Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers FEBRUARY 2023 AUTHORS Timothy Bates, MPP; Jacqueline Miller, BA; and Susan Chapman, RN, PhD, MPH, FAAN; Healthforce Center at UCSF About the Authors Contents Timothy Bates, MPP, is a senior research data analyst with the Philip R. Lee Institute for 3 Executive Summary Health Policy Studies (IHPS) at UCSF. Susan Chapman, RN, PhD, FAAN, is a professor of 4Methodology social and behavioral sciences in the School of Nursing at UCSF and is a faculty affiliate of IHPS 5Limitations and Healthforce Center at UCSF. Jacqueline Miller, BA, is a senior research data analyst with 5Findings IHPS at UCSF and is affiliated with Healthforce Center at UCSF. 23 Appendix About IHPS IHPS is an interdisciplinary collection of con- cerned researchers who share a mission - to improve health and transform health care in the United States by working across competing interests, collecting evidence, informing policy, and improving practice. Acknowledgments See the appendix for a list of the advisory board members. Understanding California's Community About the Foundation Health Worker/Promotor Workforce: The California Health Care Foundation (CHCF) The Series is dedicated to advancing meaningful, measur- Despite being a critical part of California's able improvements in the way the health care health workforce, there are relatively little delivery system provides care to the people of comprehensive data on community health California, particularly those with low incomes workers and promotores (CHW/Ps) in Cali- and those whose needs are not well served by fornia. With funding from CHCF, Healthforce Center at UCSF fielded surveys of CHW/ the status quo. We work to ensure that people Ps, the institutions that train them, and the have access to the care they need, when they organizations that employ them. The survey need it, at a price they can afford. data, published in a series of reports, paint a more complete picture of the current CHCF informs policymakers and industry leaders, CHW/P workforce as well as challenges invests in ideas and innovations, and connects and opportunities related to training and with changemakers to create a more responsive, employment. This picture can inform policy patient-centered health care system. decisions as the state looks to support and expand this important workforce. To learn more, visit www.chcf.org/collection/ understanding-californias-community-health- DESIGN BY DANA KAY DESIGN worker-promotor-workforce. Executive Summary Summary of Key Findings In California, one of the most culturally diverse states Key findings from the collected data include: in the country, health care must bridge cultural and $ A minority of hospital-based employers who linguistic divides to serve all communities equitably. responded to the survey (39%) employed CHW/Ps. As trusted community members with lived experi- In contrast, the vast majority of clinic-based ence, community health workers and promotores employers who responded to the survey (79%) (CHW/Ps) have a long history of connecting those employed CHW/Ps. not well served by the traditional health care system with culturally competent health and social services. $ Among hospitals and community clinics that employed CHW/Ps: There is increasing recognition in California that $ Most hospitals and community clinics reported CHW/Ps are a critical part of the health care that their CHW/P employees worked full-time. workforce. In 2019, the California Future Health Both hospital and community clinic employ- Workforce Commission recommended scaling the ers reported that a majority of their CHW/P CHW/P workforce to broaden access to preventive employees worked 32 hours or more per and social support services as well as to team-based week. integrated primary and behavioral health care. In 2022 CHW/P services were added as a Medi-Cal $ Wages differed according to employer type. preventive services benefit. Hospital-based employers provided higher wages for CHW/Ps compared to clinic-based Little is known about CHW/P employment across employers at both entry- and senior-levels. employer types in the health care sector in California, $ Nearly all respondents had a minimum edu- and little is known about why organizations choose cation requirement for CHW/P employment. to employ or not employ CHW/Ps. This report Most hospital-based and clinic-based employ- describes current hospital and community health ers reported that the minimum educational center employer practices and prospective hospi- requirement for entry-level CHW/Ps was a tal and community health center employer opinions high school diploma. related to the employment of CHW/Ps in their organizations. CHW/P