Table 2 Triangulation of survey and interview findings by each of the 8 topics. Each finding is accompanied by an explanation of findings. Additionally, focus group and unique survey findings are accompanied by supporting quotations and survey results, respectively. The right column indicates whether survey and focus group findings were complementary, divergent, or unique. No findings were divergent

1. CHWs have diverse backgrounds

Many CHWs reported being multilingual, with many having international backgrounds, and receiving a variety of education beyond a high school degree equivalent.

See Table 1.

Unique: Survey

2. CHWs are known by many titles and represent various employment settings

CHW respondents reported on their existing job titles, employment sectors and settings, and health-related topics and services they provide to their clients, patients, and communities.

Survey results revealed 11 job titles held by CHWs (see Table 3 for CHW job titles) in addition to CHWs representing XX employment sectors and setting (see Table 4). Health-related topics covered by CHWs (see Table 6), include the most common focus area, chronic disease management (13%). Specific chronic diseases that CHWs focus on include high blood pressure (7%), obesity (5%), diabetes (3%), asthma (2%), kidney disease (2%), COPD (1%), Alzheimer’s (1%), arthritis (1%), and high cholesterol (< 1%).

Unique: Survey

3. CHW clients face a myriad of challenges

Challenges that CHW clients and the communities they serve face include food insecurity, unstable housing and homelessness, high medication costs, substance use, domestic violence, lack of accessible and affordable daycare, and undocumented status.

“And the biggest thing of course…is food resources and food deserts. That’s a big issue, at least here in my territory” —CHW

“…in the community-based organizations in the community where I [work] I need housing, I need protection and the domestic violence situation, I need access to food. And those are things that really contribute to the health disparities that we’re seeing.”—EMP

Complementary: Survey & Focus Groups (CHW & EMP)

4. CHWs are highly motivated

CHWs indicated having a strong desire to help their communities and to work with clients from diverse backgrounds. This finding aligns with C3 Core CHW Role 1: Cultural Mediation Among Individuals, Communities, and Health and Social Service Systems and Role 2:

Providing Culturally Appropriate Health Education and Information.

“I decided to move to this field because it is more related to compassion and passion for people and [people] need help.”—CHW

“I love the idea of being able to work with families and to work with not just trying to prevent but intervening, and also trying to address other areas of social determinants of health.” —CHW

Unique: Focus Groups (CHW)

5. CHWs possess a myriad of qualities to effectively develop trust between themselves and communities served

Several attributes contribute to CHWs trustworthiness including, patience, compassion and passion, inclusivity, dependable and consistent, creative, and flexible, adaptable, shared life experiences, ability to set healthy boundaries. This finding aligns with C3 Core CHW Qualities.

“I think it’s really important to be very open-minded and non-judgmental and having a very open demeanor.” —CHW

“We’re just kind of helping people with their barriers. And the addiction groups, we’re using our own addiction history, if some of us have that, to help people understand that it’s going to be okay, and it can be okay. It can even be better than before you know, so we’re kind of like that hope.” —CHW

“Life and lived experience is more valuable than the credentialing that would come otherwise in helping families and be able to identify with the needs in the communities.”—EMP

Unique: Focus Groups (CHWs & EMP)

6. CHWs’ have shared life experiences and are relatable to community and clients

Often CHWs are from and/or live in the communities that they serve and can relate the clients they work with because of their own life and lived experiences. This finding aligns with C3 Core CHW Skill 11: Knowledge base.

“…having that knowledge base [previous life experiences] allowed me to really hone in on what was needed [in the community] and also to be able to convey information [to clients] in an easy to understand way.”—CHW

“…I think you have to have that passion to work in this position. You come up against a lot of walls, a lot of barriers, and you’ve got to be very creative in how you address some of those issues. You don’t want to burn any bridges.”—EMP

Unique: Focus Groups (CHW & EMP)

7. CHWs are essential links between their clients, services, resources, and communities

CHWs and employers described CHW roles as bridges between their clients and the services they need and connect clients to medical and social services. This finding aligns with C3 Core CHW Skill 3: Service Coordination and Navigation Skills and Core CHW Role 3: Care Coordination, Case Management, and System Navigation.

