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In-depth analysis on state health policy surrounding the public health workforce. This is part of ASTHO's annual legislative prospectus series.

Learn how territorial and freely associated state health agencies can support community health workers and their vital work in this brief.

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

Three ways policymakers are addressing access to care are through telehealth, safety net and emergency services, and adjusted reimbursement rates to Medicaid-enrolled providers.

Why Kentucky Chose to Pursue Community Health Worker Certification astho, association of state and territorial health officials, certification program, kentucky department for public health, community health worker, public health workforce, kentucky association of community health workers, national association of community health workers, health affairs, cultural competence of service, professional certificate, community health workers chws, department for public health, range of activities, kentucky department for public, chronic disease, centers for disease control and prevention, public health worker, builds individual and community, covid-19 pandemic, health care, public health Shelby Rowell ASTHO | Kentucky shares how they collaborated with the CHW workforce to develop a CHW certification process. Community health workers (CHWs) play a critical role in improving public health outcomes by serving as a bridge between systems of care and the communities they serve. They are often trusted members of the communities they work in and can provide culturally appropriate and linguistically accessible health services and information to individuals who may have limited access to traditional health care settings. Many states are considering certifying CHWs to ensure they have the necessary training and skills to provide high-quality care. Given every jurisdiction’s varied needs and policies, determining whether to pursue CHW certification should be discussed state-by-state. Kentucky and Louisiana are examples of states that have taken two different approaches to supporting the CHW workforce. While Louisiana chose not to pursue CHW certification, Kentucky has opted to develop a CHW certification program. ASTHO spoke with Laura Eirich, Kentucky Office of Community Health Workers administrator, to discuss the state’s decision-making process behind implementing CHW certification and how the Kentucky Office of CHWs has maintained shared decision-making with their state’s CHW workforce. When did Kentucky develop a CHW program within its state health department? Kentucky has funded several programs to deploy CHWs across the state, including the first Kentucky CHW program in 1994 called Kentucky Homeplace and a CHW program that served migrant farm workers with outreach and case management services. In 2014, the Kentucky Department for Public Health (KDPH) dedicated part-time staff to form a CHW Advisory Workgroup, which established three sub-committees (Certification, Curriculum, and Evaluation) that met monthly to draft a state CHW certification manual, core competencies, and a code of ethics. The work group brings together CHWs, representatives from state and local public health departments, federally qualified health centers, community-based organizations, universities, and other organizations who want to employ or otherwise advance the CHW workforce. By 2017, KDPH formed the Kentucky Office of Community Health Workers (KOCHW) and hired an administrator. What was the process for determining if Kentucky would have a certification program? The CHW Advisory Workgroup held formal discussions regarding a potential certification program beginning in 2014. The workgroup reviewed other states’ CHW training curricula and certification processes to develop Kentucky’s draft core competencies. In 2018 and 2019, Kentucky participated in a technical assistance project with ASTHO to renew its focus on CHW efforts. With ASTHO’s assistance, Kentucky conducted a statewide survey of CHWs to gather insight into attitudes towards the CHW profession and certification, which showed widespread interest in pursuing certification. Nearly half of the respondents identified as CHWs. Between 2019 and 2022, KOCHW launched an approval process for CHW training organizations and instructors to be certified, as well as an official Continuing Education Unit approval process. In 2022, Kentucky’s legislature passed legislation that outlined statutory requirements for CHW certification, continuing education, certification renewal, and associated duties of KDPH. Kentucky Administrative Regulation authorized KDPH to promulgate administrative regulations for CHW certification. How did Kentucky work with CHW groups to develop a CHW certification process? Kentucky CHWs were initial advocates for pursuing certification. They were instrumental in helping with outreach, conducting research, and drafting a certification manual, policies, code of ethics, and core competencies. One of the top priorities of KOCHW was to ensure that the certification