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Empowering Community Health Workers to Advance Health Equity ASTHO, Association of State and Territorial Health Officials, community health workers, health equity, covid-19, health inequities, public health infrastructure, public health, public health professionals, public health workforce, healthcare system, advancing health equity, contact tracer, testing treatment, local health department, government agencies, community engagement, advancing equity, advancing equity grant, health and human services, social determinants of health, community partnerships, marketing and outreach, sustainable funding, health outcomes, health department Keon Lewis, Karla Granado, Yoann Sophie Antoine Jean-Felix ASTHO | The importance of recognizing the critical impact of community health workers (CHWs) in advancing health equity, sustaining their partnership with local health departments, and setting them up for success by implementing sustainable funding sources and employing the CHW settings continuum framework. The COVID-19 pandemic exposed the health inequities and deficiencies in our public health infrastructure that leave many communities behind. To close the health equity gap and meet the challenges ahead, public health professionals must institutionalize the role of community health workers (CHWs) within the healthcare system and public health workforce. Doing so will take recognizing the critical impact of CHWs and equipping them with the necessary tools for continued success and advancing health equity. Recognizing the Impact of Community Health Workers in the Public Health Workforce Pandemic and Beyond During the peak of the pandemic, local health departments employed CHWs as contact tracers, health educators, and care navigators for individuals diagnosed with COVID-19. CHWs promoted and increased access to testing, treatment, and vaccination. At a time when there was a sense of mistrust towards government agencies and the COVID-19 vaccine, CHWs also educated their communities. As the pandemic continues to subside, local health departments must sustain their partnership with CHWs to close the health equity gap and build a relationship with the communities they serve—thereby enhancing trust and a sense of belonging among residents. With proper training and sustained funding, CHWs will be crucial in bridging the gap between government agencies and promoting community engagement on issues other than COVID-19. Case Study: Advancing Equity Grant When the CDC (Centers for Disease Control) announced its two-year $2.25 billion Advancing Equity Grant (AA466), the funds addressed COVID-19-related health disparities and advanced health equity. One central component of achieving the established deliverables of the grant was assessing participating agencies' ability to expand their capacity to serve historically marginalized populations. The North Carolina Department of Health and Human Services was fortunate to receive $39,638,025 in AA466 funding to distribute to 57 participating agencies for joining this worthwhile mission. As one of the 57 recipients, the Cabarrus Health Alliance (CHA) utilized CHWs as trusted liaisons with lived and learned experiences to advance the organizational strategic plan by addressing the social determinants of health. By adopting a deployment model centered on Public Health 3.0, the CHWs effectively launched a referral program that helped close accessibility gaps by improving communication methods, expanding community partnerships, and leveraging technology. Results from satisfactory surveys and client-reported demographics demonstrated that of the nearly 3,000 community stakeholders who served from 2021 to 2023, 68.4% identified with the organization’s priority population. The outcome was immediate improvements in accessibility gaps for county focal areas such as food insecurity, housing instability, unemployment, healthcare access, and transportation. Recognizing the rapid impact of the referral program, CHA implemented a marketing and outreach strategy designed for public viewing and conference platforms to highlight its critical role in strengthening the public health infrastructure. Setting Community Health Workers Up for Success Implementing Sustainable Funding Sources As evidenced by the case study above, CHWs bring invaluable skill sets and experiences that can help achieve public health goals and advance health equity. However, they are undervalued for their contributions to improving health outcomes. Research shows that nearly half of health outcomes can be traced back to one’s zip code and social determinants of health. In Nov. 2023, the White House released the first-ever U.S. Playbook to Address Social Determinants of Health, which lays the foundation for agencies and organizations to provide a holistic approach to health by acknowledging and addressing social and economic conditions that affect well-being. CHWs will be the backbone of these efforts, as they bridge healthcare and social care systems by screening for social determinants of health and connecting individuals to social support—making it easier for patients or community members to navigate complex systems. To continue to support CHWs, there must be broad implementation of sustainable funding sources such as reimbursing CHW services at the Medicaid level. In a survey conducted among employers of CHWs in Texas, only 27% stated that their organization received funding from the Centers for Medicaid and Medicare Services, with 25% not receiving any federal funding. Texas is one of many states that will begin to require managed care organizations to reimburse for CHW services. As of Jan. 2024, only 24 states had reimbursement mechanisms for CHW services through managed care organizations, the 1115 demonstration projects, or Medicaid state plan amendments. Employing the CHW Settings Continuum Framework The Community Health Worker Core Consensus (C3) Project provides a setting continuum framework that highlights how a CHW might be employed in a community or clinical setting and, regardless, their role is consistent and rooted in community advocacy and support. Providing CHWs with training tailored to their community and the setting in which they are employed is crucial to their success. CHWs can be integrated at the local health department level, creating a sense of belonging among community members and removing fear of communicating with a government agency. The C3 Project recommends 10 core skills and competencies, from advocacy to communication, research, and evaluation. While CHWs already have a wealth of knowledge about their communities, their impact strengthens when equipped with the proper training to advocate for their community successfully and support long-lasting changes. Conclusion CHWs are vital to the success of public health efforts. They usually have shared lived experiences with the people and communities they serve, which creates a connection essential to advancing equity—as community members rely on individuals, they know they can trust to make informed decisions about their health. Ultimately, CHWs foster stronger relationships between community members, community organizations, local health departments, and healthcare organizations, which are essential to rebuilding trust that historically harmful and racist practices in the public health and healthcare field destroyed. As such, investing in CHWs as the heart of our public health workforce will help to eliminate inequities in health outcomes. website yes

