Written by the staff of MHP Salud. A version of this article originally appeared on the MHP Salud blog.
There is no question that the Community Health Worker (CHW) movement has expanded its profile in recent years. From the front lines of the Ebola fight abroad to the constant changes in health care reform here at home, the profession gained profile, utility and respect.
Less prominent, but equally important, has been the growing role of the CHW supervisor. Supervisors are an indispensable component of the CHW profession that requires as much attention, care and training as the CHWs themselves receive.
With more than 30 years’ experience designing, running, evaluating and improving CHW programs, as well as more than 20 years’ experience spreading that knowledge via technical assistance to other organizations around the country, MHP Salud has gained insight, experience and a deep understanding of CHW supervision.
From all our experience, we collected this list of six tips for supervision success, which includes insights from MHP Salud staff who supervise CHWs every day. These six tips can be used to strengthen, solidify and promote the CHW model through the professional development of their supervisors.
1. Not everyone is right for the role.
Just as CHWs must possess innate qualities and life experiences to be successful, their supervisors need some baseline skills and qualities as well.
First, if a CHW supervisor is working with a population that is multilingual, the supervisor must have the ability to communicate in the language used by the CHWs he or she supervises. Additionally, in order to read the landscape of the community served, he or she should have a strong knowledge, understanding of or experience with its culture.
Solid time management and independent working skills are also vital to serve as an effective CHW supervisor. Much of a program manager’s day is spent juggling CHW supervision, reporting to funders and the organization and attending local meetings in order to maintain community partnerships and relationships. These broad responsibilities are only effectively met through careful planning and an ability to prioritize independent work.
Apart from life experience and skills, MHP Salud’s Chief Programming Officer Colleen Reinert says there are some innate characteristics needed. “In relation to specifically supervising the CHWs,” she said, “I would say the most important thing is to trust the work of the CHWs.”
To maximize their impact, CHWs spend much of their time away from the supervisor out in the field. Because of this, neither role will function if a supervisor constantly checks that the CHWs are doing what they said they would be doing. Regular check-ins and management tools are still necessary in CHW supervision, but without trust, no one will be able to get their work done.
Reinert says flexibility is also key. “The work of CHWs is not necessarily a nine-to-five job,” she said, “so a supervisor has to also be flexible in the work that their CHWs are doing.” For example, CHWs may not be able to come into the office at a set time in the morning if they stayed out late the night before at a health fair event. The CHWs are inherently flexible around the schedule of the community they serve, and the supervisor must mimic this flexibility.
2. It’s different from other supervisory roles.
Apart from the other organizational requirements for employees, Reinert says a good CHW supervisor needs to be able to recruit quality CHWs. This requires an ability to spot those characteristics that make a CHW successful: compassion, trustworthiness, empathy and the abilities to motivate other individuals and navigate the health system and social services. “Identifying these things isn’t something you can learn at school or receive training on,” said Reinert.
Once hired, measuring and understanding the CHWs’ performance requires additional specialized skills and experience. Good supervision might include holding team and individual meetings to grasp the realities on the ground in the communities served and the CHWs’ impact on it.
“In another position, effective work might be monitored via sales, or number of phone calls, but in CHW programs, there might not be something so concrete,” said Reinert. “It’s more of an art and less of a science.”
CHW supervision hinges on the supervisor understanding that even though a CHW’s impact may not be as clearly legible as other roles in the health care field, a good supervisor will seek to understand this impact through trust and the ability to listen. “Something I have seen over the years is, as much as CHWs appreciate support and seek support, they’re also generally not very willing to express concern when they’re not receiving the support that’s needed,” said Reinert.
She says it is important for managers and upper managers to remember to ensure that there is that time or environment to allow the CHWs to express their needs or concerns that they have within the community and within their organization.
3. Good CHW supervisors champion the work of their staff.
As the CHW movement is expanding and being applied in a larger variety of organizations, health care systems and federal governments, it will be key to find ways for both CHWs and their supervisors to maintain the integrity of the CHW profession. “I don’t want to see it turn into something that it’s not,” said Reinert. “Supervisors have a huge role in ensuring that that doesn’t happen.”
To successfully do this, the supervisor must understand the work of a CHW. They may have been a CHW themselves. If not, they need to have spent enough time getting to know the work of a CHW so that they can appreciate the unique role CHWs play and the challenges and successes that come with that role.
It is also important that supervisors advocate for their CHWs—both internally and externally. Within some organizations, like MHP Salud, who are wholly focused on and invested in the CHW model, advocating for the role of their staff may not be a challenge. In others, such as hospital systems, CHW program services may be a small component of the organization’s work. In these cases, the rest of the employees may lack a full understanding of what a CHW is actually doing, and it is often up to the supervisor to educate them.
