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Community Based Organization Resources

Assessment

Pear Suite and the California Health Care Foundation (CHCF) are working together to help Community-Based Organizations (CBOs) like yours. We have released a new CBO Readiness Assessment. This tool helps your team see what they need to better support the delivery of high quality, efficient and effective services to people enrolled in Medicaid in your community.

If you have not completed the CBO Assessment, please click on the button below to learn more!

CBO Readiness Assessment
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Resources for the Pear Suite CBO Readiness Assessment

These materials specifically address leadership engagement, strategic planning, and the operational integration of Community Health Workers (CHWs).

Part 1: Leadership & Strategic Operations

I. Understanding Care Management and CHW Reimbursement

  • Full Title: How Managed Care Organizations Can Authentically Partner with Community Health Workers
  • Description: This brief, developed by NACHW and UnitedHealthcare, provides a historical overview of the CHW profession and offers practical recommendations for healthcare leaders and Managed Care Organizations (MCOs). It focuses on how to authentically integrate CHWs into care delivery systems, sustainable financing models, and effective workforce development strategies to improve health and racial equity.

II. Strategic Alignment

    • Full Title: Community health worker team integration in Medicaid managed care: Insights from a national study (Abstract/Study)
    • Description: This peer-reviewed study examines the roles and integration status of CHWs within Medicaid Managed Care Organizations across the United States. It highlights current integration gaps, such as the tendency for MCOs to focus on clinical referrals rather than community-level advocacy, and provides data to help CBOs align their internal structures with broader Medicaid goals.

 

  • Full Title: Leveraging Medicaid to Support Community Health Workers
  • Description: This policy brief from the Association of State and Territorial Health Officials (ASTHO) explores state-level pathways for sustaining the CHW workforce through Medicaid. It provides a strategic roadmap for organizations looking to navigate different Medicaid reimbursement mechanisms, such as State Plan Amendments (SPAs) and 1115 waivers.

III. CHW Certification & Readiness

    • Full Title: A Guide to Community Health Worker Certification
    • Description: This resource from Pear Suite breaks down the importance of certification for the CHW profession, explaining how it legitimizes the workforce and opens doors for sustainable billing. It provides a state-by-state perspective on certification requirements and helps organizations understand how to support their staff in becoming certified to meet Medicaid billing standards.

 

IV. Financial Sustainability

  • Full Title: Sustainable Financing of Community Health Worker Employment: Key Options for States to Consider
  • Description: This comprehensive NACHW report outlines key pathways for moving CHW programs away from time-limited grants toward permanent funding. It identifies critical options for CBOs and state actors, including:
    • State Medicaid Policy: Using 1115 waivers and State Plan Amendments (SPAs) to embed CHW services into core operations.
    • Managed Care Contracts: Incorporating CHWs into health plan agreements as “value-added” services.
    • Blended and Braided Funding: Combining multiple streams (federal grants, local taxes, and private provider budgets) to support specialized CHW roles.

V. Insurance and Risk Management

    • Full Title: What Basic Insurance Coverage Should a Nonprofit Consider?
    • Description: A foundational guide from the Nonprofit Risk Management Center that identifies the essential “lawsuit insurance” needed for CBOs. It breaks down:
      • General Liability: Covers bodily injury, property damage, and personal injury claims (like libel or slander).
      • Directors & Officers (D&O): Protects the organization and its leadership from “wrongful acts” in management decisions.
      • Professional Liability: Often called “Errors and Omissions,” this is vital for CHWs delivering counseling, referral, or other specialized professional services.

 

  • Full Title: State of the Insurance Market | 2025 Outlook | Nonprofit and Human Services
  • Description: This outlook report provides a 2025 forecast for the nonprofit insurance landscape. Key takeaways for CBOs include:
    • Rate Softening: Management liability (D&O) and Cyber insurance rates are starting to stabilize or even decrease.
    • Hard Markets: Organizations should prepare for continued rising costs in Umbrella and Professional Liability lines (expected to increase 15–30%) due to unpredictable claim settlements and “social inflation”.
    • Risk Management Mandates: Carriers are increasingly requiring “enhanced risk management oversight” as a condition for competitive rates.

Part 2: Change Management, Data and IT

These tools specifically support organizations in navigating complex cultural shifts and adopting new technology for specialized service benefits.