employers and prospective $ Only 29% of hospital-based and 10% of clinic- employers in hospitals and community clinics were based employers required CHW/P-specific asked to fill out a survey distributed by the Hospital training for employment. Association of Southern California (HASC) and the $ Compared to hospital-based employers, California Primary Care Association (CPCA), respec- clinic-based employers more often reported tively. The HASC survey was fielded from June to that CHW/Ps were strategically very important July 2021, and the CPCA survey was fielded from to several organizational goals. December 2021 to January 2022. $ Eighty-five percent of clinic-based employers reported there were opportunities for CHW/Ps to advance in the organization, compared to just 36% of hospital-based employers. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 3 $ Both hospital- and clinic-based employers planned to hire more CHW/Ps in the next 12 Methodology months. However, hospital employers reported The surveys created and analyzed for this report were that if funding were not a barrier, they would part of a larger project about the current CHW/P ideally hire about 12 times more CHW/Ps workforce and strategies for the future. Funded by than they planned to hire, and community the California Health Care Foundation, this project clinic employers reported that they would ide- was conducted by researchers at the University of ally hire about three times more CHW/Ps than California San Francisco (UCSF). The project was they planned to hire. approved by UCSF's Institutional Review Board. $ Hospital- and clinic-based employers had rela- This report comprises findings from a hospital- tively similar concerns about the sustainability based employer survey and a clinic-based employer of CHW/P employment in their organizations, survey. The Hospital Association of Southern including funding for the role and finding and California (HASC) used the survey platform Salarity retaining qualified CHW/Ps. However, every (developed by HASC to administer the association's clinic-based employer, compared to only 60% human resources survey program) to administer of hospital-based employers, reported sus- the hospital-based employer survey to members tainability concerns. of the California Hospital Association, which com- $ Among hospitals and community clinics that did prises 390 hospitals across 51 systems throughout not employ CHW/Ps: the state. The California Primary Care Association (CPCA) used the survey platform Survey Monkey to $ Anticipated hiring of CHW/Ps differed administer the clinic-based employer survey to its between hospital and community clinic member clinics. CPCA comprises 1,103 health cen- employers. Nearly all hospitals reported that ter sites across 157 member systems throughout they did not anticipate hiring CHW/Ps in the the state. HASC and CPCA were chosen to adminis- next 12 months. By contrast, a majority of com- ter the surveys because both have well-established munity clinics did anticipate hiring CHW/Ps relationships with hospitals and clinics across the in the next 12 months. state, and they survey their members regularly. As $ The perceived impact of statewide certifica- a result, it seemed more likely that higher response tion of CHW/Ps on hiring barriers differed rates would be achieved if HASC and CPCA sent according to employer setting. Few hospital- the surveys directly. based employers felt that certification would help alleviate CHW/P hiring barriers in their Both surveys were created by the research team at organizations, compared to over half of clinic- UCSF with the help of an advisory group composed based employers, who said that statewide of representatives from HASC, CPCA, a nation- certification would help with hiring barriers. ally recognized CHW/P educator, CHW/P policy experts, and representatives of the CHW/P com- munity (see the appendix). California Health Care Foundation www.chcf.org 4 During the dissemination process, both HASC and Figure 1. CHW/Ps Employed, Hospitals vs. Clinics CPCA emailed reminders for members to fill out the survey if they had not done so already. The HASC Hospitals survey was fielded from June to July 2021, and the CPCA survey was fielded from December 2021 to January 2022. Once the surveys closed, the UCSF research team analyzed the survey data with Stata, a statistical Employ CHW/Ps analysis software program. The results are pre- 39% sented in this report. n = 62 Do not employ CHW/Ps 61% Limitations The hospital survey was conducted from June to July 2021. The clinic survey was conducted from December 2021 to January 2022. Conducting these surveys during the COVID-19 pandemic likely Clinics contributed