process was developed in partnership with Kentucky CHWs so that any resulting certification program would effectively meet their needs. The launch of the Kentucky Association of Community Health Workers (KYACHW) provided an opportunity to connect and collaborate with more CHWs in the state. Staff from KOCHW have attended association meetings across the state to share updates and request KYACHW members to approve, deny, or suggest alternative wording or changes. For instance, we shared each iteration of the draft certification manual in-person at these KYACHW meetings and virtually to increase opportunities for feedback. What were the benefits of certification that you identified in your discussions? The most significant benefits and drivers of certification include the following: Increased recognition and respect for the profession. Increased confidence for individual CHWs. Opportunities for professional growth. Potential for future Medicaid reimbursement and financial sustainability of the profession. However, it is important to note that the Centers for Medicare & Medicaid Services does not require certification as a requirement for Medicaid reimbursement; this decision is made on a state-by-state basis. What measures do you take to ensure all interested CHWs can participate in your certification program? Each year, KOCHW sends a survey to all known CHWs, providing an anonymous space for feedback. All formal and informal CHW feedback is cataloged, and KOCHW periodically holds discussions to dive deeper into concerns or issues. When we make changes to the CHW certification manual and process, KOCHW is transparent about the reasoning behind the changes. It is worth noting that CHWs had (and currently have) the power to approve or reject any proposed changes. Soliciting and incorporating changes based on CHW feedback helps demonstrate that certification is for all CHWs. It’s important for CHWs to know that this is their certification and their voice matters. For example, KDPH and the CHW Advisory Workgroup suggested charging a fee for certification and renewal. KYACHW members felt it was important to assess a fee, but they decided on the price. To avoid creating a financial barrier, a fee of $50 for initial certification and $25 for renewal was decided upon by CHWs. These fees are now in the Kentucky statute. One way to make certification more accessible was to change the GED/High School Diploma requirement to a “strong recommendation,” which allows those without formal degrees to become certified. Additionally, KOCHW does not perform background checks on applicants pursuing CHW certification, which allows those who have experience with the justice system to use that lived experience to assist others. Did you communicate with states with existing CHW certification programs to inform your decision? Yes! We met with representatives of several states, including Massachusetts, Texas, and Connecticut. We also learned from state and national experts, such as Carl Rush, MRP, and were fortunate to participate in two ASTHO learning communities supported by HRSA. These projects were integral to understanding the national CHW landscape, identifying best practices, and formalizing the process in Kentucky. What advice would you give to states and territories currently assessing if a certification program is right for them? Talk to your CHWs! Initiating and building relationships with existing programs and associations is essential to ensuring CHW voices are heard. Take advantage of the existing plethora of resources! Talk to states and territories that have opted in and out of pursuing certification. The beauty of CHW work is that each state and territory is different, and there is no wrong path. Consult subject matter experts, such as ASTHO and the National Association of Community Health Workers (NACHW) who have a wealth of knowledge and can help convene groups, identify goals, and formalize your process. State comments have been edited for length and clarity. 2 UD3OA22890-10-00 website yes

When rural hospitals close, it increases the distance people must travel for essential healthcare services. The COVID-19 pandemic has highlighted and magnified the factors leading to rural hospital closures across the country. Many healthcare facilities suspended elective procedures to conserve critically needed personal protective equipment and reduce the risk of exposure to COVID-19 by patients and hospital staff. For many rural hospitals, however, the suspension of elective procedures with the reduced the use of non-urgent services by apprehensive patients meant a loss of revenue and the furloughed healthcare staff. Since the onset of the COVID-19 pandemic, approximately half of all rural hospitals are experiencing negative operating margins due to reduced outpatient revenue. The rate increases in states that have not expanded Medicaid. Unfortunately, these kinds of challenges are not new to rural hospitals.

On this episode, graduates of ASTHO’s Essentials of Leadership and Management share how the program has improved their work and helped them grow as leaders.