I. Change Management

    • Full Title: A Step-by-Step Guide to Change Management
    • Description: This guide from the Nonprofit Risk Management Center provides a practical roadmap for nonprofit leaders to navigate organizational shifts. It outlines actions for every stage of change, including scanning the environment (“balcony time”), communication strategies to build alignment, and supportive practices like “pre-mortems” to identify potential failures before they happen.

 

  • Full Title: A Change Management & Deep Equity Primer: The What, Why, How & Nuance
  • Description: Published by Movement Tapestries and Grantmakers for Effective Organizations (GEO), this primer introduces the Equity-Embedded Change Management (EECM) approach. It helps organizations move beyond standard DEI to “Deep Equity” by addressing social, structural, and energetic dimensions of change and encouraging a process of “reckoning” to restore trust.

II. Data, IT, and Billing Readiness

 

    • Full Title: ECM Billing Overview (Informative, INTERNAL)
    • Description: This set of presentation slides developed by BluePath Health provides a high-level overview of health care claims billing including sample billing solutions commonly seen within the healthcare claims billing landscape and sample billing workflows to assist organizations developing internal processes to generate and submit claims.

 

 

    • Full Title: Data Exchange Framework Education Session (Informative, INTERNAL)
    • Description: This presentation from BluePath Health provides an introductory overview of different health data types including: Admit, Discharge and Transfer data (ADTs), claims data, and labs and patient records. It also covers different types of data exchange methods to send and receive these different types of health information.

 

    • Full Title: HIE vs CIE Overview (Informative, INTERNAL)
    • Description: This presentation from BluePath Health provides an introductory overview regarding data sharing and highlights overall similarities and differences between health information exchanges (HIEs) and community information exchanges (CIEs).

 

 

    • Full Title: NIST Multi-Factor Authentication [PDF] (Informative)
    • Description: This page from the National Institute of Standards and Technology (NIST) covers the basics and key questions/considerations of implementing multi-factor authentication to improve organizational cybersecurity.

 

    • Full Title: Pear Suite ECM Key Performance Indicators/Metrics (Informative, INTERNAL)
    • Description: This resource developed by BluePath Health contains a variety of sample key performance indicators (KPIs) and metrics for care management providers to track to improve performance and compliance. The KPIs and metrics span three primary categories: operational, financial, and health outcomes.

 

 

Part 3: Technology Readiness

Goal: Data infrastructure, HIPAA compliance, and system integration.

 

 

    • Full Title: HIPAA Privacy and Security Requirements Overview (Informative, INTERNAL)
    • Description: Developed by BluePath Health, this presentation provides an overview of key HIPAA privacy and security basics and requirements. It covers the background and history of HIPAA; types of organizations that must comply with HIPAA; and operational and policies and procedure requirements required by the HIPAA Privacy and Security Rule.

 

    • Full Title: HHS HIPAA Security Rule Guidance Materials (Informative)
    • Description: This webpage, maintained by the U.S. Department of Health and Human Services (HHS), covers various resources for HIPAA covered entities and business associates to learn more about requirements under the HIPAA Security Rule and other standards for safeguarding electronic protected health information.

 

    • Full Title: HIPAA Privacy and Security P&P Checklist
    • Description: The HIPAA Privacy and Security P&P Checklist developed by BluePath Health outlines specific policies and procedures that a HIPAA-covered organization must develop and maintain in order to meet HIPAA’s documentation requirements. It covers documentation requirements across HIPAA Security, Privacy, and Breach Reporting Rule and additional operational actions an organization must consider.

 

    • Full Title: Privacy Explained for CBOs Webinar (Informative)
    • Description: Hosted by HC2 Strategies, in collaboration with Hooper Lundy & Bookman P.C. and BluePath Health, this webinar aims to demystify privacy laws and reveal how technology can support privacy compliance, ease data-sharing and support care collaboration among community-based organizations (CBOs) and healthcare partners.

 

  • Full Title: ONC/ASTP Security Risk Assessment Tool (Actionable)
  • Description: The Security Risk Assessment Tool was developed by Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC), in collaboration with the Department of Health and Human Services Agency (HHS) Office for Civil Rights (OCR), to assist small- to medium-sized organizations with conducting an internal security risk assessment to meet the security risk analysis requirements under the HIPAA Security Rule.

Part 4: Workforce Readiness

Building on your capacity-building toolkit, here are the full titles and detailed descriptions for the resources provided. These tools offer advanced guidance on supervision, program planning, integration strategies, and social needs screening.