Supervisors are also key in promoting the CHW professional movement outside of their own organization. “It is important to have CHWs participate in conferences, whether to present on their own program, to network or to gain more professional development,” said Capacity-Building Assistance Program Director Anne Lee.
Experienced supervisors who understand the CHW point of view can also amplify that viewpoint in group-settings to ensure that the CHW voice is heard. Instinto Maternal Program Director Randi McCallian says she has learned that supervising CHWs is about more than simply ensuring a job gets accomplished. “As a supervisor, I try to remember that my role is two-fold,” said McCallian, “to reach program goals and ensure fidelity to the program plan, but to also allow for the professional growth and experience of those I supervise.”
4. There is more than one way to run and supervise a program.
As the profession grows, it is increasingly common for programs to employ CHWs with varying levels of responsibilities. A multi-tiered model is used to distribute the responsibilities of CHWs based on the time commitment and expectations of their position, which can range from a part-time volunteer to a full-time staff member.
When used effectively, this model allows a program to maximize resources, extend the reach of CHWs and create a greater program impact. “Regardless of the CHW tier,” said Reinert, “what’s important to remember is that all CHWs still require a supervisor, coach or mentor—somebody providing support.”
Just as program form can vary, so can the communication between supervisors and their CHWs. With recent advances in technology, it is easy to have proper communication with the CHWs if they receive appropriate tools. “Several years ago, it could have been that a supervisor sends an email a CHW, and it took a week for the CHW to get access to the email in order to respond,” said Reinert.
These days, especially if an organization can provide proper communication to a CHW, such as a smartphone and internet services, it’s possible for a CHW to remain in the field and communicate with their supervisor remotely a majority of the time.
Though Colonia Community Project Program Director Moises Arjona, Jr. spends the majority of his time supervising CHWs remotely while they provide door-to-door outreach in the field, he finds it invaluable to change up his supervisory style occasionally and shadow his staff in the field in order to understand the realities of their work up close. “Once you actually work alongside the CHWs, you can appreciate the work that they do and see the barriers they encounter,” he said. “For example, I saw what it was like to go along door-to-door and have the door closed in my face constantly.”
5. Initial plans don’t always pan out, and that’s okay.
With more and more health agencies adopting CHW programs of their own as a way to address social determinants of health, lofty program objectives are sometimes hampered by realities on the ground.
“Often, a development team has designed a program with goals and expectations,” said Reinert, “but when the program begins, and the CHWs are out on the ground doing their work, the numbers that the development team originally identified are unrealistic.”
Supervisor flexibility comes into play in these instances. Otherwise, if a supervisor continues to push a team of CHWs to meet those goals without making accommodations for the reality of the situation, the CHWs could burn out.
To prevent this, supervisors must be able to listen to their staff to understand the barriers they encounter in the community, so that they can adapt their goals, bring on more staffing or work together to find a solution to a problem.
Instinto Maternal Program Director Randi McCallian says she’s learned that listening is key to revising expectations and solving problems.
“Listen to the CHWs and through them, the community,” she said. “CHWs have a close relationship and understanding of the strengths and needs of a community, so if anything needs to be addressed, their input on strategies that will work is invaluable.”
6. Support is out there.
Currently, there are more opportunities than ever for CHW supervisors to develop their work. Local, state and national CHW associations, conferences and other meetings provide supervisors a chance to network with others in the field in order to receive peer support and learn from best practices.
In 2015, MHP Salud developed several materials and trainings geared toward supporting the work of CHW supervisors, all of which are released on our Resource Portfolio. These tools assist managers in their hiring, supervision, evaluation and greater professional development.
The new Supervision Manual for Promotor(a) de Salud Programs is an 88-page resource available for free download from MHP Salud’s Resource Portfolio. It covers everything from recruiting CHWs to resolving programmatic challenges as they arise, and the Manual’s appendix includes nine tools ready to be personalized for any CHW program. MHP Salud also offers personalized trainings for supervisors across a wide set of managerial topics.
MHP Salud is a national nonprofit organization that implements and runs Community Health Worker programs. These programs provide peer health education, increase access to health resources and bring community members closer. MHP Salud also has extensive experience offering health organizations training and technical assistance on Community Health Worker programming tailored to their specific needs
Rhonda Barcus, Program Specialist
For the past three years, I had the opportunity to work with the Kansas Department of Health and Environment (KDHE) and Sara Roberts, Director of Kansas Office of Primary Care and Rural Health and more recently with Jennifer Findley from Kansas Hospital Association on a Revenue Cycle Management (RCM) project. We supported 19 hospitals in Kansas with technical assistance to assess their current practices and benchmark those against best practices in RCM.