“…intermediary between the clinicians and like real people…the community it’s a very important role.” —CHW

“…six of our CHWs are on [that] diabetes project to see patients who are dying due to uncontrolled diabetes, and it helps to coordinate their care as well as linking them directly to community resources.”—EMP

Complementary: Survey & focus Groups (CHW & EMP)

8. CHWs address client needs’ and improve their lives through various actions and avenues

CHWs improve the lives of their clients by serving as advocates as well as developing and implementing programs to address health disparities in order to better client lives and wellness. This finding aligns with C3 Core CHW Role 5. Advocating for Individuals and Communities.

“Part of my job is to also help develop programs that address those needs that we [identify through] our needs assessments with the community.”—CHW

“The CHWs that work here in the community are actually advocates…they do presentations on health disparities, blood pressure, diabetes…because most of our community members don’t’ have the proper documentation to actually go into a doctor’s office, or they don’t have the financial means…so they [CHWs] go into the community and talk to them about what is blood pressure, or how to use a blood pressure cuff. And they build rapport with them…guide them to the different resources that we have in the community.”—EMP

Complementary: Survey & Focus Groups (CHW & EMP)

9. Hire CHWs to provide health education and bridge critical gaps to care and community resources

Employers emphasized that CHWs work with and advocate for individuals and communities at large to address identified needs that are not being met as well as providing programming and support that registered nurses and other medical professionals cannot disseminate.

“Our CHWs work both with individuals as well as neighborhoods. So addressing the individual’s specific needs, self, personal identified needs and goals, but then also the environment that allows for access…and so the importance of the neighborhood learning to advocate for their environmental needs, and to build a community is really helpful…that really doesn’t fall into case manager or social worker space.”—EMP

“…identified those community resources that were reliable, that we knew were going to give good service, because we didn’t want our clients to be going someplace where they couldn’t receive, you know good care. So that’s a big part of the [CHW]work.”

Unique: Focus Groups (EMP)

10. Employer-identified facilitators of the hiring process

Facilitators of the CHW hiring process include, recruiting directly from client populations and include community partners, creating clear job descriptions with specific roles, provide full benefits to CHWs, have current CHWs present during interviews and onboarding, aim to hire internally, and include proper organizational leadership and relevant stakeholders during hiring process.

“…have the right people at the table at the beginning, even if [the CHW position is] not even approved yet. So that way we can plan, and other leaders are not blindsided to things that may impact their current workflow, or some of their staff.” —EMP

“I feel really strongly that those CHWs do need to be from the community, known in the community as the natural or informal leader” —EMP

Unique: Focus Groups (EMP)

11. Benefits of certification

CHW certification provide legitimacy and validation and offers CHWs the opportunity to strengthen their overall skill-base.

“It was a good…certification…just to kind of let people know in the community I’ve been doing this for a while. I’m a CHW, and I’m focused on what’s going on in the community.” —CHW

“The benefit to us for the community health worker certification, though, for our licensed Indiana navigators, that it just gives them another layer of competence. So as people contact us, you know, seemingly that they just need health coverage, but they might also need to be connected to the application for food stamps, or you know, other things. It’s just kind of this multi layered interaction with people and so that’s the benefit to us.”—EMP

Unique: Focus Groups (CHW & EMP)

12. Certification training programs and preferences

CHWs were introduced to certification and encouraged to become certified by their employers and felt that the in-person training was positive, provided opportunities to network, and was preferred.

“I did the weeklong in person, and it was a ton of information. I felt that it could have at least been a good additional 2 days. It was just so much.” —CHW

“They [CHWs] really liked it…people always had good things to say about that [in-person] training.” —EMP

Unique: Focus Groups (CHW & EMP)

13. Certification vendors and guidance

CHWs reported what vendor they received their certification from while employers spoke of the guidance from the state regarding CHW certification.

