Community Health Workers: A Key Workforce to Promote Health Equity for Children in Immigrant Families

In the United States, children in immigrant families and their caregivers must often navigate complex, inefficient, and exclusionary health and social service systems to access necessary health care and public health services. Government benefit programs for children in immigrant families are often poorly designed and fragmented, with complex enrollment paperwork and eligibility rules that are difficult to interpret. Immigrant children may also face xenophobia and discrimination in health care and educational settings, and their families may have limited local financial and social supports to help them navigate these challenges. Collectively, these factors can generate and perpetuate inequities in child health outcomes.

Community health workers (CHWs) are trustworthy individuals who come from the communities they serve and often share a background, demographic characteristics, and lived experiences with patients and families. CHW programs have been shown to improve families’ ability to navigate the healthcare system, communication with medical teams, and satisfaction with medical care.¹ These programs can also improve chronic disease management and reduce acute care utilization for both children and adults with chronic conditions.^2,3 Because CHWs work at the intersection of health systems and the surrounding communities, they are an ideal workforce for supporting immigrant families. CHWs can provide culturally and linguistically concordant health education, patient navigation, social support, assistance connecting with benefit programs and community resources, and individual and community-level advocacy.

Designing Effective CHW Programs for Children in Immigrant Families

To develop effective CHW interventions for children in immigrant families, health systems should partner with community-based organizations serving their target population and immigrants and refugees with lived experience navigating health and social service systems, including any existing CHWs from immigrant communities. CHWs should be recruited from the communities they will serve, and recruitment should be based on character traits, including compassion and empathy.⁴ Once hired, CHWs should complete structured, standardized training focused on effective communication, motivational interviewing, understanding health and social service systems, and navigating the local landscape of resources available to immigrant families.⁵ CHWs must be provided with adequate compensation and appropriate supervision and support, as well as with opportunities for career growth and advancement. CHW programs should be evaluated rigorously, including with randomized controlled trials or quasi-experimental studies when possible, with a focus on ensuring they are supporting families and meeting their stated goals. In Table 1, we highlight several examples of CHW programs serving immigrant children and adults.

Table 1.

Community Health Worker Programs Serving Immigrant and Refugee Children and Adults

Program and Location	Brief Program Description and Outcomes Reported
Family Bridge Program1 Seattle, WA	A trained bilingual, bicultural former interpreter was hired and trained as a Family Bridge guide for children in immigrant families, among others, who were hospitalized in the pediatric inpatient setting. Program elements included orientation to the hospital and medical team, assessment of unmet social needs, a communication and cultural preference assessment, communication coaching for the parent or caregiver, and emotional support delivered through frequent check-ins. Caregivers participating in the program reported feeling supported, improved communication, and increased knowledge of the health system and of their child’s care.
Health Focal Points9 Philadelphia, PA	Bilingual adult refugees from the Bhutanese community were hired and trained as patient navigators, completing a 30-hour curriculum focused on navigating medical and safety net systems. Patient navigators assisted other Bhutanese refugees with a range of tasks including applying for health insurance, scheduling medical appointments, and applying for benefits. In this small pilot study, clients were less likely to miss or forgo care due to language and navigation barriers and were more likely to report high levels of patient activation after the intervention. Patient navigators felt they gained skills they could use to assist their own family members and friends and that their experience with the program contributed positively to their own professional development.
Refugee Community Health Worker Initiative10 Providence, RI	Eight multilingual refugees speaking a range of languages, including Arabic, Swahili, and Somali, were recruited and trained as CHWs to serve refugees from Iraq, the Democratic Republic of the Congo, and Somalia. CHWs completed 30 hours of paid, structured training, with a focus on motivational interviewing, community assessment and social service navigation, and health system navigation. CHWs were then matched with recently arrived refugee families, with a plan to work with them longitudinally during their first six months in the United States. This pilot study reported that structured training improved CHW’s knowledge of key health system and social service navigation topics but did not report on program outcomes for enrolled families.
Individualized Management for Patient-Centered Targets (IMPaCT)3,8 Philadelphia, PA	IMPaCT is a standardized CHW intervention developed using a theory-based approach informed by participatory action research. IMPaCT CHWs were recruited based on key character traits, including empathy. CHWs worked with patients to set individualized goals, provide longitudinal support tailored to these goals, and then helped connect them with long-term supports at the end of the intervention. IMPaCT reduced hospitalizations, improved patients’ access to preventive care, enhanced perceived quality of care, and generated a positive return on investment. Although IMPaCT was originally implemented in a predominantly low-income, English-speaking population in Philadelphia, the program has since been adapted and implemented at 50 organizations across 20 states, successfully serving many immigrant patients, including patients with a primary language other than English.

