Sonoma County Framework for Equitable Community Health Worker (CHW) Employment

The American Public Health Association defines a CHW as “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” Sonoma County additionally defines CHWs as trusted community experts that are widely recognized for their role in providing care with cultural humility and building the capacity of the people they are working with as peers. They provide health education and connect community members to resources. Many CHWs are multilingual and multicultural and have a shared lived experience with the communities they serve.

CHWs can also be described by their scope of practice, outlined by the National CHW Council on Core Consensus Standards (formerly the C3 Project) in the 10 CHW Core Roles, found in Appendix A. Organizations employing CHWs in both clinical and community settings should draw from as many of these roles as possible when forming job descriptions and avoid assigning job tasks outside of this list.

As mentioned in the definition above, CHWs are members of and experts in their communities. When recruiting individuals to fill a CHW job posting, you should prioritize finding someone with that connection who exhibits the qualities of a successful CHW, such as commitment, friendliness, compassion, open-mindedness, and dependability.

For more information about how to recruit CHWs, including frameworks for recruitment, sample job descriptions, and examples of interview questions, visit the following resources:

• Hiring Practices that Support State Integration of Community Health Workers
  • This toolkit from the Association of State and Territorial Health Officials (ASTHO) includes tips for the CHW hiring process, sample interview questions, potential barriers and enablers for hiring CHWs, and a crosswalk of CHW roles with job description language.
• Community Health Worker Assessment Toolkit
  • This toolkit from the National C3 Council (formerly the C3 Project) contains sample job descriptions, interview guides, and case studies of CHW performance assessments across various CHW organizations.

Medicare and Medi-Cal do not specify a minimum number or training hours required for CHWs to be eligible to bill for reimbursement. We encourage employers to provide sufficient experiential and on-the-job training, such as shadowing opportunities.

We will not suggest a minimum time frame for training, but we encourage CHW employers to partner with local CHW training institutions to provide CHWs at your organization with basic core competency training to ensure their ability to fulfill the ten core roles mentioned above.

• North Bay CHW Training Program
• Center for Well Being

Additionally, you can find online training on the California Association of CHWs’ website and consult the

Foundations for Community Health Workers textbook from the City College of San Francisco.

As of Summer 2024, the recommended minimum hourly rate range for entry level CHWs in Sonoma County is $25-$29/hour, with an expectation of regular cost of living adjustments and wage increases based on experience. CHWs should be provided paid sick and mental health leave as well as paid vacation time and other generous standard benefits. Given the variable nature of CHW work hours, with night and weekend tasks, CHWs should be afforded a flexible working schedule.

Many CHWs are undocumented and not eligible for employment. If you are contracting with any CHW, you should pay them as generously and fairly as possible, considering an increased rate to account for self-paid benefits and taxes, and ensuring that you follow all state and federal laws around misclassification. Some organizations chose to contract with CHW-led LLCs or cooperatives to provide CHW services. If your organization currently works with CHWs that volunteer, plan to pay them moving forward. Prioritize finding sustainable funding for CHW salaries and stipends.

CHW services can now be paid for through billing Medi-Cal and Medicare. Reimbursement for CHWs is still emerging in California and implementation of both Medi-Cal and Medicare billing is complex. If you choose to pursue reimbursement for CHW services as part of a braided/blended funding strategy for CHW positions, here are some resources to consult but the best resource is networking with other organizations doing this work, for example through a learning collaborative:

Medicare:

• Policy Brief - Changes to 2024 Medicare Physician Fee Schedule for Community Health Integration Services from the Association of State and Territorial Health Officials
• Webinar - The Medicare Physician Fee Schedule Includes Codes to Address HRSNs...What Happens Next? from the Partnership to Align Social Care and Centers for Medicare & Medicaid Services (CMS)

Medi-Cal:

• Medi-Cal Provider Manual for the Community Health Worker from CDHCS
• CHW Services Benefit Guidance Letter from CDHCS (still under review)

It is critical that you evaluate CHW programs to tell a story of impact and support advocacy for the workforce. The CHW Common Indicators from the CHW Center for Research and Evaluation (CHW CRE) is a list of best- practice indicators to use in evaluations of CHW programs. If you cannot incorporate all the indicators into your evaluation plan, choose the ones that are most important to you.

Ideally, CHWs should be supervised by other CHWs. If this is not possible, CHW supervisors in both clinical and community organizations should meet the following criteria:

• Have the time and bandwidth to invest in supportive CHWs have unique roles and often face unique challenges – their supervisors must be available to provide sufficient support.
• Deeply understand the CHW role and If you are new to the CHW field, you should search out CHW supervisor training or other educational resources to help them understand the CHW role and their role as a CHW supervisor.

While there are many ways to help CHWs feel supported and equipped to do their job and thrive, these are the most important elements:

• Be supportive and available. You must be willing to be flexible around the social determinants of health that many CHWs themselves face and take time to help CHWs process and find support for stressful situations they encounter with their clients and communities.
• Hire at least two CHWs at a CHWs must have access to peer-to-peer support.
• Build formal career ladders that allow CHWs to progress within their profession, either as higher-level CHWs or as managerial program staff.
• Find ways to provide job stability and sustainable funding for CHW positions should not rely solely on grants so that positions do not have end dates.
• Support CHWs in their Give CHWs a voice to guide their work and programs and carve out time for them to participate in local, state, and national workforce initiatives.
• Work with team members across the organization, especially top leadership, to share understanding of the CHW role and learnings from CHWs’ knowledge of clients and community.