“They’re [certifications] from various organizations and schools…Health Visions, IUPUI…I can’t think of them all.”—CHW

“I think we just need the state to say, this is the training. And this translates to what you’ll be able to bill, without there being any question about that. And so I think the legislative piece, like that state piece, being in place, would be huge. And to know… this is the training that leads to this, that leads to you being able to bill through this, having that, and I know, we’re trying to piece all that together. But putting that to bed would be great… that would be a huge step.” —EMP

Complementary: Survey & Focus Groups (CHW & EMP)

14. Certification affordability

Certification was often paid for by the employer organizations, grant or funding agencies, or by scholarships and there are opportunities for certification cost reimbursement and discounts that are covered by the state. The many avenues for certification reimbursement and cost have led employers to feel confused.

“[Our employers paid for] the six of [to go] off site to another location and took our certification training with other people from other agencies. So someone came in and gave us all training, that 40 h training. We took it all in 1 week.”—CHW

“I had heard that taking the class for just CHW [certification] was kind of expensive…it was even more money than just doing the whole CRS/CHW program. So I think that could deter some people from becoming CHWs” —EMP

Complementary: Survey & Focus Groups (CHW & EMP)

15. Continuing education

While continuing education is not required by the state of Indiana, CHWs expressed a desire to completed additional educational and training opportunities but had to seek these opportunities out on their own.

“Some annual conference or something that goes on every year, speakers are brought in and things like that…to learn from other CHWs about best practices would be very beneficial in person or on zoom at least.” —CHW

“It [training] was on the front end. And then it was just me like ‘oh that looks good, I should learn about this.’ A lot of it is on us to stay trained. But then also like if we aren’t people that take initiative, we’re just missing out.”—CHW

Complementary: Survey & Focus Groups (CHW)

16. Challenging aspects of the jobs

Challenges discussed by CHWs included a lack of understanding on who CHWs are and their positions, working in an undervalued and underpaid role, and a lack of resources to support their communities but feeling pressure to find resources anyway.

“Well, one of the problems we had before is, nobody had a clear definition of what a CHW was or does. And we’re still grouped into a lot of different things. We have people who do insurance, we have people who do education, we have folks who do goal setting, we’re still all over the place, so to speak. But it’s being defined more readily now. So people are starting to learn about it, because I don’t think my job really knew what a CHW did either.” —CHW

“It kind of falls squarely on us when a patient has need for housing, like immediately, or has need for legal help, or whatever it may be. So I feel like it puts a lot of pressure on for us to kind of pull a rabbit out of the hat…”—CHW

Unique: Focus Groups (CHW)

17. Rewarding aspects of the job

CHWs enjoyed making a difference in the lives of and empowering their clients as well as being recognized by their team.

“Just knowing that you’ve helped somebody today, that what you’re doing literally could be changing somebody’s life. And that’s very powerful, very rewarding. And makes all of the hassles that you deal with at work on a daily basis, the end of the day, you go home, you know someone’s day, someone’s life is better, because you’ve stepped in.” —CHW

“We sit down and have this action plan and kind of hold them accountable, it makes them feel good that they’re accomplishing it. And it makes me feel good that I gave them the tools and resources to make them feel competent in that.” —CHW

Unique: Focus Groups (CHW)

18. CHW recommendations

Recommendations to address identified job challenges were shared by CHWs. For example, expanding the workforce and receiving more CHWs, improving coordination and communication between service organizations and state agencies, demonstrating the importance of the workforce, and providing additional resources and trainings were offered to improve CHW positions.

