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LeagueTLC Innovation Express
Exploring Issues, Innovations, and New Developments with Information Technology Professionals

Performance-Based Certification for Community Health Workers at City College of San Francisco 

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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