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LeagueTLC Innovation Express
Exploring Issues,
Innovations, and New Developments with Information Technology
Professionals
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Performance-Based
Certification for Community Health Workers at City
College of San Francisco
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In 1992, regional
and California State labor market research documented an
unmet need for first-level health professionals as liaisons
between diverse, isolated communities and health and social
service systems. Community Health Workers (CHWs) have become
increasingly important in the U.S. health care system, but
their status and visibility have not kept pace with their
wider presence. While conducting a randomized regional survey,
City College of San Francisco (CCSF) department staff found
that one out of four health provider institutions employed
CHWs. Within the last 40 years, CHWs have been increasingly
incorporated into community health promotion and primary
care programs in the United States, particularly in underserved
communities.
Six Barriers to CHW Program Development
Recognizing substantial need and significant contribution,
program developers also identified six major barriers to
the wider acceptance and use of CHWs in the health workforce.
The first is a basic issue of nomenclature. The visibility
of CHW programs has been obscured by the fact that they
work under nearly 70 job titles, including community health
representative, advisor, or specialist; community health
outreach worker; public health aide; social worker assistant;
and pomotora, as well as topic specific titles, e.g. nutrition
assistant or perinatal assistant.
The obscure title and lack of definition lead to the second
longstanding barrier, the absence of a standard definition
of who community health workers are and what they do. A
third barrier to the full integration of CHWs has been the
lack of a standardized approach to education and training.
Initial surveys of programs and curriculum throughout California
and the San Francisco Bay Area found that training for CHWs
was a hodge-podge of informal programs, many workplace-based
and topic-specific. It was evident that more systematic
and consistent education was important to CHW acceptance,
use, and professional development.
A fourth barrier was the deficiency of systematic evaluation
of the CHW role, along with a demonstration of cost-effectiveness.
While the CHW field has generated a fairly large and promising
evaluative literature, studies are often not rigorously
designed, not outcomes-oriented, and not built on one another.
In a recent promising development, the Federal Health Services
Resource Administration (HRSA) made an important commitment
to evaluating the health outcomes of the CHW role.
A fifth barrier is the lack of permanent revenue sources
to institutionalize the CHW role. The regional survey found
that half of the CHW programs and positions operate on temporary
grant funding. This destabilizes the role of CHWs in general
and the careers of individual CHWs. A sixth and final identified
barrier is the reality of CHWs and their early stages of
self-organization. Although pioneering efforts at national,
regional, and state organization, including annual conferences,
are underway, they have not gained great force or momentum.
The Need for CHWs
Noting the barriers to professional and program
development, three economic, demographic, and social trends
drive the labor market demand for well-prepared community
health workers. The economic impact outlines decades of
dramatic structural and organizational transformation of
health care in the U.S. This structural change includes
such features as (a) the spread of managed care, (b) the
concurrent shift of care out of hospitals to ambulatory
care clinics and homes, with an attendant emphasis on prevention
and primary care, and (c) growing numbers of uninsured.
In the U.S., 42 million people have no health insurance;
many of these people rely on the health safety-net institutions,
which are the primary employers of CHWs.
A second trend driving demand for CHWs is a fundamental
shift in the ethnic and racial demographics of the U.S.,
a shift that is most dramatic in border states, such as
California and the southwestern region. These population
shifts are accompanied by increasing linguistic diversity.
For example, California-the most diverse state in the U.S.-is
home to more than 200 language groups. This culture and
language gap poses great challenges to a health care system
with providers who are overwhelmingly monolingual and white.
The third trend has had significant impact on labor market
demand and social implications, particularly since preventive
and primary care are increasingly emphasized as alternatives
to hospitalization. Documented research has confirmed the
ability of CHWs to provide effective preventive services,
bridge cultural and linguistic barriers to care, and help
individuals successfully navigate complex and fragmented
health and social service systems. According to this national
research, studies in the United States have demonstrated
the efficacy of using CHWs to educate populations about
health issues, increase access to prenatal care and other
preventive services, increase early cancer detection, impact
rates of immunization, decrease low birth weight and infant
mortality rates, control hypertension, and facilitate smoking
cessation. Both internationally (particularly in developing
nations) and in the U.S., the use of CHWs has also demonstrably
improved health knowledge, behaviors, and outcomes for a
wide variety of chronic conditions. In recognition of this
evidence and of the need to confront resource constraints
in health care financing, national and state entities have
called for the expansion and institutionalization of CHWs.
Albeit these trends and labor market demand for CHWs demonstrate
evidence of need, survey analysis indicated major weaknesses
in the preparation of CHWs. Project Directors recognized
that in order to meet labor force demand for CHWs, training
must develop toward standardized competencies and assessment
tools.
Certification Development
The first steps in the content development of the
CHW Certificate Program required attention to two major
issues. First, the project team focused on defining the
field of community health work and articulating the core
skills. Second, program directors developed standardized
performance indicators organized around these skills.
