Transforming Lives: How Community Health Workers, Promotoras, and Health Representatives Address Food Insecurity

Feature Story

By Alejandra Cabrera, MPH, and Kathryn Jantz, MSW, MPH

Published July 11 2024

Picture being an adolescent with significant behavioral health challenges and poor dental health, making it difficult to eat properly and consume the appropriate level of nutrients needed to continue to grow. Now, add the complication of needing to take medication that causes nausea if not taken with food. This is the reality for Dani (name changed for anonymity), a teenager in Massachusetts. Dani is already receiving Supplemental Nutrition Assistance Program (SNAP) benefits, but finds that the funds simply aren’t enough to address their nutritional needs – a challenge compounded by the need for soft, palatable food and a lack of necessary kitchen appliances, such as a blender, to prepare suitable meals. This fragile situation puts Dani at risk for worsening health issues due to inadequate nutrition.

A Dedicated Community Health Worker Steps in to Help

Enter Emma Goulet, a dedicated Community Health Worker (CHW) at Community Care Cooperative (C3), an Accountable Care Organization (ACO) that leverages the collective strengths of Federally Qualified Health Centers (FQHCs) to improve the health and wellness of the members they serve. As a CHW for one of C3’s Care Management programs, Emma’s role focuses on supporting Medicaid enrollees during the critical two months following their discharge from a psychiatric hospital stay.

As part of her intake process, Emma conducted a screening to talk with Dani about their social circumstances, and in that conversation, she discovered that Dani was experiencing food insecurity. Emma referred Dani for nutrition services through the Massachusetts Flexible Service program (Community Care Cooperative Flexible Services Program Page), a program authorized by the Massachusetts Medicaid 1115 demonstration waiver that allows healthcare organizations to provide direct nutrition and housing services to its members. Through this program, Dani received kitchen supplies, including a blender, and grocery vouchers to supplement their SNAP benefits. To learn more about other state-based, Medicaid-funded food programs, visit the Medicaid Food Security Network Policy Dashboard.

But Emma didn’t stop there. Understanding the broader needs of her clients, she started a utility and clothing drive within her community. The response was overwhelmingly positive, allowing her to acquire an ice cream maker for Dani, which helped them prepare more palatable foods, making eating easier and more enjoyable.

Emma’s professional commitment extends beyond referrals and donations. She supports her clients by accompanying them to their first outpatient therapy appointments, visiting food pantries, and helping them complete SNAP applications, as well as connecting to other benefits and community resources. For those unable to complete SNAP applications independently, she provides telephonic consent to complete them on their behalf. Each application process, she notes, takes between ten minutes (if she fills it out) and thirty minutes (if the client does).

The Power of Community Health Workers

During the two months she works with her clients, Emma is usually able to follow the SNAP application process through to activated benefits. While SNAP provides an important foundation for increasing food stability, it often does not cover a household’s entire food costs, particularly for teenagers with high caloric needs. As an expert in community resources, she knows how to help her clients navigate these resources. For example, she knows which food pantries require proof of residency and income, which can be challenging for her clients to provide, and which ones are more flexible.

Emma’s story is a testament to the vital role of Community Health Workers, Promotoras, and Community Health Representatives (CHW/P/Rs) nationwide in addressing food insecurity among children and families. Every CHW/P/R we’ve had the honor of connecting with in writing this article showcased the power of a community-based workforce with local knowledge, lived experience, and the ability to cultivate trust within their communities to address their clients’ social and health needs. Recognizing this, the Medicaid Food Security Network has included Community Health Worker funding as an important strategy to address food in our Promising Strategies document.

Yvonda Carcini, a CHW at Health Net of West Michigan that the MFSN also connected with, recounted an instance where a homebound client who lacked access to food expressed gratitude for ensuring she had sustainable food delivery services. Yvonda emphasized that “no one should be stressed out about not having food in their fridge.” Similarly, Sarybet Gonzalez, another CHW at Health Net of West Michigan, shared the story of a client who recently lost his sight and struggled with navigating the process of applying for SNAP. By assisting him in accessing food delivery services and supporting him through benefit applications, Sarybet felt a deep sense of pride in supporting him through his challenges.

