COMMUNITY HEALTH WORKER SERVICES

GENERAL

This chapter contains rules regarding community health worker (CHW) services.

(1) For the purpose of this chapter, CHWs are frontline public health workers who are trusted members, or have a close understanding, or both, of the community served. This trusting relationship enables CHWs to serve as liaisons, links, or intermediaries between health or social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

(2) CHWs may provide preventive services at any of the following three levels:

(a) Primary prevention. This level focuses on preventing the onset of disease or injury before it occurs by reducing risk factors and promoting healthy behaviors;

(b) Secondary prevention. This level focuses on early detection and prompt intervention to halt the progress of a disease, injury, or event during its initial phase. This includes conducting appropriate screenings and assessments for conditions; or

(c) Tertiary prevention. This level focuses on reducing the impact of an ongoing disease or injury and on managing and improving the quality of life for individuals with established diseases or conditions.

The following definitions and those found in chapter 182-500 WAC apply to community health worker (CHW) services.

"Agency" - See WAC 182-500-0010.

"Care coordination and health system navigation" - Helping clients to:

(a) Identify providers to receive services;

(b) Make appointments for services, arrange transportation to health care appointments, and attend appointments with clients for health care services; and

(c) Find other relevant community resources such as support groups.

"Client" - A person who is an applicant for, or recipient of, any Washington apple health program, including managed care and long-term care. See definitions for "applicant" and "recipient" in RCW 74.09.741.

"Community health representative (CHR)" - Community health representatives (CHRs) are well-trained, medically guided, tribal and Native community people, who provide a variety of health services within American Indian and Alaska Native communities. CHRs are recognized as CHWs for the purposes of CHW services.

"Community health worker" or "CHW" - A frontline public health worker who is a trusted member, or has a close understanding, or both, of the community served. This trusting relationship enables the CHW to provide direct services as well as serve as a liaison, link, or intermediary between health or social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.

"Community health worker services" - A type of preventive health services that:

(a) Helps prevent disease, disability, and other health conditions or their progression; prolongs life; and promotes physical and mental health and efficiency;

(b) Provides tailored support and system navigation to help address unmet health-related social needs that significantly limit a practitioner's ability to carry out a medically necessary treatment plan; and

(c) Provides navigation in the treatment of a serious, high-risk condition or illness. These services help guide the client through their course of care including addressing any unmet social needs that significantly limit the client's ability to engage and follow their plan of care.

"General supervision" - The medicaid-enrolled, licensed practitioner supervising the CHW is responsible for providing guidance, support, and oversight to ensure that CHWs and CHRs are effectively performing their roles, monitoring the course of care, and delivering quality services to the community.

"Health education and promotion" - Helping clients to:

(a) Contextualize health education provided by the client's treatment team with the client's individual needs, goals, and preferences, in the context of the principal illness and/or SDOH need(s) and educating the client on how to best participate in medical decision making; and

(b) Build client self-advocacy skills, so that the client can interact with members of the health care team and related community-based services addressing the principal illness and SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment.

"Health-related social needs (HRSN)" - Health-related social needs (HRSN) are an individual's unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health (conditions in which people are born, grow, work, and age).

"Lived experience" - Having first-hand knowledge and insight gained from navigating challenges similar to those faced by the people in the community. This can include shared experiences like cultural backgrounds, socioeconomic status, health conditions, or barriers accessing the health and social service systems.

"Medicaid agency" - See WAC 182-500-0070.

"Person-centered assessment" - Conducting a person-centered assessment to understand the client's life story, strengths, needs, goals, preferences, and desired outcomes including understanding cultural and linguistic factors and including unmet SDOH needs to establish a plan of care.

"Preventive services" - Services that help prevent disease, disability, and other health conditions or their progression; prolong life; and promote physical and mental health efficiency.

"Supervision" - Key aspects of supervision include, but are not limited to:

(a) Training and professional development;

(b) Performance monitoring;

(c) Support and mentorship; and

(d) Problem-solving and conflict resolution.

