Community Health Workers and Promotoras

Community health workers operate at the boundary between healthcare systems and the communities they serve. They are community members helping community members navigate health, translating between clinical expectations and lived reality. In rural America, where healthcare access barriers compound with social determinants, CHWs provide connection that licensed professionals cannot replicate.

The CHW workforce has grown substantially. More than half of state Medicaid programs now provide some form of CHW coverage, up from roughly 29 states in 2022. The 2024 Medicare Physician Fee Schedule introduced the first Medicare billing codes for CHW services. RHTP applications from nearly every state include CHW deployment in some form. This is not marginal programming; it represents a significant evolution in how healthcare systems engage communities.

Yet CHW programs face a fundamental tension that threatens their effectiveness. The community voice versus healthcare expertise tension shapes everything from training requirements to employment models to scope of practice. Healthcare systems value CHWs for their community connection, then frequently attempt to transform them into clinical extenders. The professionalization that enables sustainable financing may destroy the authentic community relationship that makes CHW intervention effective.

This article examines whether CHW programs can support rural health transformation and under what conditions. The answer is conditional: CHWs can bridge community and healthcare when their community identity is protected, but clinical absorption destroys what makes them valuable.

The CHW Model

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What Community Health Workers Are

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Community health workers are trusted members of their communities who serve as bridges between health services and community members. They share ethnicity, language, socioeconomic status, and life experiences with the populations they serve. This shared identity enables trust that healthcare professionals, however skilled and well-intentioned, cannot achieve.

The Bureau of Labor Statistics defines community health workers as those who “assist individuals and communities to adopt healthy behaviors” and “conduct outreach for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health.” The definition captures functions while understating the relationship dynamics that distinguish CHWs from clinical staff.

Promotoras (also promotoras de salud) represent the CHW model within Latino communities. The term translates roughly as “health promoter” and carries cultural meaning beyond the English equivalent. Promotoras typically are women from the communities they serve, operating through trust networks built on shared language, immigration experience, and cultural understanding.

Other terms describe similar roles: community health representatives (CHRs) in tribal communities, patient navigators, health coaches, and peer support specialists. The common element is community membership as qualification, distinguishing these workers from clinicians whose qualifications derive from formal education.

What CHWs Do

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CHW functions span health education, care navigation, social service connection, and advocacy:

Health education and coaching: Teaching chronic disease self-management, medication adherence, nutrition, and preventive care. CHWs deliver this education in community contexts, using culturally appropriate approaches that clinical settings cannot replicate.

Care navigation: Helping community members access healthcare services, understand insurance coverage, complete paperwork, and overcome administrative barriers. For populations unfamiliar with healthcare systems, navigation support can determine whether care occurs.

Social needs screening and referral: Identifying food insecurity, housing instability, transportation barriers, and other social determinants affecting health. Connecting community members to available resources.

Outreach and enrollment: Reaching community members who do not engage with traditional healthcare channels. Building relationships that enable eventual healthcare connection.

Translation and interpretation: Not merely linguistic translation but cultural interpretation, helping healthcare providers understand community perspectives and helping community members understand clinical recommendations.

Advocacy: Representing community perspectives within healthcare organizations. Surfacing barriers that clinical staff may not recognize.

What Makes CHWs Different

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The distinctive element is community membership, not training. CHWs know their communities because they live there, share experiences, face similar challenges, and maintain trusted relationships. A promotora helping her neighbor manage diabetes brings credibility that a diabetes educator with superior clinical knowledge cannot match.

This distinction matters for understanding CHW effectiveness. Studies consistently show that CHW interventions improve outcomes for chronic disease management, cancer screening, maternal and child health, and healthcare utilization. The mechanism of effectiveness is relationship and trust, not clinical expertise. CHWs succeed not despite lacking clinical training but because their different knowledge base enables different relationships.

Healthcare systems often struggle with this concept. Trained to value credentials and expertise, clinical leaders may view CHW limitations as deficits requiring remediation rather than features enabling effectiveness. The impulse to “improve” CHWs through clinical training can destroy precisely what makes them valuable.