States Stay Prepared by Supporting the Public Health Workforce Margaret Nilz, Christina Severin Learn how states use policy to support emergency preparedness and bolster the public health workforce. Public health — particularly public health preparedness — continues to experience workforce shortages, driven by longstanding systemic challenges such as chronic underfunding, high turnover, limited recruitment, and an aging workforce. While some jurisdictions report increased capacity to hire and train public health staff in recent years, they often rely on short-term or temporary funding streams, which limit long-term sustainability. State, local, tribal, and territorial health agencies have varying capacities to respond to public health emergencies, particularly in rural and underserved communities. Because a limited workforce can inhibit emergency preparedness efforts, jurisdictions recognize the importance of cultivating a resilient public health preparedness workforce to respond to future emergencies. In recent years, jurisdictions have pursued several policy interventions to bolster the public health preparedness workforce such as legislation supporting front-line clinical staff and first responders, and rulemaking and other executive powers to provide structural and financial support to critical personnel. Legislative Efforts Legislative efforts to increase benefits and support for health care and public health workers can help address the root causes of workforce challenges and lay the groundwork for sustainable, long-term investment in public health preparedness. Laws that establish standards and expectations for the preparedness workforce, including expansions of benefits or additional training, support workforce growth and retention. Since 2024, several jurisdictions expanded mental health benefits and related support for first responders and other preparedness personnel. Both Alaska (SB 103) and California (AB 2859) enacted legislation that allows peer support programs for emergency service personnel. In Alaska, the bill creates programs for entities such as law enforcement agencies, firefighters, and emergency dispatchers, while California’s bill creates programs to serve a variety of health care providers involved in emergency medical care, including physicians, nurses, paramedics, and emergency medical technicians (EMTs). Utah enacted HB 378, which requires the Department of Public Safety to annually distribute information about its critical incident stress management program to first responder agencies. The bill also requires first responder agencies to annually notify employees about the availability of mental health resources, including periodic screenings for employees and continued support for retired or separated first responders and their spouses. On a broader scale, Hawaii SB 3279 recently established a well-being project tasked with mental health trainings and support for several community organizations, including first responders, hospitals, and medical staff. In Washington, HB 2311 directs the state’s Criminal Justice Training Commission to develop resources for first responder wellness, including a peer support network for active and retired first responders and their families. States have also enacted legislation expanding traditional employment-related benefits, including Colorado (HB 24-1219), which expanded certain health benefits for firefighters to include part-time and volunteer firefighters, and Idaho HB 55, which allows retired public employees to volunteer with public employers without it being considered reemployment. In addition, Georgia HB 451 requires state and local entities to provide disability benefits for first responders who experience occupational or volunteer-related post-traumatic stress disorder. Finally, several jurisdictions enacted legislation to support education and training for their public health and health care workforce. For example, Kentucky HB 484 established an emergency medical service education grant program that provides tuition support for students pursuing paramedic certification, wage reimbursement to ambulance providers whose employees pursue certification, and funding for institutions planning to offer EMT, advanced EMT, and paramedic programs. Oklahoma HB 1696 expands eligibility for the Oklahoma Medical Loan Repayment program to include certified nurse practitioners. Two new laws in Puerto Rico require police officers with the Puerto Rico Police Bureau to be certified in first aid or immediate rescue (PC 0859) and adds seminars on sign language, suicide prevention, and conflict mediation to the Bureau’s continuing education training (PC 0543). Other Policy Levers: Beyond the Legislature Jurisdictions can also use non-legislative policy tools to enhance workforce capacity in public health preparedness. This includes rulemaking, where executive agencies use existing legal authority to adopt or amend regulations. Regulations have the force of law and can help support the public health workforce by establishing licensure standards, training requirements, and operational protocols. Wisconsin, following the enactment of AB 576 in 2024, is developing rules to establish a program for peer support and critical stress management teams in the state. And Utah recently adopted rules for its first responder mental health services grant, which helps these professionals pursue a degree or certification as a mental health provider. Government agencies can also leverage grants and contracts to fund and otherwise direct workforce development initiatives, support training programs, and expand capacity in targeted areas. Jurisdictions can strategically direct funds to address skill gaps and assist local, state, tribal, and territorial agencies build a more resilient workforce. One example of this is in Michigan, where in 2024 