to a lower response rate. These surveys were distributed only to member organizations of HASC and CPCA, and not all mem- Do not employ ber organizations responded to the surveys. The CHW/Ps 21% survey findings may not represent all hospitals and community clinics across the state. n = 42 Findings Employ CHW/Ps 79% Overall Employment of CHW/Ps More clinics than hospitals were likely to employ CHW/Ps. More than three-quarters of clinic-based employers that responded to the survey reported Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic that they employ CHW/Ps. Only 39% of hospital- (distributed December 2021 through January 2022) settings. based employers reported current employment of CHW/Ps. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 5 Historical Employment Full-Time and Part-Time Employment Figure 2 shows the number of hospital- and clinic- Hospital-based employers reported that about 84% based employers that indicated they started hiring of full-time equivalent (FTE) CHW/Ps were working CHW/Ps in the listed timeframes. Some hospitals 32 hours per week or more, compared to 96% at and community clinics started hiring CHW/Ps at clinic-based employers. their organizations before 1995. However, these data suggest that clinic-based employers were Figure 3. E mployment Status of CHW/Ps, more apt to start employing CHW/Ps over the past Hospitals vs. Clinics two decades and that hospital-based employment of CHW/Ps has become more common over the past five to seven years. Hospitals Figure 2. Initial Employment of CHW/Ps, Hospitals and Clinics FTEs working <32 hours/week 16% NUMBER OF RESPONSES Before 1995 ■ Hospitals (n = 23) n = 24 4 ■ Clinics (n = 25) 4 FTEs working 1995 to 2005 32+ hours/week 3 84% 6 2006 to 2015 7 Clinics 10 <32 2016 or later hours 4% 9 5 FIGURES 2 AND 3: Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic n = 20 (distributed December 2021 through January 2022) settings. FTEs working 32+ hours/week 96% California Health Care Foundation www.chcf.org 6 Work Hours Required to Receive Benefits Benefit Types Hospital-based employers most often reported that Common types of employee benefits, includ- CHW/Ps needed to work at least 20 hours per week ing health, dental, and vision insurance coverage; to obtain employee benefits. Clinic-based employ- vacation and sick leave; and access to a pension or ers most often reported that CHW/Ps needed to retirement plan were reported by nearly all hospi- work between 24 and 32 hours per week to obtain tal and community clinic employers (see Figure 5, benefits. page 8). Differences between the two types of employers were that hospital-based employers much more often reported providing tuition assis- Figure 4. M inimum Number of Hours per Week Worked tance and to a lesser extent personal leave, while for Benefits Eligibility, Hospitals and Clinics clinic-based employers much more often reported providing mileage reimbursement. A commuter NUMBER OF RESPONSES subsidy, educational leave, and child care were not 20 hours/week common employee benefits reported by either 15 employer type. 5 Wages 24 to 32 hours/week Hourly wages earned by CHW/Ps employed in 4 hospitals are higher than those earned by CHW/Ps 15 working in clinics (see Figure 6, page 8). Most clinic- based employers reported that the hourly wage 35 hours/week ■ Hospitals (n = 24) for entry-level CHW/Ps was between $16 and $20 5 ■ Clinics (n = 20) per hour. Almost half of hospital-based employ- 0 ers responding to the survey reported entry-level Source: Author surveys of CHW/P employers and prospective employers wages of at least $26 per hour. This same pattern in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. held for senior-level employees: All clinic-based employers reported hourly wages between $21 and $30 per hour, whereas hospital-based employ- ers most often reported that senior-level CHW/Ps earned more than $30 per hour. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 7 Figure 5. T ypes of Benefits Received by CHW/Ps, Figure 6. A verage Hourly Wages Paid to Entry- and Hospitals and Clinics Senior-Level CHW/Ps, Hospitals and Clinics PERCENTAGE OF RESPONDENTS OFFERING BENEFIT NUMBER OF RESPONSES Dental Insurance Entry Level 100% ≤$15/hour 100% ■ Hospitals 0 ■ Clinics Health Insurance 2 100% 100% $16 to $20/hour Vision Insurance 4 100% 14 95% $21 to $25/hour Vacation Accrual 6 96% 4 85% Pension/Retirement Plan $26 to $30/hour 92% 6 95% 0 Sick Leave >$30/hour 83% 3 95% 0 Tuition Assistance 79% Senior Level 40% ≤$15/hour Personal Leave 0 75% 0 55% Mileage Reimbursement $16 to $20/hour 54% 0 90% 0 Parking $21 to $25/hour 38% 15% 1 10 Commuter Subsidy 21% $26 to $30/hour 15% 4 Educational Leave 7 8% 15% >$30/hour 