The program directors settled on a performance-based approach
to teaching and assessment, combined with popular education
pedagogy. The performance-based approach offers evaluation
of student work not by traditional pencil-and-paper methods,
but by demonstrated competency in necessary skills. This
is particularly appropriate for nontraditional students
who have a wealth of practical skills but weak academic
preparation. This educational approach incorporates students'
life experiences as an educational tool, deeply engaging
them and improving the retention of students from the underserved
communities in which a majority of community health workers
are needed and, in fact, work. Placing their life experiences
into a larger context enables students to gain a big-picture
understanding of the social and political determinants of
health, knowledge that is important to their care and empathy
of patients navigating the complex and changing health care
and social safety-net system. Finally, using popular education
methods, program directors have integrated a classroom forum
as part of the content activities. The classroom forum nurtures,
fosters, and values the exploration of cultural differences
as represented by the members of the class, offering hands-on
experiences for working respectfully and effectively with
ethnically and racially diverse clientele through moderated
discussion and dialogue.
The Performance-Based Curriculum in CHW
The Community Health Workers Certificate consists
of 17 semester units of credit (equivalent to 175 classroom
hours) from the City College of San Francisco. It is intended
to help working CHWs sharpen and validate their skills and
to prepare other interested community members in community
health work. Full-time students can complete the certificate
in one year. Most working students attend classes one to
two evenings per week, completing the program in three or
four semesters.
The content of the curriculum is subdivided into the core
curriculum and specialty areas. The core curriculum combines
the development of critical process competencies with instruction
in important topical and system knowledge. It is designed
to give each learner a background in essential knowledge
and attitudes and to ensure that any CHW completing the
certificate has a solid grasp of the core competencies required
for health promotion and primary health care.
The CHW curriculum builds a solid infrastructure of preparation
by focusing on process and workplace competencies. Program
research identified a set of five process competencies that
apply to all CHWs: client intake and interviewing, client
orientation to the agency, care coordination (or basic case
management), one-on-one health advising, and outreach. Although
it is not universally employed by CHWs, program directors
included the outreach competency because evidence indicated
that a significant number of CHWs were doing outreach on
a regular basis. These process competencies constitute skills
common to and required for most community health worker
positions regardless of topical focus, and this common set
of skills, knowledge, and attitudes is the nucleus of the
program.
A second element of the certificate program includes instruction
in overall leadership and work culture competencies, such
as time management, self-organization, communication, conflict
resolution, and resume writing. Program instructors have
also tested and refined a range of active learning techniques
designed to maximize the effectiveness of performance-based
learning: student-facilitated projects, small group work,
role plays, and workplace simulations.
Each community health worker also needs content knowledge.
First, CHWs must have a breadth of familiarity with common
health conditions, enabling them to know when they are interacting
with a person who requires referral to more information
and services. The CHW core program includes introductory
knowledge and referral information on fifteen topical areas.
These areas were chosen by identifying the primary topical
areas CHWs work in and integrating the results of ongoing
discussions with certificate program students and working
CHWs.
Each student also completes a one-semester internship, working
8 hours per week as a community health worker in a community-based
organization, community clinic, the Department of Public
Health, or, starting this year, a community organizing and
action project.
The program is developed so that topical content knowledge
in the core CHW competencies can be combined with specialty
certificates in particular health topic areas. As part of
building a broad community health curriculum at the community
college level, program directors have already developed
a series of specialty certificates in HIV/STD education,
drug and alcohol studies, health care interpretation, and
a related certificate for nutrition assistants. Offering
a combination of generalist and specialty certificates allows
the program to respond to the diversity of job roles across
different types of CHWs and health care organizations and
over time as the needs and characteristics of the client
population change.
Finally, the core curriculum is based upon a foundation
of knowledge of overarching policy issues as well as social,
political, and cultural determinants of health. These concerns
include topics such as managed care, primary care, multicultural
competence, Medicaid and Medicare, and immigration and welfare
policies. These issues disproportionately impact low-income,
diverse, urban communities, and are therefore critical to
helping CHWs understand the systems they work in and the
social context their communities live in. This understanding
is fundamental to prepare CHWs to be strong and effective
advocates for individual clients and their communities as
a whole.
Program Outcomes and Results
Careful annual evaluation was conducted during the
first nine academic years (1992-2001) of the CHW Certificate
Program. Three main outcomes have guided assessment of the
efficacy of the program: retention, career outcomes, and
student proficiency.
The CHW Certificate Program was explicitly designed to attract
and to maximize retention of students from the communities
in which CHWs largely work, communities often uninsured
or underinsured and, therefore, dependent on the social
safety net, as well as communities facing linguistic and
cultural barriers to health care. These students have faced
similar challenges themselves, not only in health care,
but also in the educational system. Through these experiences,
they have often been ill-served by conventional health care
and conventional education.
As intended, the program has attracted a nontraditional
student population, many of whom are poor or working poor.