The Role Tension

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Healthcare Systems Want Clinical Extension

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Healthcare systems facing workforce shortages and access challenges see CHWs as potential capacity extenders. If CHWs could perform clinical tasks, they would partially address provider shortages at lower cost. This framing drives pressure to expand CHW scope of practice toward clinical functions.

The pressure manifests in several ways:

Task creep: Asking CHWs to perform activities closer to clinical work than their training supports. Medication reminders become medication management. Health education becomes clinical counseling. The boundary between CHW and licensed professional blurs.

Documentation requirements: Imposing clinical documentation standards designed for licensed providers. CHWs spend increasing time on paperwork and decreasing time on community relationship.

Clinical supervision focus: Emphasizing clinical oversight rather than community connection. Supervisors evaluate CHW performance by clinical metrics while community relationship quality receives less attention.

Healthcare-based employment: Hiring CHWs directly into healthcare organizations where clinical culture predominates. CHWs absorb healthcare organization values, perspectives, and assumptions, potentially at the cost of community identity.

CHW Value Comes from Community Perspective

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The alternative view holds that CHW effectiveness depends on maintaining community identity distinct from clinical roles. CHWs who become quasi-clinical staff lose the community connection that enables their effectiveness.

Evidence supports this view. Programs that over-medicalize CHWs often underperform. CHWs who maintain community identity and employment show stronger outcomes than those absorbed into clinical organizations. The trust that enables CHW effectiveness requires CHWs to remain community members first.

The promotora tradition illustrates this principle. Promotoras operate through existing community networks, often affiliated with churches, schools, or community organizations rather than healthcare facilities. They help neighbors because they are neighbors, not because employment requires it. This authentic relationship creates effectiveness that employment-based models struggle to replicate.

Finding Balance

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Some clinical training improves CHW effectiveness without destroying community connection. CHWs need sufficient health knowledge to recognize when clinical referral is necessary, understand basic health conditions, and provide accurate information. The question is whether training adds to community knowledge or replaces it.

Training that builds on community wisdom, respecting what CHWs already know while adding specific health knowledge, can enhance effectiveness. Training that implicitly devalues community knowledge, treating CHWs as blank slates requiring clinical education, undermines effectiveness.

Employment models matter. CHWs employed by community organizations maintain community identity more easily than those employed by healthcare systems. Even healthcare-employed CHWs can maintain community connection when organizational culture values community identity. Structure shapes identity.

The Vignette: Promotora Program at the Crossroads

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The Esperanza Community Health Program had operated for 12 years in a Central Valley agricultural town. Fifteen promotoras, all women from the community, provided health education, care navigation, and social support to their neighbors. Operating through a community nonprofit with church partnerships, the program reached farmworker families that clinical services could not access.

Outcomes were strong. Diabetes self-management improved. Prenatal care utilization increased. Emergency department visits for preventable conditions declined. Evaluations attributed success to promotora relationships: neighbors trusted neighbors in ways they did not trust the clinic.

The regional health system, recognizing program success and facing RHTP pressure to address social determinants, proposed absorption. The health system would employ the promotoras directly, providing benefits, job security, and higher wages. In return, promotoras would follow clinical protocols, document in the electronic health record, and participate in care team meetings. The community nonprofit could focus on other programs.

The board debated intensely. Economic arguments favored absorption: promotoras deserved benefits and job security that the nonprofit struggled to provide. Integration arguments favored absorption: promotoras in care teams could coordinate better with clinical staff.

But the longtime program director, herself a former promotora, raised concerns. “Our women are trusted because they are community, not clinic.” Clinical protocols would change how promotoras spent time. Documentation requirements would pull them from relationship into paperwork. Care team participation would align promotora perspective with clinical perspective. The women would become healthcare employees who happened to live in the community, rather than community members who happened to work in health.