Ensuring CHW program sustainability is also critically important, particularly when members of an immigrant or refugee community are employed as CHWs. Many CHW programs are funded through short-term grants, which can result in interrupted services for families and inconsistent employment for CHWs when funding periods end. Organizations implementing CHW programs must therefore prioritize evaluating their impact on patients’ health care use and expenditures and assessing for potential cost savings, as these data could help build the business case for health systems to invest in and sustain these programs. In addition, there is an urgent need for policies and payment models that support sustainable CHW program implementation and reimbursement.

Policies and Payment Models to Support CHW Programs for Children in Immigrant Families

Medicaid reimbursement for services provided by CHWs represents one promising approach to financing and sustaining CHW programs. In 2014, in response to the Patient Protection and Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) released regulations allowing state Medicaid agencies to reimburse for preventative services provided by CHWs through Section 1115 waivers or state plan amendments. As of 2021, 21 states have started providing Medicaid reimbursement for CHW services, although many of these states cover only a limited range of CHW services or limit services to specific populations.⁶ State Medicaid agencies could better support CHW programs serving immigrant families by adopting state plan amendments or 1115 waivers that allow for CHW reimbursement and by explicitly defining immigrant children as a target population for their existing CHW models.

Unfortunately, CHW programs serving children in immigrant families cannot rely on Medicaid reimbursement alone, as many of these children are barred from accessing non-emergency Medicaid and Children’s Health Insurance Program (CHIP) benefits due to their immigration status. Although 11 states and the District of Columbia have enacted state-funded programs providing Medicaid or CHIP to some or all unauthorized immigrant children, more than 600,000 foreign-born children across the United States, including both unauthorized immigrants and permanent residents with fewer than five years in permanent resident status, are still not eligible to receive Medicaid or CHIP benefits.⁷ Expanding Medicaid and CHIP coverage for immigrant children, regardless of immigration status, could help ensure they have access to needed medical care and to important social supports like CHW programs. Providing Medicaid coverage for immigrant women during and after pregnancy, regardless of immigration status, could help ensure optimal birth outcomes for their children and support dyadic CHW programs serving pregnant and postpartum women along with their infants.

As payers across the United States shift towards value-based care models, there may also be opportunities for health systems to fund CHW programs as a strategy for improving population health. Non-profit hospitals could invest some of their required community benefit spending in building and sustaining CHW programs, particularly programs serving populations at risk for inequitable exclusion from care, like children in immigrant families. Studies have found that standardized CHW interventions for children and adults with chronic conditions can generate a positive return on investment, due to reductions in acute care utilization among enrolled patients.^2,8 Recent federal policies could help support these efforts; the 2021 American Rescue Plan Act included grant funding for academic health centers and community-based organizations to use in hiring, training, and deploying CHWs, and the Building a Sustainable Workforce for Health Communities Act, which is currently under consideration in the US Senate, proposes extending and expanding this program beyond the pandemic.

Children in immigrant families can face a variety of barriers to accessing the health care and public health services they need to thrive, and CHWs represent a key workforce for supporting these children and their families. By implementing well-designed, effective CHW programs and supporting policies and payment models that ensure program sustainability, payers, policymakers, and health systems can help promote equitable health outcomes for immigrant children in the United States.