Organizations in value-based contracts, particularly those taking on Medicaid risk, have a mandate to reduce acute care utilization for high- and rising-risk patients—or face financial penalties. However, at-risk patients with multiple complex clinical and social needs can be difficult to manage at scale given the limited budgets of population health departments.

A community health worker (CHW) program is one sustainable approach to supporting complex patients. As defined by the CEO of City Health Works, Manmeet Kaur, a “‘community health worker’ is an umbrella term that means one thing: a non-clinical person hired from the community that they serve.” These lower-cost staff, often salaried by a provider organization, address social needs and support disease self-management. CHW programs offer substantial return on investment (ROI) when implemented effectively.

This toolkit outlines five steps for implementing a sustainable CHW program: Determine program scope, secure funding, source talent, create a retention plan, and demonstrate long-term performance. Each step is supported by sample resources including ready-to-use slides, recruiting guidelines, day-in-the-life summary, and sample performance dashboards.

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Step 1: Determine program scope

There is no standard job description for a CHW. The best programs tailor their model to the specific needs of their communities. While all programs aim to address patients’ social determinants of health, CHWs can also support self-management among those with chronic conditions. Once leaders determine program goals, they should scope the CHW role. Key elements to consider include target patients and panel sizes, patient management timelines, service offerings, and referral strategy.

This section includes tools to help providers determine program scope, including:

• Tool: CHW program case study compendium
• Tool: CHW cheat sheet

Step 2: Secure sustainable funding

The concept of a CHW—a lay community member who helps patients achieve care plan goals—is not new. However, program leaders need to socialize the CHW role across key organizational stakeholders to secure long-term funding.

This section includes tools to help providers secure sustainable program funding:

• Tool: Ready-to-use slides to make the case for program investment
• Tool: Funding sources brainstorming guide

Step 3: Source talent using nontraditional methods

CHW program efficacy hinges on recruiting and training the right talent. However, organizations that use the same hiring practices as they do for more traditional roles often fail to hire the right people, train them effectively, or use them at top-of-license.

This section includes tools to help providers source talent using nontraditional methods:

• Tool: Staffing model decision guide
• Tool: Sample job description
• Tool: Recruiting and hiring guidelines

Step 4: Create a retention plan

There are several reasons why CHW programs can have high turnover rates. To provide effective care, CHWs need sufficient training, proper tools, and supportive day-to-day management. Program leaders also develop tools to support CHWs across settings and maximize role efficiency.

This section includes tools to help providers create a retention plan:

• Tool: Sample training schedule
• Tool: Overview of a CHW’s daily role
• Tool: Sample financial needs assessment
• Tool: Sample career mapping process

Step 5: Demonstrate long-term performance

Most CHW services are not reimbursable in fee-for-service contracts except in states where CHWs are fully enrolled as Medicaid providers. Leaders often measure program ROI by estimating avoided downstream costs in both the short and long term. Providers should track performance management indicators that ensure CHWs operate at full capacity.

This section includes tools to help providers demonstrate long-term performance:

• Tool: Program metric picklist
• Tool: Sample performance measurement dashboard
• Tool: Calculator for the value of saved clinical time saved
• Tool: CHW ROI estimator