After months of discussion, they negotiated a hybrid arrangement. The health system contracted with the nonprofit rather than employing promotoras directly. Promotoras received higher wages funded by the contract while remaining nonprofit employees. Clinical integration occurred through care coordination meetings without requiring clinical documentation or protocol compliance. The nonprofit retained hiring, training, and supervision authority.

The State Policy Environment

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CHW program sustainability depends substantially on state policy:

States with established certification and Medicaid reimbursement provide the infrastructure that enables sustainable CHW programs. Texas established CHW certification in 2001 (160-hour curriculum). California has CHW certification and Medicaid coverage for CHW services. Oklahoma developed a CHW benefit through its state plan. These states have built infrastructure that CHW programs can rely on beyond grant funding periods.

States without certification or reimbursement leave CHW programs dependent on grants that end. When RHTP funding ends in 2030, programs without Medicaid billing capacity face collapse. The absence of state infrastructure transforms what could be sustainable community investment into temporary programming.

Medicare CHW billing codes introduced in the 2024 Physician Fee Schedule create new revenue streams for CHW programs affiliated with Medicare-participating providers. The ACCESS model within CMMI includes care management payments that could support CHW coordination roles. These federal mechanisms partially compensate for state policy gaps.

When CHW Programs Can Support Transformation

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Community-based employment preserves community identity: CHWs employed by community organizations maintain identity more easily than those absorbed into healthcare systems. Where community employment is not possible, healthcare employment with explicit cultural identity protections can work.

Training builds on community knowledge: Programs that add specific health knowledge to existing community wisdom enhance effectiveness. Programs that treat community knowledge as deficient require remediation that destroys effectiveness.

Certification supports sustainability: State CHW certification creates career pathways and enables Medicaid reimbursement that extends program viability beyond grant funding.

Scope definitions protect community function: Clear scope of practice that emphasizes community connection, navigation, and education rather than clinical function protects CHW effectiveness.

Supervision values community relationship: When supervisors assess CHW performance by community relationship quality alongside service delivery metrics, programs maintain effectiveness.

When CHW Programs Cannot Support Transformation

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Healthcare employment absorbing CHWs into clinical culture: When CHWs become healthcare employees first and community members second, relationship authenticity erodes. Clinical productivity expectations pull CHWs from relationship into documentation.

Training replacing community wisdom with clinical protocols: Training that treats CHW community knowledge as deficient rather than valuable, imposing clinical frameworks that contradict community understanding, undermines effectiveness.

Roles defined by clinical task completion: Job descriptions emphasizing clinical functions rather than community connection misalign structure with CHW strength.

Funding dependent on clinical productivity metrics: Payment tied to billable units incentivizes CHWs to prioritize documentable activities over relationship building. The most valuable CHW contributions often resist quantification.

The Clinical Absorption Risk

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Healthcare systems absorbing CHWs face predictable dynamics: initial enthusiasm for CHW community connection leads to gradual pressure as clinical productivity expectations apply to all employees; documentation requirements standardize across roles; CHWs spend increasing time on paperwork; identity erodes as CHWs adopt clinical language and perspectives; and effectiveness declines as program outcomes weaken while community members perceive CHWs as clinic representatives rather than neighbors.

This trajectory is not inevitable but is common. Organizations resisting it require conscious effort to protect CHW community identity against institutional absorption pressure.

Alternative Perspective: The Healthcare Integration View

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The perspective deserving serious assessment holds that CHW programs become more effective through clinical integration. Better clinical knowledge enables better patient support. Healthcare employment provides stability enabling long-term community service. Clinical supervision ensures quality.

Healthcare systems have resources, infrastructure, and sustainability that community organizations lack. CBO-employed CHWs face 50% annual turnover partly because CBOs cannot provide competitive wages, benefits, or job security. Healthcare employment offers stability enabling CHWs to develop long-term community relationships rather than cycling through positions.

Clinical training improves CHW capacity to recognize serious conditions, understand treatment protocols, and support care plan compliance. CHWs with better clinical knowledge can provide more valuable patient support. Training additions need not replace community knowledge.