8 Child Care 4% 0 ■ Hospitals (n = 24) 15% ■ Clinics (n = 20) Notes: Fewer hospital and clinic respondents answered the question about senior-level employees compared to entry-level employees. This could FIGURES 5 AND 6: indicate that some hospitals and clinics do not employ CHW/Ps at the Source: Author surveys of CHW/P employers and prospective employers senior level. Hospitals (n = 19 for entry-level, n = 13 for senior-level) and in hospital (distributed June through July 2021) and community clinic community clinics (n = 20 for entry-level, n = 17 for senior-level). (distributed December 2021 through January 2022) settings. California Health Care Foundation www.chcf.org 8 Education Requirements Other Employment Requirements Most hospital-based and clinic-based employers Clinic-based employers were more likely to report reported that the minimum educational require- other types of employment requirements compared ment for entry-level CHW/Ps was a high school with hospital-based employers. These included diploma (see Figure 7). Only one hospital-based "relevant lived experience," own transportation, employer reported that having a CHW/P certificate and being bilingual. Very few employers reported was required for entry-level employment. that prior CHW/P training of any kind was required for employment. Figure 7. M inimum Educational Requirements for Figure 8. R eported Job Requirements for Entry-Level Entry-Level CHW/Ps, Hospitals and Clinics CHW/Ps, Hospitals and Clinics Hospitals Hospitals NUMBER OF RESPONSES • CHW/P Certificate ■ Hospitals (n = 24) • CHW/P Certificate ■ Clinics (n = 20) 5% 5% Work Experience 18 Bachelor's (BS)* 14 Bachelor's (BS)* 14% 14% California Driver's License Associate (AS)* n = 21 11 Associate (AS)* n = 21 14% 13 14% High school High 67% school 67% Bilingual 7 14 CHW/P Training 7 Clinics 2 Clinics Own Transportation None 6 BS None 10% BS 5% 10% 12 5% AS AS 5% Relevant Lived Experience 5% 4 n = 20 12 n = 20 FIGURES 7 AND 8: Source: Author surveys of CHW/P employers and prospective employers High school in hospital (distributed June through July 2021) and community clinic High 80% school (distributed December 2021 through January 2022) settings. 80% * Degree in Health/Human/Social Services Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 9 Anticipated Versus Ideal Hiring of New CHW/P Service Delivery CHW/Ps Comparing hospital-based and clinic-based There was a significant gap between the number employers, a slightly larger share of hospital-based of CHW/Ps that hospital-based or clinic-based employers reported that CHW/Ps deliver services employers anticipated hiring over the next 12 via email or other electronic communications. months, compared to the number of CHW/Ps they However, the different modes of service delivery would ideally hire. used by CHW/Ps were generally the same, whether employed by a hospital or clinic. Figure 9. A nticipated and Ideal Number of CHW/Ps (FTE) Figure 10. M odes of Service Delivery Performed Hired in Next 12 Months, Hospitals and Clinics by CHW/Ps, Hospitals and Clinics NUMBER OF FTEs HIRED ■ Hospitals (n = 23) ■ Anticipated ■ Ideal ■ Clinics (n = 20) Telephone-based, one-on-one visits 273 96% 100% 225 In-Person, one-on-one visits 91% 95% Visits as part of a care team 79 78% 75% 23 Hospitals Clinics Email or other electronic communications Notes: Two community clinics reported they were unsure or didn't know 78% how many CHW/Ps they anticipated hiring or would ideally hire in the next 12 months. Hospitals (n = 24 for anticipated, n = 23 for ideal) and 55% community clinics (n = 20 for anticipated and ideal) Group classes/sessions FIGURES 9 AND 10: Source: Author surveys of CHW/P employers and prospective employers 65% in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. 70% Video-based, one-on-one visits 65% 65% Text-based, one-on-one visits 39% 50% California Health Care Foundation www.chcf.org 10 CHW/P Roles Clinic-based employers reported that the roles most Hospital-based employers reported that the roles often performed by CHW/Ps were those associ- most often performed by CHW/Ps were those asso- ated with care coordination, case management, and ciated with care coordination, case management, system navigation, as well as providing direct ser- and system navigation; individual and community vices to individuals. More than half of clinic-based capacity building; and advocating for individuals employers also reported that CHW/Ps performed in and communities. roles related to linking patients to community-based resources, ensuring patients follow through on refer- rals, and building individual and community capacity. Figure 11. M ost Important Roles Performed Figure 12. M ost