capacity Building Skills

• Ability to help others identify goals and develop to their fullest potential

• Ability to work in ways that increase individual and community empowerment
• Ability to network, build community connections, and build coalitions

• Ability to teach self-advocacy skills

• Ability to conduct community organizing

Advocacy Skills

• Ability to contribute to policy development

• Ability to advocate for policy change

• Ability to speak up for individuals and communities

Education and Facilitation Skills

• Ability to use empowering and learner-centered teaching strategies

• Ability to use a range of appropriate and effective educational techniques

• Ability to facilitate group discussions and decision-making
• Ability to plan and conduct classes and presentations for a variety of groups
• Ability to seek out appropriate information and respond to questions about pertinent topics
• Ability to find and share requested information
• Ability to collaborate with other educators

• Ability to collect and use information from and with community members

Individual and Community Assessment Skills

• Ability to participate in individual assessment through observation and active inquiry
• Ability to participate in community assessment through observation and active inquiry

Outreach Skills

• Ability to conduct case-finding, recruitment and follow-up
• Ability to prepare and disseminate materials
• Ability to build and maintain a current resources inventory

Professional Skills and Conduct

• Ability to set goals and to develop and follow a work plan
• Ability to balance priorities and to manage time
• Ability to apply critical thinking techniques and problem solving
• Ability to use pertinent technology
• Ability to pursue continuing education and life-long learning opporotuunities
• Ability to maximize personal safety while working in community and/orclinical settings
• Ability to observe ethical and legal standards (e.g. CHW Code of Ethics, Americans with dis abilities Act [ADA], Health Insurance Portability and Accountability Act [HIPAA])

• Ability to identify situations calling for mandatory reporting and carry out mandatory report- ing requirements
• Ability to participate in professional development of peer CHWs and in networking among CHW groups

• Ability to set boundaries and practice self-care

Evaluation and Research Skills

• Ability to identify important concerns and conduct evaluation and research to better under- stand root causes

• Ability to apply the evidence-based practices of Community Based Participatory Research (CBPR) and Participatory Action Research (PAR)
• Ability to participate in evaluation and research processes including: i) Identifying priority issues and evaluation/research questions ii) Developing evaluation/research design and methods
iii) Data collection and interpretation iv) Sharing results and findings
v) Engaging stakeholders to take action on findings

Knowledge Base

• Knowledge about social determinants of health and related disparities Knowledge about pertinent health issues
• Knowledge about healthy lifestyles and self-care
Knowledge about mental/behavioral health issues and their connection to physical health Knowledge about health behavior theories
• Knowledge of basic public health principles Knowledge about the community served
• Knowledge about United States health and social service systems

Lessons Learned: Selection Process That Favors “The Right People”

Source 1:  Community Health Worker Integration into a Healthcare Team:  A Bronx Tale

Source 2:   Minnesota Community Health Worker Toolkit, 2016

A study of Bronx-Lebanon Hospital PCMH articulates the lessons learned on the importance of recruitment processes that favor the “right” people.  “Being a good CHW requires engagement and dedication, and not everyone can be a CHW (Findley et al., 2012). Therefore, hiring the “right” people required selection criteria and a recruitment process focusing on identifying individuals with the attributes for being a good CHW: empathic, natural helper, communicator, and experienced in the community culture.”  (1)

Bronx-Lebanon Hospital PCMH’s revised selection process is described as follows:

1. Initial Interview. An initial interview narrowed the applicant pool to those CHWs who were friendly and communicative, fluent in 1 or more languages spoken by the patients (Spanish, French, South Asian languages), natural helpers, able and willing to serve as role models, and courageous advocates for the community.

2. “Pre- training” for  potential CHW candidates. The second recruitment step was to provide a “pre- training” for these potential CHW candidates. During this training, participants could decide if they were suited to the role, while the department could observe the best candidates and invite them for second interviews. This 3-step process has led to successful recruitment of CHW candidates, with very few subsequently let go during probation.