Care team integration enables better coordination. When CHWs participate in care conferences, contribute to care plans, and access clinical information, they can provide more targeted community support.

Assessment: The integration argument has partial validity. Healthcare employment can provide stability. Clinical training can add value. Care team participation can improve coordination. The question is whether these benefits require clinical absorption or can be achieved while preserving community identity. Evidence suggests preservation is possible but requires intentional effort. Healthcare systems must actively protect CHW community identity against institutional absorption pressure. The hybrid arrangements that protect community identity while enabling clinical partnership represent the path most likely to preserve CHW effectiveness.

Assessment and Recommendations

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For CHW Programs

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Protect community identity even within healthcare partnerships: Maintain employment through community organizations where possible. When healthcare employment is necessary, negotiate arrangements preserving community identity and relationship time.

Value what makes you different: CHW effectiveness comes from community membership, not clinical training. Resist pressure to become quasi-clinical staff. The community connection that enables effectiveness cannot be replaced by clinical skill.

Accept appropriate scope boundaries: CHWs should not perform clinical functions beyond their training. Scope creep undermines effectiveness and creates liability. Maintaining clear boundaries protects both CHWs and the communities they serve.

For State Agencies

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Build CHW certification and Medicaid reimbursement infrastructure: States without established certification and reimbursement face sustainability challenges when RHTP ends. Use the five-year program period to build infrastructure enabling program continuation.

Fund community-based CHW employment: CBO-employed CHWs maintain community identity more easily than healthcare-employed CHWs. Subawards supporting community organization CHW employment preserve effectiveness.

Assess training program quality: Training that builds on community knowledge enhances effectiveness. Training that replaces community knowledge with clinical frameworks undermines effectiveness. Not all training programs serve CHW interests.

Protect CHW scope of practice: Define CHW roles clearly and resist healthcare system pressure to expand scope toward clinical functions. Scope creep undermines effectiveness and sustainability.

For Healthcare Partners

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Value CHWs for community connection: The distinctive CHW contribution is relationship and trust, not clinical skill. Employing CHWs to perform clinical functions wastes their actual capability.

Avoid absorbing CHWs into clinical culture: When hiring CHWs directly, create protected space for community identity. Allow relationship time not consumed by documentation. Supervision should value community connection, not just clinical productivity.

Build community capacity rather than extracting it: Partnerships that strengthen community organization CHW programs build sustainable infrastructure. Partnerships that absorb effective programs into healthcare employment may gain short-term capacity while depleting long-term community resources.

Accept that CHWs are not clinical extenders: The impulse to address provider shortage through CHW scope expansion misunderstands CHW effectiveness. CHWs add to care teams through community connection, not clinical substitution.

Conclusion

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Community health workers and promotoras bridge the gap between healthcare systems and the communities they serve. Their effectiveness depends on community identity that enables trust healthcare professionals cannot achieve through credentials alone.

RHTP has accelerated CHW program development nationwide. Nearly every state application includes CHW deployment. Certification programs have expanded. Medicaid reimbursement pathways have multiplied. This represents genuine progress toward sustainable CHW workforce infrastructure.

The community voice versus healthcare expertise tension threatens this progress. Healthcare systems that value CHWs for community connection frequently attempt to transform them into clinical extenders. The professionalization that enables financing may destroy the community identity that enables effectiveness.

Protecting CHW effectiveness requires intentional commitment to community identity preservation. Employment models, training programs, supervision structures, and scope definitions all shape whether CHWs maintain community connection or absorb into clinical culture. The organizations and states that navigate this tension successfully will develop CHW programs supporting genuine transformation. Those that allow clinical absorption will undermine exactly what they sought to create.

The question is not whether CHWs can support transformation. Evidence demonstrates they can. The question is whether the systems deploying CHWs will preserve the community identity that makes them effective, or whether the institutional pressures of healthcare systems will transform CHWs into something less valuable than what they were.