Community Health Worker (CHW) Movement in Hawai‘i: Moving Towards a CHW Association

Abstract

This editorial presents the perspectives of allies - a group of governmental, university and public health organizations that support the creation of a professional association for CHWs in Hawai‘i. We support the efforts of CHWs as they organize and move towards establishing a professional association. Hawai‘i CHWs have held monthly meetings starting in 2017 to discuss variety of issues around their work and share information and experiences. A group of CHWs and allies developed a strategic plan in 2018 in preparation to establish a professional association. They shared the results with colleagues from across the state. One desirable outcome for many was a professional CHW association. Such an association could be a forum of shared learning, information sharing, networking, and advocating for workforce and professional development issues, such as training, reimbursement for services, credentials, and certifications. Furthermore, allies support CHW-led efforts to develop an association, for instance, by securing diversified funding sources for CHW trainings, networking, and planning activities. Allies also help by informing supervisors, employers, and policymakers about the importance of trainings and other workforce and professional development for CHWs. A professional association for CHWs in Hawai‘i could be useful to many. This editorial provides more insights into this topic.

Introduction

This article presents the perspectives of allies—a group of governmental, university and public health organizations that support the creation of a professional association for Community Health Workers (CHWs) in Hawai‘i. We will describe the CHW-led effort to organize and establish a professional association and why this could be useful, including how allies have supported their efforts and roles they can play going forward in a CHW-led Association.

CHWs are “trusted and culturally responsive,” frontline public health professionals who typically work in underserved communities, and are the integral connection between health care consumers and providers.^1,2 They take on diverse job titles, roles, and tasks such as health education, outreach, and assist patients to navigate through the complex health care system.³ CHWs respond to systemic issues - addressing health disparities and breaking down barriers - by using flexible and creative responses appropriate to patients and the communities they serve.⁴

Policy Changes Creates Impetus for an Association

The Patient Protection and Affordable Care Act of 2010 included provisions to fund CHWs - a testament to their effectiveness to improve health outcomes, reduce health disparities, and reduce health care costs.⁵ Furthermore, changes in the Medicaid rules made in 2013 opened the possibility for CHWs to be reimbursed for preventive services. States such as Massachusetts and Minnesota initiated policies to increase utilization of services rendered by CHWs, and to make these services reimbursable under Medicaid.⁶ The possibility for reimbursement has initiated a movement towards setting training and credentialing standards for CHWs. Organizations such as the National Association of Community Health Workers (NACHW) and the American Public Health Association (APHA) have worked to develop standards of practice at the national level, while certification and credentialing are primarily regulated by state-level policies.

A professional association for CHWs serving in Hawai‘i communities could ensure collective agency and voice in important determinations about workforce and professional development issues. A professional association would provide a forum for CHWs to discuss, reach consensus, and advocate for training standardization and credentialing regulations.

CHW National Advocacy Goals

Nationally, CHWs and their allies have advocated for training, reimbursement, role definition, and identification of professional core competencies according to the National Community Health Workers Advocacy Study.⁷ They also advocate to educate supervisors and the public about their impact and work in communities across the United States.⁷ CHWs may inform policymakers and industry leaders that states providing CHW training programs to improve standards of care, core skills, and competencies are able to achieve better health outcomes.⁸ Also, reimbursements for preventive services increase job security and wages, leading to improved retention rates and overall productivity among CHWs.⁸ Advocacy for professional and workforce development is essential to enhance the CHW's capacity to break down barriers to access and to improve health outcomes.

Groundwork for Establishing a Hawai‘i CHW Association

Over the last two decades, Hawai‘i CHWs have engaged in diverse training and networking opportunities with support from State and public health organizations, including Wai‘anae Coast Comprehensive Health Center's Wai‘anae Health Academy; Hawai‘i Primary Care Association's CHW program; Papa Ola Lokahi's ‘Imi Hale program for cancer education and prevention among Native Hawaiians. They also had opportunities to participate in state and county-wide conferences hosted by the Hawai‘i Primary Care Association (HPCA) in 2006; CHW Network's gatherings in 2015 and 2016; and the Hawai‘i Community Health Worker Leadership Conference, Kulia I Ka Nu'u - Strive for the Highest in 2017, funded by Hawai‘i Department of Health (DOH). These CHW trainings and conferences have created and supported an impetus for CHWs to form a professional association that would increase shared learning, identify training needs, provide networking opportunities, set priorities, frame issues, and advocate for their profession.

Beginning in 2017, CHWs from across the state held monthly meetings to network, share information, and discuss professional and workforce development issues. A core group of 15 CHWs representing all counties, joined by their allies, conducted a strategic planning session in 2018 to set the groundwork to establish a professional association. CHWs and allies organized regional meetings to share the results of the strategic planning with 37 CHWs in Kona, Ka‘u, Hilo on Hawai‘i island, Kaua‘i, Maui, and Lāna‘i. They shared the results with approximately 150 Hawai‘i-CHWs through a listserv.

The goal of establishing an association is currently ongoing. CHWs will commence their search for a leadership team at the June 2019 CHW conference. The leadership team will make decisions about the organizational structure of the association. A detailed description of CHWs and allies' efforts to build a professional association is documented in Table 1.

Table 1.