"Washington apple health" - See WAC 182-500-0120.

(1) The medicaid agency gives the client written notice of an action under chapter 182-518 WAC.

(2) The client has the right to appeal the agency's adverse action according to chapter 182-526 WAC.

To receive community health worker (CHW) services, a person must:

(1) Be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060, except for the medical care services (MCS) programs; and

(2) Be recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130, following an initiating visit with one of the following criteria:

(a) An unmet health-related social need (HRSN) that limits the ability to engage in health care services;

(b) A positive adverse childhood experiences (ACEs) screening;

(c) One serious, high-risk condition that places the client at risk of any of the following:

(i) Hospitalization;

(ii) Institutionalization/out-of-home placement;

(iii) Acute exacerbation or decompensation; or

(iv) Functional health decline or death;

(d) Two or more missed health care appointments within the previous six months;

(e) The client, client's spouse, or client's family member expressed a need for support in health system navigation or resource coordination services;

(f) A need for recommended preventive services; or

(g) A condition that requires monitoring or revision of a disease-specific care plan and may require frequent adjustment of the medication or treatment regimen or substantial assistance from a caregiver.

(1) Community health worker (CHW) services must be initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130.

(2) During the initiating visit, the health care professional:

(a) Identifies that the client exhibits one of the criteria found in WAC 182-562-0200(2);

(b) Establishes a care plan; and

(c) Provides a written recommendation for the client to see a CHW or community health representative (CHR). A written recommendation for services may be provided in physical or electronic form including, but not limited to, electronic health records (EHRs), secure digital forms, or other compliant electronic documentations.

(3) The initiating visit must be personally performed by the licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130.

COMMUNITY HEALTH WORKERS

(1) To be paid for providing community health worker (CHW) services to Washington apple health clients, a CHW must:

(a) Deliver the CHW services under the general supervision of a medicaid-enrolled, licensed practitioner within the scope of their licensure as described in state law;

(b) Have lived experience that aligns with and provides a connection between the CHW and the community being served;

(c) Have 2,000 supervised hours working as a CHW in paid or volunteer positions within the previous three years and demonstrated skills and practical training in the areas listed in this section;

(d) Possess the following skills or core competencies:

(i) Communication;

(ii) Interpersonal and relationship-building;

(iii) Service coordination and navigation;

(iv) Advocacy;

(v) Capacity building;

(vi) Professional conduct;

(vii) Outreach;

(viii) Individual and community assessment;

(ix) Knowledge base in public health principles and social determinants of health (SDOH);

(x) Education and facilitation; and

(xi) Evaluation and research; and

(e) Demonstrate minimum qualifications through one of the following:

(i) CHW/CHR certificate. A certificate of completion including, but not limited to, any certificate issued by the Washington state department of health, or its designee, or Indian health services of a curricula that attests to demonstrated skills or competencies, or both, listed in (d) of this subsection; or

(ii) Supervisor attestation. Medicaid-enrolled, licensed supervisors may demonstrate the CHW's skills and competencies by conducting a CHW assessment and attesting to the CHW's skills and competencies. The supervising provider must maintain documentation of the CHW assessment. Trainings may also include health-specific topics including, but not limited to:

(A) Health coaching and motivational interviewing;

(B) Immunization across the lifespan;

(C) Family planning and wellness;

(D) Cardiovascular health and heart disease;

(E) Understanding disparities and social determinants;

(F) Behavioral health care;

(G) Cancer screening and prevention;

(H) Conducting food insecurity screening;

(I) Child development/early relational health;

(J) Mental health first aid; and

(K) Substance use.

(2) CHWs that do not meet any of the identified skills or practical training areas listed in this section must obtain the necessary training within 18 months of employment during which CHW services may still be billed. Once the 18 months have been completed, if the CHW does not meet the necessary training requirements, the agency will no longer pay for services billed until the training requirements are met.

(3) CHWs must complete a minimum of six hours of additional training annually. The supervising provider must maintain documentation of the CHW's completion of continuing education requirements.