I. Workforce Readiness: Supervision and Skills

    • Full Title: Supervision Strategies and Community Health Worker Effectiveness in Health Care Settings
    • Description: This discussion paper from the National Academy of Medicine (NAM) introduces the concept of supportive supervision, which emphasizes mentoring, joint problem-solving, and two-way communication. It provides a list of 18 essential qualities for CHW success and offers guidance for supervisors on how to assess these traits during hiring through role-playing and scenario-based questions.

 

  • Full Title: CHW Program Best Practice Toolkits (Center for Community Health Alignment)
  • Description: A comprehensive four-part series designed in collaboration with CHW experts. It provides actionable strategies for:
    • Recruitment and Onboarding: Finding the right CHWs and preparing teams for implementation.
    • Workflow Integration: Establishing caseloads, documenting activities, and creating effective feedback loops within clinical teams.
    • SDOH Screening: Evaluating organizational capacity to address social determinants and selecting the right tools for community needs.

II. Operational Readiness: Integration and Checklists

    • Full Title: Community Health Workers (CHW) Inclusion Checklist
    • Description: This CDC-archived tool provides a non-prescriptive framework for integrating CHWs into healthcare settings across four phases: Planning, Implementation, Evaluation, and Sustainability. It includes 59 potential action steps to help practitioners evaluate their current policies and ensure organizational capacity.

 

    • Full Title: Advancing CHW Engagement in COVID-19 Response Strategies (CWBA Playbook)
    • Description: Developed by the National Association of Community Health Workers (NACHW), this playbook uses the CHW Assessment and Improvement Matrix (CHW AIM) to help organizations move toward “robust engagement”. While focused on pandemic response, it serves as a general guide for integrating CHWs as essential partners in contact tracing, vaccine education, and social resource navigation.

 

  • Full Title: CHW Integration (Arizona Community Health Workers Association)
  • Description: A central hub for organizations in Arizona and beyond to evaluate organizational readiness. It provides links to national studies on CHW effectiveness and offers specialized technical assistance for starting or enhancing CHW programs, including CHW Supervisor’s Training and care coordination support.

 

 

 

 

 

 

 

        • Full Title: ECM Billing Overview (Informative, INTERNAL)
        • Description: Developed by BluePath Health, this presentation provides a high-level overview of health care claims billing including sample billing solutions and workflows for internal processes.

 

 

III. Technology and Data: Screening and Referrals

  • Full Title: Social Needs Screening and Referral Resources (AHA)
  • Description: Part of the American Hospital Association’s (AHA) “Value Initiative,” this resource hub helps care teams move from “understanding” to “addressing” social needs. It features:
    • The AHC Health-Related Social Needs (HRSN) Screening Tool: A 10-item standard tool for finding patient needs in core domains like housing, food, and transportation.
    • Strategic Guidelines: Best practices for having empathetic discussions with patients about sensitive social factors.
    • Case Examples: Real-world studies on how interprofessional teams use technology to close the loop on community referrals.

Part 5: Care Management

These materials are primarily from the CDC and are designed to provide clinical job aides and patient education tools for heart health.

I. Care Management: Heart Disease and Stroke Prevention

    • Full Title: A Community Health Worker Training Resource for Preventing Heart Disease and Stroke
    • Description: This extensive training resource provides CHWs with the clinical knowledge and teaching strategies needed to manage chronic conditions like high blood pressure and cholesterol. It is divided into modules that cover the anatomy of the heart, risk factors for stroke, and methods for helping community members make healthy lifestyle changes.

 

    • Full Title: Promotora Guide: How to Control Your Fat and Cholesterol
    • Description: This resource serves as a “job aide” for CHWs and promotoras de salud to use alongside the fat and cholesterol fotonovela. It provides talking points, key questions to ask community members, and a structured way to lead a group discussion or individual session on heart health.

II. Recursos en Español (Spanish Resources)

    • Full Title: Guía de la Promotora: Cómo controlar la grasa y el colesterol
    • Descripción: Esta es la versión en español de la guía para la promotora. Proporciona las mismas herramientas estratégicas y puntos de discusión para ayudar a las familias latinas a comprender cómo reducir los riesgos de enfermedades cardíacas a través de la dieta y el ejercicio.

 

  • Full Title: Fotonovela: Cómo controlar la grasa y el colesterol
  • Descripción: Esta fotonovela es la herramienta de educación para el paciente en español. Utiliza narrativas culturalmente relevantes para enseñar a los miembros de la comunidad sobre la importancia de controlar sus niveles de grasa y colesterol para prevenir infartos y ataques cerebrales.

 

Thank you!