Process of Developing a Hawai‘i Community Health Workers Association

Milestones	I. Convening Monthly Meetings: (On-going). Since 2017, CHWs have held regular meetings through monthly conference calls and shared information through listservs.	II. Strategic Planning and Consensus Building: (On-going) From 2018 to early 2019, CHWs developed a strategic plan to establish a professional association, shared the plan with colleagues, and gained consensus to develop an association.	III. Developing Leadership and Organizational Structure: (In-progress) Starting from the June 2019 Hawai‘i CHW Conference, CHWs will identify a leadership team to develop organizational structure of the association.	IV. Fully Established Organization: (Anticipated). The fully-established Hawai‘i CHW Association (“Association”) will implement their strategic plan.
CHW Activities	CHWs convened monthly conference call meetings to discuss issues salient to professional and workforce development: 1. Identify training needs for professional development as well as the training needs of new CHWs. 2. Create opportunities for professional networking to share knowledge and information about programs and events. 3. Discuss current best practices set by NACHW and APHA. 4. Address core standards of practice and guidelines on CHW roles and responsibilities. Approximately 150 CHWs participate in discussions on a listserv.	A core group of 15 CHWs, along with allies, conducted a strategic planning meeting to establish goals, outcomes and direction of a professional association for CHWs in Hawai‘i. They shared the strategic plan with colleagues in all counties to build consensus to establish a professional association for CHWs in Hawaii. As of mid-2019, consensus building is an on-going and active process. They are reaching out to as many CHWs in the field to build consensus, including CHWs who do not necessarily identify as CHWs. The goal is for CHWs to come together and support the establishment of a professional association.	The identified leadership team will be responsible for developing the organizational structure of the professional association: 1. To determine roles and responsibilities of leadership and association members. 2. To determine membership structure such as membership criteria and dues, for example. 3. To build a presence in the community through meetings, website and social media. 4. To learn about building professional associations from established groups such as Arizona Community Health Workers Association (AZCHOW) and Massachusetts Association of CHWs (MACHW).	The Association is a CHW-led platform: 1. To foster unity, shared learning, networking, and collaboration among CHWs. 2. To advocate for professional and workforce development issues such as standards of practice; roles and responsibilities; credentials and certification, and reimbursement for CHWs. 3. To advocate for policies and educate policymakers on issues that impact the community's health. The Association will be situated within an established non-profit organization. The leadership team and allies will secure diversified funding to hire staff to coordinate and implement the association's programs.
Allies Support for CHWs	Allies assisted CHWs by securing funding, coordinating, and providing logistical support to convene monthly conference calls, as well as creating a listserv.	Allies secured a consultant to facilitate the strategic planning meeting in 2018. Allies assisted CHWs by coordinating logistics and securing funding for all meetings. Allies and CHWs inform employers and directors of various organizations about the importance of supporting CHW professional and workforce development opportunities and establishing a professional association.	Allies secure services of consultants to facilitate planning meetings about the association. Allies will assist the leadership to identify long-term funding sources to operate an association and implement programs. Allies and CHWs will inform employers, policymakers, and other decision makers about the importance of supporting professional and workforce development opportunities, and professional association.	Allies assist the Association to secure long-term funding, provide technical assistance, and capacity building as they develop their organization and implement their programs. Some examples of assistance from allies: 1. Identifying consultants to support organizational development, and, trainers for capacity building in policy development and advocacy. 2. Identifying potential funding sources to implement programs and sustain the Association.

The fully established CHW association would provide a platform for CHWs to share and network by hosting dialogues, monthly meetings, and conferences for collaboration, shared learning, and networking. The Association could serve as a vehicle for CHWs to set priorities and frame issues that impact their work and the well being of their communities. Its leadership and members would provide input on core competency recommended by NACHW and APHA; advocate for training to enhance skills and core competencies; advocate for reimbursement, standards of practice, credentials, and certification; advocate for legislation that impact the community's health and develop leadership skills of CHWs.

The Role of Partnerships in the CHW Movement

Allies are core supporters of the CHW-led movement to organize and exercise self-determination over workforce and professional development issues. Allies in the Hawai‘i CHW movement are from diverse areas such as: government, academia, and non-profit public health organizations. Allies and other collaborators provided support, for example, funding development, technical assistance, logistical support, capacity building, and advocating for legislation that impacts CHWs and their work.⁹ For example, they secured diversified funding from federal, state, foundation, and nonprofits for trainings as well as support for networking opportunities and planning efforts.

Further Steps

The process of organizing and planning takes time. Hawai‘i's CHWs continue to engage with their colleagues, and to outreach to CHWs who do not necessarily identify as CHWs, through presentations and discussions to ensure wide awareness and agreement with the association's mission and vision. Ongoing dialog among CHWs and with allies is necessary to understand and overcome barriers to creating a Hawai‘i CHW Association. CHWs and allies will collaboratively educate supervisors, employers and state policymakers on various issues such as the importance of ongoing training for CHWs, credentialing and certification, as well as support for the development of a professional association for CHW in Hawai‘i.

Practical Implications

A professional association for community health workers in Hawai‘i could unite and bring CHWs together to share, learn from each other, network, and advocate for their profession. A resilient and cohesive workforce with a strong role for CHWs will ensure that Hawai‘i's communities will be strong and healthy.

Abbreviations and Acronyms

APHA

American Public Health Association

CHWs

community health workers

NACHW

National Association of Community Health Workers

NCHWAS

National Community Health Workers Advocacy Studies

Conflict of Interest

None of the authors identify a conflict of interest.