3. Job description. The job description for CHWs was made more explicit, so the department could be more selective of candidates sent to them from Human Resources.

4. Candidate interview questions. The CHW Administrator (supervisor) developed candidate interview questions to better screen potential candidates for the desired attributes, with specific questions to elicit the candidate’s experience in working with the low-income, minority populations typical of the hospital’s patient population and their interaction skills (communication, demonstrating empathy, teaching or coaching, providing support or encouragement).

5. Interview team. The CHW Administrator and a senior CHW together interviewed potential candidates, so one could observe body language and attitude. This improved selection of qualified candidates.

Children’s Hospitals and Clinics of Minnesota

When Children’s Hospitals and Clinics of Minnesota first launched its Service Coordinators (their term for CHWs), its hiring priorities focused on candidates who had obtained post-high school education, had experience with patient coaching and possessed clinic awareness and familiarity. Over time, they found that recruiting the “right person” meant identifying someone with a demonstrated mix of strong communication skills, the ability to create trusted relationships with patients and families, and the understanding to meet the families “where they are.” When these qualities are combined with cultural and language skills and some health background, a Service Coordinator (CHW) will be able to identify where to start and move forward with families from one set of goals to the next. To successfully recruit such candidates, Children’s uses a two-tiered interview process including an initial interview with a manager followed by a second team interview that relies heavily on behavioral interviewing techniques. (2)

Most newly hired community health workers will bring a mix of relevant work experience, personal lived experience and perhaps some formal or on-the-job training, and also significant gaps in formal education and training. Employers will find it productive and cost-effective to invest in upfront and ongoing training of Community Health Workers.

Initial CHW training should generally be designed to:

1. Introduce CHWs to their roles, goals and parameters of their work,
2. Provide foundational knowledge and skills on working with complex and chronic conditions,
3. Prepare CHWs to integrate into their clinical teams, and
4. Introduce CHWs to key administrative and documentation systems.

Additional Training Components to Consider

1. Human Resources Orientation to CHW Hiring. HR Depts are unaccustomed to asking people about their life experience, and are trained to avoid such questions.  Successful CHW hiring requires nuanced tailoring of traditional HR processes. CHW Human Resources Orientation to CHW hiring can be arranged through the CHW Employer Resource Center by contacting Lissette at [email protected].
2. CHW Supervisor Initial Training. CHW Supervisor Training can be arranged through the Regional CHW Training Centers. 
3. Team Initial Training:  CHW Employer Resource Center can provide orientation and training on best practices for integrating community health workers to maximizing program value and impact.
4. Community Health Worker Core Competency Training: Massachusetts is a national leader in defining Community Health Worker Core Competencies and in providing a pathway for CHW Certification.  CHW Core Competencies are considered foundational skills for all community health workers, regardless of role, and certification is NOT required for employment.   While some new employees may have attended a formal CHW Core Competency Training Program, many will not have had this opportunity prior to employment. CHW Core Competency Trainings are offered regionally across Massachusetts. Employers typically pay for CHWs to attend this fundamental skill-building training within their first year of employment. Information on CHW Core Competency Trainings across Massachusetts and information on CHW Certification can be found here.
5. Ongoing Professional Development. MA Association of Community Health Workers hosts professional development workshops in its 5 regions, 2-3 times each year.  To receive notification about workshops and our annual conference, sign up here. 
6. On-The-Job Training. A regular, consistent schedule of on-the-job training is essential to a fledgling CHW program.  As a workforce that is not required to receive professional training prior to employment, CHWs require a unique level of training and investment.  Planning the time and resources for regular staff development is critically important to the success of this workforce.  Employers can take advantage of training resources through a network of CHW Training Centers across MA. Topics for ongoing training might include:

• • Motivational interviewing
  • Health-specific interventions and protocols ·      
  • Complex chronic conditions
  • Behavioral health with an emphasis on trauma
  • Substance abuse
  • Domestic violence
  • Goal setting
  • Social determinants of health
  • Cultural mediation
  • Working with primary care teams
  • CPR
  • Safety and Self-Care