For all the 13 hospitals participating in years one and two, I had the opportunity to talk with their leadership teams at six and nine months about their progress of implementing the best practice recommendations. The progress and outcomes for most of them were astonishing! What really stood out to me were the common themes from the most successful projects. I wanted to share the top three themes with you.
Revenue Cycle Management (RCM) involves the process of patient charge capture from beginning to end, from creation to payment. It includes a number of steps that begins with patient registration and continues through the delivery of care to billing and to eventual payment. It is a process that involves a number of hospital departments: business office, clinical providers, registration, utilization review and coding to name a few. Because of its complexity and the number of staff that “touch” this process and the reliance on detailed, specific and accurate information at each step, hospitals may find that small errors can result in big financial losses, wasted staff time and decreased staff morale. A well-run RCM impacts patient satisfaction while a fragmented process results in frustration and patient dis-satisfaction.
The first step that every team took was to create a revenue cycle team. The team included business office folks, yes, but also included staff from clinical areas, registration, health information management (HIM) and information technology (IT). This team met weekly. Every leader said the success of this project was dependent on frequent meetings so that RCM issues could be addressed quickly and as close to real time as possible. The team looked at any issue or problem involving RCM over the last week and took immediate steps to remedy it. This kept them focused and they were all aware of the need for constant and consistent attention to make steady progress.
A second factor in their success was the focus on pre-registration. Patient information, coverage for upcoming procedures, co-pays and deductibles were all identified prior to a patient coming for their scheduled procedure when possible. Checks and balances were put in place to ensure accurate collection of information since one small error could impact the success of the entire revenue process. Staff were included in discussions about this so that they were very aware how they affected the success of the process.
A final theme, and was the hardest for many hospitals, was requesting payment from the patient! The hospitals were very transparent with the patient prior to coming for services about their financial responsibility at the time of service. Great care was taken to make sure all staff involved had the right education, training and re-education to do this effectively and with sensitivity. The hospitals also talked openly with patients about needing to pay prior balances and some future scheduled procedures were contingent on something being paid on previous balances. More than one hospital noted that this is part of their culture now and the community and patients just accept it. One CEO noted that almost all patients now come prepared with some type of payment. They noted that while many hospitals fear losing patients if they take this step, when done with sensitivity and skill by staff, that fear has been unfounded.
In addition to the common themes in implementation of best practices, all the hospitals were able to identify measurable outcomes. These outcomes included a decrease in accounts receivable, decrease in claim rejection, and an increase in collections. Also significant were the “non-measurable” outcomes. The hospitals all reported that there was better teamwork within and among departments, staff pride in the success of their work and more accountability across the organization!
This article was written by David Mortimer, MDiv, Director of the Hospital Sisters of St. Francis Foundation Innovation Institute, for the January 2017 edition of “Networking News.” The Network Technical Assistance Project is funded by the Federal Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services through a contract to Rural Health Innovations, LLC, a subsidiary of the National Rural Health Resource Center.
I grew up on a rural farm in Wisconsin. Two silos next to the barn were a picturesque fixture, and they were designed to store fodder, forage, or grain. Although they may be a critical feature to some farming livelihoods, silos in rural health care organizations are a metaphor for systems, processes, or departments that operate in isolation. These silos tend to drain the organizational lifeblood because a lack of interaction with other groups can result in inefficiency, missed opportunities for innovation, and even stagnation.
Over the decades, rural health care has been experiencing a cultural shift away from silos. This shift has been accentuated by advances in communications technology and remote presence telemedicine. Many rural organizations have been energized by exploring new self-governed collaborative, network, consortium, and cooperative models that actually replace silos with bridges. The basic idea is that collective action is an indispensable tool to counter the great challenges faced by rural communities.
Articulating the need for collective action
It’s no secret the typical rural health landscape in America faces growing challenges and that rural dwellers face a kind of penalty when compared to urban populations. Not only has rural America experienced declining population, jobs, opportunities, and resources, but a digital divide creates barriers in education, business development, and quality of life. (Many young rural friends of mine graduate high school and leave home, and will never even consider settling down in a community with poor internet connectivity.) Due to demographics and the impact of globalization on local economic development, many rural counties are experiencing an eroding tax base and declining representation in state and federal government.