“Some training on how to show your work because for grants, you have to show your work for your bosses, you have to show your work in order to impress them or show them the need for more of you.” —CHW

“Be more visible in the community, so more people know what CHWs are, what we do.” —CHW

Unique: Focus Groups (CHW)

19. Importance of collecting and reporting data on CHW outcomes and outputs

Reporting CHW impacts justifies CHW position, demonstrates a return on investment, and makes the case to hire additional CHWs.

“I always wanted to show our outcomes. And I think that’s a good way to try and release yourself a little bit from grants to show how valuable you are to the organization. The bottom line is finances do count.” —CHW

“You have to make the case mathematically. That is something that I think that statewide, we could do something about, like having a system where we could help CHWs show their math, show the work because administrators typically aren’t going to hire more people unless you can show them how it’s affected the budget…how many more patients were brought in, how many people actually showed up to their follow up visits…how many people got insurance instead of us putting them in the write off bucket…we go them insurance, and they are now insured patients instead of uninsured.” —EMP

Unique: Focus Groups (CHW & EMP)

20. Metrics and key performance indicators for employer-defined success

Employers described output metrics, outcome metrics, and metrics for CHWs who work in community development. Examples of these metrics and key performance indicators include number of enrolled patients and community outreach events, tracking referrals and program attendance, client-reported outcomes, and follow-up rates.

“We are outcome based as well. So we keep track of how many referrals we get each week and in our tracking system we don’t’ count until that person has received their medication or that person successfully received SNAP or HIP or Medicaid…”—EMP

“And so now we’re at a better state because we’ve got with the Epic. We have what we call registries that can capture that information [A1C, ERA diabetic] behind the scenes, that looks at all that metrics, and all we have to do is plug in, like we enroll our patients within what we call episodes of care, which crack those patients who are in there. But we can pull reports that shows people within this episode what their data looks like compared to those who are not.”—EMP

Unique: Focus Groups (EMP)

21. Metrics and key performance indicators for CHW-defined success

CHWs identified establishing relationships with clients and community they serve, the amount and quality of resources provided to their clients and reaching programmatic benchmarks and enrollment goals as success measures.

“For me, I would define success as going into my job every day to the best of my ability, having a positive attitude, leaving any issues I may personally have the side and letting the customer or client be the focal point to try to find out whatever I can and fulfill what they need to try to help them because after all, they do appreciate what we do. So it’s important that we find the resources for them [clients] or make the connections for them. And once I do those things, I feel like I’m doing pretty good.” —CHW

“For me, I would say using data, like our enrollment numbers every month and seeing if we had losses and membership of certain programs. And if you’ve seen an increase, what attributed to that increasing? So I will use enrollment data a lot to help gauge how I’m doing.” —CHW

Unique: Focus Groups (CHW)

22. Current and needed tools to track CHW outcomes and outputs

Several employers expressed the need for standardized tools to track metrics or key performance indicators of CHW impact. Some employers utilize electronic medical record-based registries, Recovery Inventory, Star, Strength and Risk Assessment, Child and Adolescent Needs and Strengths and Adult Needs and Strengths Assessment state tools, and Insight Vision

“One thing I notice is that when we were looking for evaluation tools for CHWs they’re not really there. If they are, I just haven’t found them because I thought that maybe there’d be some evidence-based tool out there that we could just pick up and then bring here and use. And I think we tend to do it more so on our own looking at these are the metrics we need to be measuring. But we’ve really looked at like different studies that are out there, but nothing has been usable that I’ve look for…I really would like to get out of grant world.” —EMP

“So now it’s easily done by our EMR system, and a lot of it boils down to what are the health outcomes? Form a medical standpoint, how are these CHWs benefiting the patients and how’s their A1c improving…blood pressure control…health condition metrics that we have to monitor now, to be able to compare against our other cohorts who are not utilizing our service to say that this is the return on investment. I think we’ve gotten better with the EMR tool that we chose.” —EMP

Unique: Focus Groups (EMP)

23. Supervision

The potential for CHWs to “train-up” into a supervisory role and group and one-on-one supervision models were discussed. CHWs also described characteristics of an ideal supervisor as someone who has done the work of a CHW and is supportive.