Important Roles Performed by CHW/Ps in Hospitals by CHW/Ps in Clinics Care coordination, case management, and system navigation Care coordination, case management, and system navigation 57% 85% Advocating for individuals and communities Providing direct services to individuals 43% 75% Building individual and community capacity/outreach Referring/linking patients to community-based resources 43% 65% Providing direct services to individuals Ensuring that patients follow through on referrals 35% 60% Implementing individual and/or community assessments Building individual and community capacity/outreach 13% 55% Translating and/or interpreting Advocating for individuals and communities 13% 35% Cultural mediation (individuals, communities, health/social services) Translating and/or interpreting 9% 35% Ensuring that patients follow through on referrals Cultural mediation (individuals, communities, health/social services) 9% 30% Participating in evaluation and research Implementing individual and/or community assessments 4% 30% Referring/linking patients to community-based resources Participating in evaluation and research 4% 15% Notes: Three respondents to the hospital-based employer survey Note: Respondents (n = 20) could select an unlimited number of options. reported that they "didn't know" what roles were performed by CHW/Ps. Respondents (n = 23) could select up to three options. FIGURES 11 AND 12: Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 11 CHW/P Skills Hospital-based employers most often reported Nearly all clinic employers reported it was impor- communication skills as most important to the tant that CHW/Ps employed in clinic settings have work performed by CHW/Ps employed in hospi- strong communication, service coordination, and tals. Other skills identified as important included navigation skills. Other skills identified as impor- education and facilitation, service coordination and tant to the work performed by CHW/Ps included navigation, advocacy, and individual and commu- language, education and facilitation, documen- nity assessment. No hospital employers reported tation of services, and individual and community evaluation and research as an important skill for assessment. CHW/Ps to have. Figure 14. M ost Important CHW/P Skills Needed Figure 13. M ost Important CHW/P Skills Needed in Clinics in Hospitals Communication Communication 95% 74% Service coordination and navigation Education and facilitation 90% 35% Language Service coordination and navigation 50% 35% Education and facilitation Advocacy 45% 30% Documentation of services Individual and community assessment 40% 30% Individual and community assessment Language 40% 13% Technology Capacity building 35% 9% Advocacy Documentation of services 30% 9% Capacity building Technology 25% 9% Evaluation and research Evaluation and research 15% 0% Note: Respondents (n = 20) could select an unlimited number of options. Notes: Three respondents to the hospital-based employer survey reported FIGURES 13 AND 14: that they "didn't know" what skills were needed by CHW/Ps. Respondents Source: Author surveys of CHW/P employers and prospective employers (n = 23) could select up to three options. in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. California Health Care Foundation www.chcf.org 12 CHW/P Functions Figure 15. M ost Important Health Care–Specific Functions Performed by CHW/Ps in Hospitals The health care–specific function most often per- formed by CHW/Ps employed in hospital-based settings was health system navigation, reported half Health system navigation of survey respondents (see Figure 15). One-third of 48% hospital employers identified health coaching and Health coaching and/or health literacy support health literacy support as an important health care– 35% related function performed by CHW/Ps. No hospital employers reported harm reduction, knowledge of Liaison between the community and health/social services trauma-informed practice, or prescription manage- 30% ment as important health care functions. These data Providing culturally appropriate health education suggest that CHW/Ps employed in hospitals may have a comparatively limited scope of work. 26% Helping patients navigate health care technology 17% Knowledge about social determinants of health 13% Managing chronic conditions 13% Liaison between the home and health/social services 13% Working with providers to ensure care reflects patients' needs 9% Hospital discharge support 4% Knowledge about patient privacy and HIPAA 4% Harm reduction 0% Knowledge of trauma-informed practice 0% Prescription management 0% Note: Five respondents to the hospital-based employer survey reported that they "didn't know" what health care–specific functions were performed by CHW/Ps. Respondents (n = 23) could select up to three options. Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 13 The health care–specific function most often per- Figure 16. M ost Important Health Care–Specific formed by CHW/Ps employed in clinics was health Functions Performed by CHW/Ps in Clinics system navigation, reported 90% of survey respon- dents (see Figure 16). About half of respondents Health system navigation identified health coaching and health literacy 90% support, providing culturally appropriate health Health coaching and/or health literacy support education, acting as a liaison between the com- 55% munity and health/social services, and sharing knowledge about social determinants of health as Providing culturally appropriate health education important health care–related functions performed 55% by CHW/Ps. Knowledge about social determinants of health 45% Liaison between the community and health/social services 45% Liaison between the home and health/social services 40% Helping patients navigate health care technology 35% Managing chronic conditions 35% Harm reduction 30% Knowledge of trauma-informed practice 30% Hospital discharge support 25% Working with providers to ensure care reflects patients' needs 25% Knowledge about patient privacy and HIPAA 20% Prescription management 15% Note: Respondents (n = 20) could select an unlimited number of options. Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. California Health Care Foundation www.chcf.org 14 Health Conditions Addressed by CHW/Ps Thirty percent of clinic-based employers reported Thirty-five percent of hospital-based employers that CHW/Ps do not focus on specific health reported that CHW/Ps do not focus on specific conditions in the population. Among clinic-based health conditions in the population. Among hos- CHW/Ps that do focus on specific population health pital-based CHW/Ps that do focus on specific conditions, the most often reported included man- population health conditions, the most often aging patients with complex health and social reported included pregnancy and chronic health needs, chronic health conditions, and behavioral conditions, specifically diabetes and heart disease. health challenges. CHW/Ps that focus on managing chronic health conditions most often address dia- betes and heart disease. Figure 17. T ypes of Health Conditions Primarily Figure 18. T ypes of Health Conditions Primarily Addressed by CHW/Ps in Hospitals Addressed by CHW/Ps in Clinics Pregnancy Complex health and social needs 35% 70% CHW/Ps do not focus on specific conditions Chronic health conditions 35% 60% Chronic health conditions Behavioral health challenges 30% 55% Complex health and social needs Recently discharged from hospital 22% 35% Recently discharged from hospital CHW/Ps do not focus on specific conditions 17% 30% Mental health challenges Mental health challenges 17% 30% Behavioral health challenges HIV/AIDS 13% 25% Cancer Pregnancy 13% 20% HIV/AIDS Cancer 9% 5% Note: Five respondents to the hospital-based employer survey reported Note: Respondents (n = 20) could select an unlimited number of options. that they "didn't know" what types of health conditions were addressed by CHW/Ps. Respondents (n = 23) could select up to three options. FIGURES 17 AND 18: Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 15 CHW/P Qualities Service Frequency of CHW/Ps Hospital-based employers reported that having Clinic-based employers reported that the services compassion and empathy; being respectful, sincere, CHW/Ps most often engaged in were those related and understanding; as well as being dedicated to a to program enrollment for social services and client-centered practice were the most important case/care management. In contrast, 18% of clinic- qualities that CHW/Ps should have. based employers reported that CHW/Ps provided child care–related services, and 12% reported that CHW/Ps provided services related to respite care. Figure 19. M ost Important Qualities of CHW/Ps Figure 20. F requency of Services Provided by CHW/Ps in Hospitals in Clinics NUMBER OF RESPONSES ■ Always ■ Often ■ Sometimes ■ Never Compassionate/empathetic/respectful/sincere/understanding Program enrollment for social services 14 47% 42% 11% Dedicated to client-centered practice Case/care management 10 26% 53% 16% 5% Capable/resourceful Respite care 8 6% 6% 88% Committed/motivated/persistent Grocery shopping / cooking / nutrition education 7 6% 18% 35% 41% Demonstrates cultural humility/competency Delivery of medication / medical equipment 7 6% 17% 56% 22% Connected/sociable/outgoing Employment services 4 26% 42% 32% Ethical/honest/trustworthy Child care 4 6% 12% 82% Open-minded/unbiased Notes: These questions were asked only in the clinic-based employer survey (n = 17 to 19). Segments may not sum 100% due to rounding. 