Medicaid Options for Financing Community Health Workers

Emma’s work is funded by Massachusetts Medicaid which enables Medicaid Accountable Care Organizations to support CHWs as part of primary care teams as well as through dedicated care management teams that support patients with specific health conditions. Learn more about Medicaid ACOs by visiting the Center for Health Care Strategies Accountable Care Organization Resource Center.

According to the Kaiser Family Foundation tracker of Community Health Worker policies, 29 states allow Medicaid payment for Community Health Worker services. Since Medicaid programs are administered by individual states, there are a variety of ways in which Medicaid programs can support the CHW role. States have many policy pathways to financially support CHWs. Those include section 1115 waivers, State Plan Amendments, the Medicaid Managed Care rule (which enables states to permit MCOs to categorize CHW as as services costs or to implement In Lieu of Services) and other options. While not an exhaustive list, here are some of the financing approaches we encountered in our interviews and research:

Pay for Team-Based Primary Care that includes CHWs: Many states have financing models to support whole-person primary care. Often these financing approaches support care teams that include members such as nurses, CHWs, peer recovery coaches, and family partners in addition to the primary care provider. Massachusetts Medicaid (MassHealth) implemented a primary care sub-capitation model in 2023, to pay primary care providers a per-member-per-month rate rather than reimbursing providers for patient visits and services. With a goal to address health equity, this approach can incentivize the inclusion of CHWs as part of the primary care team (more information can be found in this Milbank Memorial Fund article).
Pay for Care Management supports that include CHWs: Many states’ Medicaid Managed Care Programs include funding mechanisms for complex care management or enhanced care coordination. These programs engage nurses, social workers, and CHWs to provide intensive health care and social supports for enrollees with complex physical and/or behavioral health conditions as well as those who need transitional care after hospitalization. Emma’s role is funded through this type of program.
Pay Fee For Service for Community Health Workers: Some states allow CHWs to bill fee-for-service, meaning that for certain populations and certain activities, CHWs can bill directly just like a healthcare provider would submit a claim for a visit. States may have different rules around this reimbursement such as requiring that CHW care is provided under the supervision of a Medicaid-enrolled medical professional.

Challenges for Medicaid-funded Community Health Workers

While Emma’s story showcases the profound impact of CHWs, these interviews also highlight the challenges and lessons from various states’ experiences with Medicaid reimbursement for CHW services:

Administrative Burden

Organizations that offer CHW services that are not existing Medicaid providers face significant barriers in becoming CHWs. Two strategies that seem to reduce the administrative burden are (1) providing flexible funding and (2) providing onboarding support.

Flexible Funding: Prior authorizations and significant documentation needed for billing can hinder the sustainability of Medicaid-funded CHWs. Massachusetts’ per member per month payment model has allowed CHWs like Emma to operate effectively and efficiently without these constraints.
Onboarding support: Health Net of West Michigan reported that Michigan’s step-by-step instructions including PDFs, videos, and pictures are helpful guides to support their organization in becoming a Medicaid billing entity. In states with 1115 waivers, this onboarding support can even include funds that go directly to clinics to support systems changes, access to technical assistance resources and support in developing contracts with MCOs.

Reimbursement

Adequate reimbursement can be a challenge to developing and retaining a CHW workforce that is able to be serving individuals in the community. Two specific challenges were elevated:

Hiring and maintaining high-quality community health workers: One interviewee noted that while the CHW/P/R role is ideal for someone in their early twenties, the salary is not sufficient to support a family. Pragmatically, we know that it is challenging, if not impossible, to effectively help someone else navigate their food insecurity when you are currently experiencing food insecurity as well.
Reimbursing for travel time and costs: Travel policies need to align with remote and community-based work. One CHW shared that their travel policy is based on distance from the organization’s office, but she was hired to work remotely, and so this model doesn’t accurately reflect the distances she is actually traveling. On her salary, the costs of driving to meet clients can be prohibitive.

The Path Forward

In developing this blog post, we heard numerous stories of CHWs building critical relationships and supporting individuals in countless ways, including addressing food needs. Our research also highlights the critical need to ensure that emerging Medicaid CHW funding and policies are designed in a way that supports community-based CHW programs.

To stay connected, join us for our next MFSN quarterly convening, where we’ll dive deep into this critical topic. To learn more about CHW/P/Rs and connect with CHW/P/R organizations in your area, visit the National Association of Community Health Workers. For insight into how states have integrated CHW provisions into their Medicaid contracts, explore the MFSN Policy Dashboard.