This brief examines the ways states can support certification for community health workers.

Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

States and territories have broad powers to protect public health and safety, including powers to prevent and control the spread of communicable disease typically exercised by state and territorial health departments. This authority is an essential tool in the fight to keep the public safe and healthy.

Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—we are focusing this week on mental and behavioral health as well as supporting the public health workforce.

Infusing Diversity, Equity, and Inclusion Into State Public Health Agencies: Perspectives from Connecticut, New York, and Tennessee Association of State and Territorial Health Officials, diversity equity inclusion, public health, public health agencies, connecticut and new York, tennessee and new York, public health workforce, equitable access to care, health equity, access to care, share resources, diverse executives, delph scholars, leadership development, implement dei, health agencies, office of multicultural health equity, advisory council, racial equity, human rights, health and mental hygiene, board of health, anti racism, department of health, addressing dei, health disparities, political landscape Samia Hussein, Erika Kirtz, Jannae Parrott ASTHO | DELPH Scholars share insights on creating an inclusive and equitable workplace in public health agencies from Connecticut, New York, and Tennessee perspectives. A diverse public health workforce is essential for organizations to offer equitable access to care and address the many social and political factors affecting health. Public health agencies are most robust when they mirror the diversity of the communities they serve, as this enables them to access and share resources with the community and other stakeholders more easily through established connections. Therefore, infusing Diversity, Equity, and inclusion (DEI) into multiple levels of state and local public health agencies is vital. In a LinkedIn Study, 76% of employees indicated that diversity is essential when considering a job, and 80% of survey respondents indicated they want to work for a company that values diversity. With the recent resignation wave hitting many state and local public health agencies, the need for authentic attraction of new employees who share our DEI values is more urgent than ever. It is time for public health practitioners to transform the systems to be more inclusive and structured to provide the necessary resources and interventions to all individuals, especially the most vulnerable. As Diverse Executives Leading in Public Health (DELPH) Scholars, we value this DEI conversation centered around equity within the workplace. Our leadership development program has allowed us to connect with others working on this same effort nationwide. Together, we have learned valuable lessons as we implement DEI at our health agencies and are eager to share them with you. This collective effort and shared purpose drive us in our DEI journey. State Perspectives on Addressing DEI Connecticut: Samia Hussein The Office of Multicultural Health Equity (OMHE) was established in 1996 as an appointed office by the then Commissioner to create health equity programs and initiatives that address our staff and client needs, including establishing our Statewide Multicultural Advisory Council (MCAC). Recently, in Connecticut, the Commission on Human Rights and Opportunities and the Commission on Racial Equity in Public Health co-hosted a statewide symposium titled “Cementing Equity in State Government” that launched the results of two fundamental equity studies across the state. The studies are a result of legislation passed declaring racism a public health crisis. The first step in our DEI journey was to ensure a foundation of definitions, terms, and a safe space for dialogue around shared experiences, which can lead to culture change. This was accomplished through buy-in from leadership by consulting with a full-service DEI agency, Kaleidoscope Group, based in Chicago. The Commissioner, Executive Leadership Team, and Union Leadership collaborated in offering this mandatory full-day DEI training to our entire agency (~3400 staff). OMHE and MCAC create a shared three-year strategic plan that is a vehicle for making a substantial DEI impact (e.g., reviewing health inequities) and provides recommendations for the Commissioner through programs/initiatives and policy changes. It is imperative to collaborate with multiple internal and external stakeholders to have a pulse on DEI issues. This existing infrastructure allowed OMHE to oversee this training mandate and continue advancing DEI programs statewide. Our preliminary data for DEI training has shown that nearly 80% of staff reported the training as a worthwhile investment, and 82.1% strongly agree that they will apply the knowledge and skills learned from the training at their workplace. We continue to look at client data points for behavioral health inequities and address DEI concerns collaboratively. New York: Jannae Parrott The New York City Department of Health and Mental Hygiene (DOHMH) has embraced a proactive and inclusive strategy to tackle DEI by prioritizing integrating health equity and anti-racism throughout