4 FIGURES 19 and 20: Source: Author surveys of CHW/P employers and prospective employers Responsible/reliable/responsive in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. 4 Other 2 Note: This question was asked only in the hospital-based employer survey. Three respondents reported that they "didn't know". Respondents (n = 23) could select up to three options. California Health Care Foundation www.chcf.org 16 Organizational Strategic Importance Figure 21. S trategic Importance of CHW/Ps, of CHW/Ps Hospitals and Clinics Compared to hospital-based employers, clinic- based employers more often reported that CHW/Ps Supporting navigation between health and were strategically very important in supporting social services systems navigation between health and social services sys- Hospitals tems, ensuring that needed care is received at the 46% appropriate time and place, and helping to elimi- ■ Very important 32% ■ Important nate health disparities among people that have 18% ■ Somewhat important disproportionately experienced health inequities 5% ■ Not important (see Figure 21). Clinics 95% 5% 0% 0% Ensuring that necessary care is received at appropriate time and place Hospitals 46% 27% 27% 0% Clinics 80% 10% 10% 0% Eliminating health disparities among persons who have disproportionately experienced health inequities Hospitals 55% 32% 14% 0% Clinics 90% 5% 0% 14% 5% Note: Hospitals: n = 22 and clinics: n = 20. Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 17 CHW/P Advancement Figure 22. A dvancement Opportunities for CHW/Ps, Hospitals and Clinics Eighty-five percent of clinic-based employers reported there were opportunities for CHW/Ps to advance in the organization, compared to just ■ Yes ■ No ■ Unsure 36% of hospital-based employers (see Figure 22). Hospitals Among respondents that reported opportunities to 36% 32% 32% advance, the ability to move into a new position or to be promoted were often reported by both types Clinics of employers (see Figure 23). Clinic-based employ- 85% 15% ers more often reported wage increases as a type of Note: Hospitals: n = 22 and clinics: n = 20. advancement opportunity; hospital-based employ- ers more often reported supervisory functions as a type of opportunity for advancement. Over 30% Figure 23. T ypes of Advancement Opportunities for of hospital-based employers indicated they were CHW/Ps, Hospitals and Clinics (among those that report opportunities to advance) unsure what advancement opportunities were avail- able to CHW/Ps. ■ Hospitals (n = 7) ■ Clinics (n = 17) Challenges of Supervising CHW/P Role Clinic-based employers were much more likely to Promotions report challenges related to supervising, training, 100% and mentoring CHW/Ps, compared to hospital- 94% based employers (see Figure 24, page 19). These Ability to move into new positions challenges included not enough time for activities 86% related to supervising, training, or mentoring, and the need for more guidelines specific to supervis- 88% ing, training, and mentoring. Nearly two-thirds of Supervisory functions hospital-based employers reported there were 86% either no supervisory-related challenges, or that the 71% topic was not applicable to their organization. Wage increases 57% 94% FIGURES 22 and 23: Source: Author surveys of CHW/P employers and prospective employers 63% in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. 70% 63% 65% 38% 50% California Health Care Foundation www.chcf.org 18 Figure 24. C hallenges Supervising, Training, and Concerns over Longevity and Mentoring CHW/Ps, Hospitals and Clinics Sustainability of CHW/P Role Approximately 60% of hospital-based employers No supervisory challenges or not applicable and all clinic-based employers reported they had 65% concerns related to the longevity or sustainability of CHW/P employment (see Figure 25). Concerns 10% most often reported among hospitals and clin- Not enough time for mentoring ics included funding uncertainty, finding qualified 13% CHW/Ps, and staff turnover. 70% Not enough time for training Figure 25. E mployer Concerns About the Longevity and Sustainability of CHW/Ps, 9% Hospitals and Clinics 65% CHW/P and supervisor work in different locations No concerns 9% ■ Hospitals (n = 23) 43% 30% ■ Clinics (n = 20) 0% CHW/P and supervisor scheduling conflicts Funding uncertainty 9% 30% 15% 90% Not enough time for supervision Finding qualified CHW/Ps 4% 22% 55% 60% More supervisory, training, and mentoring guidelines are needed Staff turnover 0% 9% 55% 60% Too many employees reporting to one supervisor Lack of acceptance for the CHW/P role 0% ■ Hospitals (n = 23) 4% 20% ■ Clinics (n = 20) 5% FIGURES 24 and 25: Source: Author surveys of CHW/P employers and prospective employers Management support for CHW/P role in hospital (distributed June through July 2021) and community clinic 0% (distributed December 2021 through January 2022) settings. 