These complex and incremental changes are causing substantial disparities in patient access to health care—particularly behavioral health—and provider shortages. Because they have less access to health care, rural Americans experience the “distance decay” effect—the lower use of health care services with increasing distance—which can result in more advanced and higher levels of disease. Rural dwellers face greater barriers in follow-up care, appointments, and compliance, and have higher rates of chronic disease, readmissions, and emergency department utilization. While these great challenges might seem overwhelming to rural stakeholders and providers, they have become compelling drivers of collective action and bridge-building.
Recognizing opportunities to collaborate
Collective action allows rural organizations to leverage limited capacity, maximize economies of scale, and share resources. The critical first step on this journey is to identify silos and opportunities for collaboration. Literally, this requires getting the right organizational representatives around a table, and this can happen in a variety of ways. I’ve personally been involved with two networks that successfully navigated this step:
The first step toward sustained collective action from a stakeholder’s point of view always involves the realization that there are tangible opportunities. In the CINC and ITN examples above, charter members began to realize that benefits of collaboration included being able to provide many more services with far fewer resources. Alone, members had little or no capacity, resources, or experience in successfully applying for a federal grant opportunity, but together, members combined the necessary resources to both apply and leverage opportunities with matching funds.
Bringing stakeholders to the table
Shared activities open doors to opportunities for grants, collaborative fundraising, and other opportunities. Alone, most ITN and CINC members would not even be eligible for many federal and state and private foundation funding. Together, network members find they are not only eligible to apply for many grant opportunities, they find they have greater resources to pool financial resources to secure matching grant funding and operationalize new projects. (Another advantage is that having different network member calendar year or fiscal year end dates provides additional year-round financial agility in committing matching funding toward a project of interest, despite thin operating budgets.)
In ITN planning meetings, several small rural hospitals without emergency department telemedicine equipment initially thought they brought little value to the ITN network, only later to learn they had exceptionally high value to the greater network because they would score very high in a USDA Distance and Learning Telemedicine grant application. In fact, their rural status serving high-poverty communities also provided great value to ITN’s other federal grant applications. Successful ITN-led grant applications secured equipment, and they were able to participate in the network’s new emergency department tele-stroke program.
As a network matures, other opportunities often follow. Group purchasing may lead to shared costs and mutual savings. With growth, ITN leverages larger patient volumes to secure better vendor price points for telemedicine services. Other shared network resources (such as job descriptions, workflows, billing and payment protocols) help all members accelerate programs and reduce costs and duplication. Depending on the project, some members contribute specific legal or financial services. Others may contribute advocacy, marketing, or public relations expertise.
Keeping stakeholders engaged
Sustained engagement in network activities by pioneer members is driven by continued benefits and prospective opportunities. Without these, members will naturally lose interest and drop out. Economies of scale experienced in the CINC and ITN examples above include collaborative support to develop new services. These networks also share equipment, allow members to share costly software applications, and even services and staff. Lastly, collaboration provides access to new resources that are only available to larger organizations.
Bridge building will always be more challenging than silo building. As Gregory Bonk noted, “Rural health networking is not easy; it requires time, trust, will, and skills.” He added, “Network members must have the ability to separate their individual goals from the common goals of the network, and the vision to see the potential benefits of joint action.” Bonk outlines key elements of network development that include a compelling need, expected benefits, form and function, and key participants.
New and emerging networks can build momentum with smaller “easy wins” that are communicated to all members, and are followed by other good-faith efforts that are inclusive and innovative in meeting member needs. Eventually, silos are replaced by bridges that are shared by all members, and improve client services and reduce costs. As one network member in CINC commented about their old silo thinking, “We’d never go back.”
David P. Mortimer, MDiv, is Director of the Hospital Sisters of St. Francis Foundation Innovation Institute. He serves as the Administrative Director for the Illinois Telehealth Network (ITN) and chairs the Communications Committee for the Chippewa Valley Inter-Networking Consortium (CINC). The Hospital Sisters of St. Francis Foundation Innovation Institute provides program investments and infrastructure to support projects that improve outcomes, increase rural access to care and decrease costs through improved efficiencies.
 Turning Point Initiative. From silos to systems: Using performance management to improve the public’s health. Turning Point National Program Office, p. 3; 2003. http://www.phf.org/resourcestools/Documents/silossystems.pdf
 Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural and Remote Health (Internet) 2009; 9: 1142. Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1142 (Accessed 12/31/16).
 Gregory Bonk, Principles of Rural Health Network Development and Management (2000), p. 1.
The National Rural Health Resource Center (The Center) is a nonprofit organization dedicated to sustaining and improving health care in rural communities. Rural Health Innovations, LLC is a subsidiary of the National Rural Health Resource Center.