the state health agency issued a request for grant proposals to award up to $9 million in EMS workforce grants, building on similar awards to address EMS shortages in 2023. Executive orders are another policy option for jurisdictions to consider as they explore different pathways to workforce sustainability. Executive orders are issued by a jurisdiction’s chief executive (often the governor) and direct certain policy actions or activities. Generally, the power to issue an executive order comes from existing law or a jurisdiction’s constitution and, in most cases, does not require legislative approval or review. Several states have leveraged executive orders to advance the public health workforce and support preparedness activities more specifically. For example, Vermont and New Jersey have recently used executive orders to create or extend advisory councils on issues pertinent to public health preparedness. In 2024, Virginia’s governor issued an executive order formalizing the Office of First Responder Wellness, which provides training, counseling, and other resources to first responders in Virginia. In 2023, the governor of Maryland issued an executive order establishing a State of Preparedness directive if there is a risk of public emergency, and the actions state agencies must undertake to promote improved coordination and hazard planning. Key Takeaways Addressing public health emergency preparedness workforce challenges demands strategic, long-term policy solutions, but several implementation options are available. Health agencies can pursue a variety of policy interventions to support and prepare their public health workforce for future emergencies. ASTHO will continue to monitor this important issue and provide updates as appropriate. article yes

Public Health Leadership Starts in the Classroom Public Health Leadership Starts in the Classroom Ashley Nanthavongsa-Mosley Learn how states are integrating public health education into K-12 schools and building pathways for future public health professionals. Governmental public health agencies across the country are showing interest in integrating public health concepts into K-12 education. This interest has been driven by a growing realization that students should understand the importance of public health work early and see it as a viable and meaningful career option. In early 2025, ASTHO members asked how public health agencies were integrating public health into K-12 schools. This interest prompted ASTHO to convene a workshop series, through which it became clear that states are not only interested in the topic — they are already doing innovative and impactful work within their jurisdictions. Below are key examples and lessons learned from states that participated in these discussions and takeaways that may help other organizations exploring similar efforts. Classroom Partnerships in Action Montana: Classroom-Ready Public Health Curriculum Montana is leveraging funding from the Public Health Infrastructure Grant (PHIG) to collaborate with the Montana Public Health Training Center to bring public health concepts directly into classrooms through a comprehensive curriculum for teachers. The curriculum is ready to use with worksheets and answer keys. The materials fit into teachers’ busy schedules and make it easier to introduce public health topics in the classroom. The curriculum has already been accessed by more than 130 people across 37 states, one U.S. territory, and eight countries. Also, with support from the Montana Healthcare Foundation, the training center is developing a toolkit to help local health departments collaborate with schools and host community health fairs that connect students directly with public health professionals. Kentucky: Career Exposure Through the Health Occupations Students of America (HOSA) With support from PHIG, Kentucky is leveraging existing student career organizations, such as HOSA, to introduce students to public health concepts and careers. At past HOSA conferences, students participated in a simulated outbreak activity that exposed them to epidemiology, public health nursing, environmental health, the public health laboratory, and public health career pathways in an engaging, hands-on way. New Jersey: Youth-Led Immunization Campaigns New Jersey hosts the Protect Me With 3+ annual poster and video contest, a joint initiative between the Partnership for Maternal and Child Health of Northern New Jersey and the New Jersey Department of Health. The statewide initiative aims to raise awareness on the importance of adolescent immunizations among preteens, teens, and parents, increase vaccination rates for several important vaccines, and, most importantly, empower students to use their creativity and voice to spread the important message of getting vaccinated. The contest invites New Jersey students in grades 5-12 to display their creativity by designing a poster or a 30-second video highlighting the importance of vaccines for themselves, their families, and their communities. Over the years, the contest has proven to be a successful and impactful model for peer-to-peer education around immunization. Connecticut: Multiple Entry Points into Public Health Through PHIG funding, Connecticut builds sustainable, credit-bearing pathways that introduce students to public health and connects them to college and career opportunities. Through the CT Science Olympiad, the Connecticut Department of Public Health sponsors the “Disease Detectives” event, giving middle and high school students hands-on experience with outbreak investigation and direct exposure to public health professionals. Over the past three years, 188 students from 35 schools have participated. Connecticut also expands access to college-level coursework. In partnership with the University of Connecticut, high school teachers are