The resources below are available to help your team grow in the four areas that area explored in the CBO Assessment. These resources will:

1. Support the organizational leaders in planning and policy development.
2. They can help your team better integrate the services of CHWs and other team members and partners.
3. They can guide you to strengthen your technology and data processes.
4. Prepare your organization to understand Medicaid billing, claims and more!

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

I. Helping Leaders Understand 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

• • 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. Departmental Readiness

• Full Title: Community Health Worker Clinical Integration Toolkit: Incorporating CHWs into Care Teams and Clinical Processes
• Description: Produced by MHP Salud, this comprehensive toolkit provides actionable strategies for CBOs to integrate CHWs into daily clinical workflows. It includes specific “lessons learned” on establishing departmental readiness through Electronic Health Record (EHR) integration, daily team huddles, and utilizing CHW-collected data for clinical decision-making.

V. 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.

   

VI. 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.

   

  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: Using “balcony time” (big-picture reflection) to identify emerging themes and immediate priorities that align with the mission.
            • Communication Strategies: Sharing the “why” behind decisions and relating the change to employees’ personal drivers to build alignment.
            • Supportive Practices: Involving employees through “pre-mortems” to identify potential failures before they happen and honoring the emotional aspect of change by making space for both sadness and joy.

           

      • 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 80-page primer introduces the Equity-Embedded Change Management (EECM) approach. It helps organizations move beyond standard DEI to “Deep Equity” by:
          • • Holistic Dimensions: Addressing social, structural, relational, and energetic dimensions of change alongside technical shifts.
            • Navigating Tension: Providing guidance for organizations that feel “stuck” in their equity journey, helping them unstick by identifying power levers and addressing deep-seated fears.
            • Strategic Reckoning: Encouraging a process of “reckoning” to restore trust and essential social infrastructure within an organization.

           

  II. Data and IT

  • • • Full Title: [On-Demand Webinar] Medi-Cal Doula Benefit Made Simple: Learn, Bill, and Thrive with Pear Suite
        • Description: This practical webinar focuses on implementing California’s Medi-Cal Doula Benefit, which provides reimbursement for prenatal, birth, and postpartum care. Key technical and data topics covered include:
          • Enrollment and Contracting: Guidance on the PAVE application, NPI requirements, and contracting with managed care plans (MCPs).
          • Service Delivery and Billing: Explaining service codes, visit limits (up to nine visits), and billing best practices for doulas.
          • Technology Integration: Demonstrating how the Pear Suite platform simplifies clinical care coordination, tracks patient outcomes, and automates billing and reimbursement requests for doulas and maternal health programs.

   

  Technology Readiness

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

  • • • HIPAA Awareness & Compliance Training (NASW/Medelearn): A six-course package covering HIPAA privacy and security basics, specifically designed for social health professionals.
      • Guide to Privacy and Security of Health Information (HealthIT.gov): A foundational PDF guide explaining how to handle protected health information (PHI) in digital and oral formats.
      • Building a Data Process for Reporting, Research and More (AHA Webinar): A technical session on collecting SDOH data from multiple sources and creating high-level reports and dashboards.

   

  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.

   

  III. Technology and Data: Screening and Referrals

  • • • Full Title: Social Needs Screening and Referral Resources (AHA)
        • • • 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.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:
              
              

              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.

                   

                  • Full Title: Fotonovela: How to Control Your Fat and Cholesterol 
                    • Description: This patient education tool uses a story-based format (fotonovela) to help community members learn about cholesterol management. It is designed for CHWs to read with community members, making clinical information about “good” and “bad” fats more accessible through relatable characters and visuals.

           

          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.

           
           
          To help Community Health Workers (CHWs) move from education to action, here are additional clinical tracking logs, training modules, and intake checklists designed to help staff document client progress and manage chronic disease workflows.

          I. Clinical Tracking and Patient Logs

          • • • • • Full Title: My Blood Pressure Log / Mi registro de la presión arterial
                    • Description: A simple, printable log for CHWs to give to community members. It allows patients to record their blood pressure readings, heart rate, and any notes about how they feel, helping CHWs track the effectiveness of heart-healthy interventions over time.
                  • Full Title: Cholesterol Tracker: Managing Your Levels
                    • Description: A professional tracking sheet from the American Heart Association (AHA). CHWs can use this during home visits to help clients record their LDL, HDL, and Triglyceride numbers, making the data in the CDC Fotonovelas actionable.

           

          II. Intake and Assessment Checklists

          • • • • • Full Title: The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) Toolkit
                    • Description: The gold standard for social needs intake. This toolkit provides a standardized screening tool that CHWs use to collect data on housing, transportation, and food security. It includes a “Quick Start Guide” for implementation and templates for capturing “Z-codes” (ICD-10-CM) to prove medical necessity.
                  • Full Title: CHW Core Competency Self-Assessment Checklist
                    • Description: A specific checklist for CHWs to evaluate their own skills in 10 core areas, such as advocacy and cultural humility. It is a vital tool for the Workforce Readiness domain of the Pear Suite assessment to identify where staff need more training.

           

          III. Advanced Training and Implementation Guides

          • • • • • Full Title: A Community Health Worker Training Resource for Preventing Heart Disease and Stroke
                    • Description: This 15-module training set helps CHWs master clinical concepts like hypertension and high cholesterol. Each module includes pre- and post-tests to track learning progress, which is a key requirement for the Operational Readiness category of the assessment.
                  • Full Title: CHW Management and Implementation Guide (AHA Value Initiative)
                    • • Description: A high-level guide for supervisors to build a “care management bridge”. It includes templates for building CHW-to-Clinical team huddle agendas and tips for integrating CHW documentation into electronic health records.

                     

          IV. Referral and “Closing the Loop” Tools

          • • • Full Title: Closed-Loop Referral Tracking Template
                • Description: A resource from the AHA hub that explains how to use technology to track if a client actually received the help they were referred to. It helps CBOs meet the Technology Readiness requirements for “Interoperability” and “Data Exchange”.