the agency. This work is primarily supported and driven by the New York City Board of Health resolution declaring racism a public health crisis. At DOHMH, the first step was to launch an agency-wide initiative to empower staff with the knowledge and tools to effectively address racial health disparities and enhance health outcomes for all New Yorkers. This initiative involves educating and training staff on how racism and other oppressive systems can impact healthcare, analyzing how racism may have influenced our past work, establishing new policies to mitigate such influences, and collaborating with local communities to explore additional strategies for combating systemic injustice. DOHMH will soon launch a new data equity skills training course to engage staff at all levels in applying practical data equity skills. Its objectives include fostering awareness of the importance of data equity, providing tools and training for people who work with data to enhance equity in data practices, and offering resources for staff involved in data-informed decision-making. Additionally, DOHMH has initiated comprehensive internal reforms aimed at dismantling silos and modernizing our data systems. This transformative process enables the agency to advance the linkage of public health, healthcare, and social service data, ultimately enhancing our understanding and efforts to improve population health. Tennessee: Erika Kirtz The Tennessee Department of Health (TDH) has been strategic in its approach to addressing DEI in the state. We have shifted our language to focus on eliminating disparities, which is the central focus of our equity work. A key priority is overcoming limitations in our data and surveillance systems to detect disparities in vulnerable populations better. Offices within TDH are linking multiple datasets to gather demographics and risk factors to understand how to serve the populations best. For example, the Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) program in TDH has implemented processes to link surveillance datasets to secondary data sources (inpatient and outpatient hospital discharge data, etc.) to gather information on demographics that aid in the understanding of risk factors associated with the acquisition of certain multi-drug resistant organisms. The findings from this data linkage allow the team to pinpoint risk factors that can be overcome with targeted interventions. We have also begun breaking down silos to collaborate across offices and divisions on the various equity-related initiatives. The overall goal is to transform the current systems to operate through an equity lens, which will be standard practice throughout TDH. There is also a push to continue diversifying the workforce by actively recruiting interns and staff from local Historically Black Colleges and Universities (HBCUs) and other institutions with minority populations. The TDH’s central office is in Nashville, TN, near two prominent HBCUs: Tennessee State University and Meharry Medical College. TDH staff have attended job fairs and specifically sent notifications to faculty at these institutions to help recruit for internships, fellowships, and employment. TDH’s approach is to remove the negative stigma around the term equity, which allows our department to continue serving the people of Tennessee. Call to Action The work of DEI can be challenging, and there is no specific blueprint for addressing it. However, we want to share key takeaways and lessons from this process. It is imperative to have leadership buy-in and support early in the process. The work will not be prioritized if it does not start with the Commissioner and the Executive Leadership Team. Also, this process is not one-size-fits-all and requires a clear vision. The first step is establishing a clear baseline of health equity measures to assess progress continuously. Guidance from the Robert Wood Johnson Foundation can assist in measuring equity in your state. Review what other agencies are doing to adopt best practices that can be applied to your agency. Please note that this process is not for one person and requires a diverse and dedicated team to champion this work. This process requires financial investment through consulting, training, or hiring core staff. There will be many people who are resistant to change or critical of this work. Remember the why and the importance of these practices. Use data to support decisions and stick to the strategies or action plans that lead to success. Also, identify key partners committed to this work and use each other to overcome challenges. Understanding the political landscape and concerns these initiatives might evoke is vital. These concerns can be overcome by being proactive in communicating the benefits and importance of this work, building relationships and awareness of social inequities, and inviting all employees to play a role in advocating for the advancement of DEI. When considering diversity and inclusion, we must think beyond gender, race, and ethnicity. Consider understanding the makeup of the diverse communities served. Expand upon client and staff demographic data. Even if the Federal and State

The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: public health authority, immunization, data privacy and modernization, public health workforce, and health equity.