A large majority (79 percent) of the program's students
have been persons of color, with 79 percent women. Unlike
the typical college student in his or her early twenties
with few obligations outside campus life, these students
are generally low-income, often in their 30s or older. Many
have both work and family responsibilities, and though most
have completed high school, they are quite likely to be
the first in their families to attend college. Many of the
students have had to address complex problems including
homelessness, drug addiction, domestic violence, and recovery.
The program is designed in ways that accommodate these aspects
of the student population. A central pedagogical issue was
the development of methods to encourage retention. In addition
to incorporating popular education pedagogy, the two most
important tools have been the use of learning teams in the
classroom and a prerequisite course to improve selection
and admissions. Between 1995 and 1998, these methods were
refined, allowing the program to successfully double class
size while maintaining retention rates of 84 percent.
Another meaningful test of the training program's efficacy
is the rate at which students who complete the program are
able to find full-time, paying jobs as CHWs, or, if they
previously worked as CHWs, the extent to which they are
promoted based on their enhanced skills and knowledge. From
1994 through 1997, post-program telephone surveys to evaluate
career outcomes were conducted one year after students completed
the core course sequence. Across these three academic years,
64 percent (n=35) of entering students were already employed
as CHWs but were seeking professional development; of these,
77 percent (n=27) received promotions. Of the 36 percent
(n=20) of students who entered without previous CHW jobs,
85 percent (n=17) obtained full-time employment as a CHW
(n=12) or became full-time students (n=5). In short, 85
percent of those surveyed reported a positive career outcome.
Respondents attributed these outcomes to their participation
in and completion of the CHW certificate.
Satisfied that a good track record of measurable success
had been established with student retention and career outcomes,
attention was turned toward developing a more sophisticated
measure of student learning. Starting with the 1997-1998
academic year, evaluative efforts focused on administering
a performance-based examination to assess student progress.
The examination involves simulating an encounter with a
standardized client in a clinic, during which students are
asked to perform certain competencies and are rated using
a detailed proficiency checklist.
Students take this exam at the beginning and again at the
end of the certificate program. Although the curriculum
has been developed as a standardized and replicable program,
having student pre-test results allows faculty to tailor
instruction specifically for the performance level of the
particular student cohort. In addition, individual students
get a clear idea of the specific skills and knowledge they
need to acquire or enhance to perform effectively as CHWs.
The pre- and post-test measures also allow program evaluators
to compare skills competency before and after students have
completed the program. In the 1997-1998 academic term, only
16 percent received a passing grade of C or better on the
pre-test, while 82 percent passed the post-test. The following
year, 59 percent of the students passed the pre-test compared
to 85 percent passing the post-test. In the 1999-2000 academic
year, the pass rate jumped from 30 percent for the pre-test
to 77 percent for the post-test. For each of these years,
the increases represent a substantial and statistically
significant (p<0.001) improvement in student proficiency
as a result of completing the certificate curriculum.
Ongoing and Future Evolution of the Curriculum
The evolution of the CHW curriculum is proceeding
on three main fronts. The first involves ongoing efforts
to make the program a stepping stone to higher education
in the field of health care through a transfer program to
San Francisco State University. The second is progress in
developing specialty content certificates as well as training
and educational materials to combine with the CHW Generalist
Certificate. Finally, program directors are engaged in disseminating
information about our program and building connections with
similar programs at state and national levels.
When the CHW Certificate Program was initiated a decade
ago, CCSF was the only institution in the U.S. offering
a college credit-bearing certificate for Community Health
Workers. More recently, alongside our dissemination efforts,
a number of sites have started developing college-supported
CHW courses, under a range of credit-bearing and noncredit-bearing
structures. At the 2001 meeting of the American Public Health
Association (APHA), program directors and the University
of Arizona hosted a meeting of representatives of college-supported
CHW programs and are developing a national network of CHW
programs. This network serves as a forum for exchanging
lessons learned, sharing program development experiences,
and addressing such issues as the role college-supported
programs should play as the profession of community health
worker matures and locates itself within the larger health
care system.
Conclusions
Ongoing structural changes in health care and an increasingly
diverse population are driving demand and providing expanded
opportunities for community health workers. A successful
shift from highly interventionist, curative care to prevention
and health maintenance-motivated not only by cost concerns
but also by growing focus on holistic notions of well-being-is
predicated on the system's ability to reach all communities,
comprehensively follow up with clients through a complex
service network, educate individuals and communities on
self-care and behavior change, and organize community-level
and policy interventions. A considerable body of research
shows that these are precisely the areas in which community
health workers are able to have the greatest impact on health
outcomes. The Certificate Program for Community Health Workers
at CCSF represents part of an ongoing endeavor to enhance
their effectiveness, increase their acceptance and diffusion
throughout the U.S. health care system, and more firmly
establish the CHW profession within the health care process.
For more information contact
Cindy
Tsai
Dissemination Specialist
Vicki
Legion
Director of Community Health Training and Development
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