trained to deliver Public Health 101 through Early College Experience, allowing students to earn transferable college credit while still in high school. Beginning in Fall 2026, students from participating schools can further their studies through Dual Enrollment with Connecticut State Community College, where they will have access to undergraduate public health courses. Washington: Teacher Licensure and Data-Driven Curriculum Washington state focuses on supporting educators while grounding public health education in real-world data. K-8 teachers are required to complete STEM hours for licensure renewal, and teams are exploring ways to integrate youth engagement into this process. With support from the Educational Service District, Washington created an asynchronous professional development model teacher training program on using Washington Tracking Network data in classrooms. This program provides licensure clock hours while helping educators incorporate local public health concepts and data into instruction. Cross-Cutting Lessons from States Across jurisdictions, several common strategies consistently supported successful efforts to introduce students to public health and build early career awareness. Build on Existing School Programs and Structures Many successful initiatives did not require creating entirely new programs. Public health agencies integrated public health concepts into existing school activities, competitions, and career organizations that already have student participation and administrative support. Agencies interested in this work can start with established programs to make it easier to introduce public health concepts while minimizing additional demands on teachers and school administrators. Co-Create Curriculum with Educators Programs are more likely to succeed when teachers are involved in the early design process. Educators understand their classroom needs, curriculum standards, time constraints, and their input ensures that materials are practical and usable. Several agencies emphasized the value of developing curriculum collaboratively with teachers and testing materials in classrooms before broader rollout. This pilot, revise, scale approach helps refine lessons, ensures alignment with educations standards, and increases the likeliness that teachers will adopt the materials. Elevate Youth Voice and Peer Engagement Agencies can get students more engaged in public health work when they can create and share their own public health messages. Youth-led campaigns, contests, and peer education initiatives allow students to translate what they learned into messages for their peers and community members. Agencies noted peer-to-peer approaches such as student-created posters, videos, or presentations can be effective for topics like prevention, immunization, and community health awareness. These activities not only reinforce public health knowledge but also help students develop communication and leadership skills. Support Teachers Through Professional Development and Data Tools Teachers are more likely to incorporate public health topics into their classrooms when they receive training, resources, and incentives that align with their professional requirements. Some states support educators by offering professional development that provides continuing education or licensure renewal hours while also teaching educators how to use public health data, case studies, or state/local health examples in the classroom. Providing ready-to-use activities, datasets, and lesson plans reduces the burden on teachers while strengthening the integration of public health into classroom education. Build Sustainable Communication Channels with Schools Successful programs often relied on consistent communication channels between health agencies and education partners rather than relying on one-time outreach. Agencies built systems that allowed educators to regularly receive information about public health learning opportunities. Examples include educator newsletters, resource portals, partnerships with school districts or health districts, and coordination with state and local education networks. These systems help ensure that teachers and schools can easily learn about new curriculum resources, competitions, professional development opportunities, and student engagement activities related to public health. Keep Evaluation Simple and Actionable Agencies also emphasized the importance of evaluating K-12 public health programs in ways that are practical for schools and partners rather than complex evaluation requirements. Many use simple feedback mechanisms such as teacher surveys, student reflections, participation counts, or brief post activity questionnaires. These short feedback loops help agencies understand what worked, what needs improvement, and how programs can be refined before expanding to additional schools. Barriers and Challenges While agencies shared many promising approaches, they also identified several common challenges when working within K-12 education systems. Limited classroom time and competing priorities. Teachers often face strict curriculum requirements and limited instructional time, which can make it difficult to introduce new topics. Programs that align with existing standards or integrate into science health or career exploration courses are more likely to be adopted. Navigating school approval processes. Introducing new curriculum or programs may require approval from school district administrators or curriculum committees. Building relationships with education partners and piloting programs with a small number of schools can help build trust and demonstrate value. Resource and staffing limitations. State and local health agencies may have limited staff capacity to support ongoing school engagement. Developing reusable curriculum materials partnering with