Community health workers must fulfill the documentation requirements in the medicaid agency's community health worker (CHW) services billing guide including, but not limited to, documenting in the client's health record:

(1) Advance client consent. Consent must be obtained by the licensed, qualified health care professional or CHW before rendering services and billing for CHW/CHR services. Consent may be verbal or in writing;

(2) The date and time/duration spent with the client and the nature of the activities;

(3) The location of services;

(4) The services performed, specifying the following:

(a) Whether they were provided to an individual or a group; and

(b) If they were provided to a group, the number of clients in the group;

(5) All identified needs of the client served including, but not limited to, health-related social needs that services are addressing (e.g., the client's diagnosis as defined by the current revision of the International Statistical Classification of Diseases and Related Health Problems); and

(6) The name of the CHW or CHR rendering the services.

The medicaid agency covers the following services when performed by a community health worker (CHW):

(1) Conducting person-centered assessments within their focus to:

(a) Identify personal health goals and preferences;

(b) Assess for physical, mental, behavioral, and social challenges; and

(c) Collaborate with the client to establish health goals;

(2) Care coordination and health system navigation including the following:

(a) Coordinating additional supports or specialty services;

(b) Managing the client's care plan; and

(c) Assisting the client in identifying and accessing resources;

(3) Facilitating behavior change and client self-advocacy including the following:

(a) Promoting client motivation to participate in care and reach person-centered diagnosis or treatment goals;

(b) Teaching techniques for self-monitoring and self-advocacy; and

(4) Health education and promotion including the following:

(a) Helping clients to contextualize health education provided by the client's treatment team with the client's individual needs, goals, and preferences, in the context of the principal illness and/or SDOH need(s) and educating the client on how to best participate in medical decision making; and

(b) Building client self-advocacy skills, so that the client can interact with members of the health care team and related community-based services addressing the principal illness and SDOH need(s), in ways that are more likely to promote personalized and effective diagnosis or treatment.

Under this chapter, the medicaid agency does not cover the following services when provided by community health workers (CHW):

(1) Clinical care management services that require a state credential;

(2) Child care;

(3) Chore services, including shopping and cooking;

(4) Companion services;

(5) Employment services;

(6) Enrollment assistance for government programs or insurance not related to improving health;

(7) Delivery of medication, medical equipment, or medical supplies;

(8) Respite care;

(9) Services that duplicate another medicaid-covered service;

(10) Socialization; and

(11) Transportation.

SUPERVISING PROVIDERS

(1) Under this chapter, a supervising provider must:

(a) Be enrolled as a provider with the medicaid agency;

(b) Be one of the following licensed practitioners:

(i) Health care professional;

(ii) Health care entity;

(iii) Supplier; or

(iv) Contractor of service; and

(c) Meet the requirements under chapter 182-502 WAC.

(2) A supervising provider must also:

(a) Understand the specific roles, responsibilities, and scope of practice for CHWs;

(b) Provide or facilitate training and professional development for CHWs; and

(c) Maintain accurate and thorough records related to supervision, performance, and compliance.

In addition to the requirements in WAC 182-502-0020, supervising providers must document the following:

(1) Required supervision records for community health workers;

(2) Continued education verification and renewal of credentials for professional staff; and

(3) Consent forms and documentation for screening, assessments, care plans, case conferences, case management, care coordination, and health system navigation for each client.

(1) The medicaid agency pays for the covered community health worker (CHW) services described in this chapter when they are:

(a) Initiated and recommended by a physician or other licensed practitioner of the healing arts, as specified in 42 C.F.R. 440.130;

(b) Provided and billed according to the agency's community health worker (CHW) services billing guide; and

(c) Documented in the client's record or chart per WAC 182-562-0900.

(2) The agency pays providers for covered services provided to eligible clients using the agency's published fee schedule.

(3) The agency uses the appropriate payment methodology found in WAC 182-531-1850 for community health worker services.

(4) For children age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program. See chapter 182-534 WAC. EPSDT is defined under WAC 182-500-0030.