“The support of the supervisor is very, very important. When they recognize what we are doing. And they realize that is really a good job. And, and it’s important. It’s, it makes a difference.” —CHW

“I manage our CHWs, but I myself became a CHW, and I do the same role that they do, even though I supervise our entire department, I still do the referrals, I still do the community outreach, I do the home visits. So I know I am able to advocate for our advocates on what they need.” —EMP

Unique: Focus Groups (CHW & EMP)

24. Professional Development

CHWs expressed few opportunities for professional development and felt their positions did not have clear pathways for promotion. Desired advancement of their roles included becoming a supervisor, teaching other CHWs in programs beyond their current role, and creating new programs.

“So within the organization, there are not too many [promotions]. But if something comes open, and you’re interested in you can apply.” —CHW

“I would like to advance at some point and either start a new program working with the same population or change a program. I’m not sure but something in an administrative role, at some point.” —CHW

Unique: Focus Groups (CHW)

25. Peer Support

INCHWA serves as the primary avenue for peer support. CHWs reported occasions participations in INCHWA functions such as email, huddles, and webinars. CHWs appreciated these INCHWA touchpoints to increase camaraderie and networking within the CHW community but expressed interest in an annual conference and were unclear of all INCHWA’s roles and responsibilities.

“I feel like they’re [INCHWA] advocating for CHWs from what I’ve seen, and for better pay, better representation, and more of a voice in the medical community. And I really applaud INCHWA for doing that [advocacy]. And making it seem legitimized as a profession.” —CHW

“Maybe having an annual conference, I just feel like that just benefits us, everyone. People really enjoy that in the camaraderie…a yearly conference that we can go to and learn more things that we otherwise might not have the opportunity to.” —CHW

Unique: Focus Groups (CHW)

26. CHW position funding

CHW position are supported by various sources of funding. Employers and CHWs agreed there is no guarantee of consistent job security for grand funded position which can lead to time-limited positions. Employers spoke about grant availability and the role funding plays in sustaining and extending the CHW workforce.

“We work for a not for profit. So things change there all the time, funding could go at any moment.” —CHW

“We definitely need to know when different grant opportunities are available…I can look for grants, like take some time out to look for them…but with everything else, I have to do I just take that much more time to actually look for specific grants that fit my programs…because it’s never really been about not being able to write…it’s more about I didn’t’ get this grant and enough time to write it.” —EMP

Unique: Focus Groups (CHW & EMP)

27. Billing and reimbursement

CHWs and employers expressed confusion and lacked awareness of the details surrounding the logistics of CHW reimbursement. Participants encountered barriers to successful Medicaid reimbursement, including the inability to bill for every client and an array of CHW services that are not clearly defined within reimbursement language.

“…it’s a chicken and egg thing, if they would reimburse more, they would hire more community health workers, but a lot of places don’t see it as a valid investment and so they don’t bother with it. Can we at least have a decent reimbursement model of some kind?” —CHW

“Because knowing that all these different levels of position exists, it’s hard to get a more concrete understanding of what’s a part of that CHW service definition.” —EMP

Unique: Focus Groups (CHW & EMP)

28. Employers offered suggestion for billing and reimbursement

Employers stated a need to expand opportunities to bill services provided by CHWs for reimbursement provided suggestions such as more effective collaboration between their organizations and the medical profession and Z code usage to support future reimbursement efforts.

“…if our doctors or providers would work closer together, and they would look through the curriculum with me, we could work as a partner, and I could educate, educate the group, and get reimbursed for his patients, because I’m helping his patients, they helped me.” —EMP

“We use the Z codes and we’re starting to track those through the ICD-10 codes. And we’re gonna start working with those just because we’re trying to set it up is if we could bill. So we’re changing our HER and we’re able to attach with our service, what we’re doing for those people.” —EMP

Unique: Focus Groups (EMP)