25% 38% 50% Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 19 Organizations That Do Not Employ Figure 26. A nticipated Hiring of CHW/Ps in the Next 12 Months by Those Who Do Not Currently CHW/Ps Employ CHW/Ps, Hospitals and Clinics CHW/P Hiring Plans Hospitals Among hospital-based employers that did not • Anticipate hiring CHW/Ps employ CHW/Ps at the time of the survey, only a 3% single respondent anticipated hiring CHW/Ps in the next 12 months. In contrast, approximately half of the clinic-based employers that did not employ CHW/Ps at the time of survey anticipated they would hire CHW/Ps in the next 12 months. The most often cited reasons for not having plans to n = 38 hire CHW/Ps included a lack of clarity regarding the value of CHW/Ps, insufficient funding to support the CHW/P role, and challenges related to integrat- Do not anticipate ing the CHW/P role into the organization. hiring CHW/Ps 97% Clinics Do not anticipate Anticipate n=9 hiring CHW/Ps hiring CHW/Ps 44% 56% Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. California Health Care Foundation www.chcf.org 20 Impact of Statewide Certification on Figure 27. P erceived Effect of State Certification of Hiring Barriers CHW/P Training Programs on Hiring Barriers for Organizations That Do Not Currently Seventy-five percent of hospital-based employ- Employ CHW/Ps, Hospitals and Clinics ers that did not employ CHW/Ps at the time of the survey were either unsure of the effect that state certification of CHW/P training programs would Hospitals have on hiring barriers, or felt that this outcome Would was not applicable to their organization. Only 6% help of these hospital-based employers felt that having 6% the state certify CHW/P training programs would help their organizations in addressing hiring bar- Would not help riers. Over half of the clinic-based employers that 19% did not employ CHW/Ps at the time of the survey Not applicable n = 36 felt that state certification of CHW/P training pro- 47% grams would help address hiring barriers through promoting understanding of the skill and compe- Unsure 28% tencies of this workforce, addressing any regulatory issues specific to the CHW/P workforce, and having a source for recruiting CHW/Ps. Clinics Would not help 44% n=9 Would help 56% Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 21 Intention to Train Existing Staff in Figure 28. O rganizations That Do Not Currently Employ CHW/Ps with Current Staff That CHW/P Role Would Like to Train as CHW/Ps, Most clinic-based and hospital-based employers Hospitals and Clinics that did not employ CHW/Ps at the time of the sur- vey were unsure whether there were current staff CURRENT STAFF THAT WOULD LIKE TO TRAIN? not working as CHW/Ps who were interested in training for that role. Hospitals Yes 3% No 28% n = 36 Unsure 69% Clinics Yes 11% No 11% n=9 Unsure 78% Source: Author surveys of CHW/P employers and prospective employers in hospital (distributed June through July 2021) and community clinic (distributed December 2021 through January 2022) settings. California Health Care Foundation www.chcf.org 22 Appendix. Advisory Group The authors would like to thank the members of the advisory group, who helped developed the CHW/P survey and guided the overall project. In addition to the report authors, the advisory group comprised these members: Esther Bejarano, community health worker/promotora and director of health programs Comite Civico Del Valle Timothy Berthold, retired faculty member, Health Education Department City College of San Francisco Gabriela Gonzalez, community health worker/promotora and director of promotores programs Esperanza Community Housing Carlina Hansen, senior program officer California Health Care Foundation Teri Hollingworth, vice president of human resources and education services Hospital Association of Southern California (HASC) Cindy Keltner, director of care transformation California Primary Care Association Ashley Kissinger, Environmental Health Investigations Branch Community Education and Exposure Prevention Section, California Department of Public Health Lisa Mitchell, workforce development program manager HASC Carl Rush, national community health worker expert Community Resources Joanne Spetz, director Philip R. Lee Institute for Health Policy Studies, UCSF Understanding California's Community Health Worker/Promotor Workforce: CHW/P Health Care Employers 23