Chapter 5. The Employers of Community Health Workers

Statistics were not available on the number or type of CHW employers. Therefore, estimates were derived from the data used to identify the total of paid and volunteer CHWs engaged to assist in the delivery of care to underserved communities.

Industry and Size Estimates

The number of organizations employing community health workers was estimated to be approximately 6,300 for the Nation as a whole. This is a rough approximation obtained when the estimated national total of CHWs is divided by the average number of CHWs engaged by the employers surveyed for the CHW National Employer Inventory (CHW/NEI).^[1]

The industries found to be more likely to employ CHWs were "Individual and Family Services" (21 percent), "Social Advocacy Organizations" (14.2 percent), "Outpatient Care Centers" (13.3 percent), and "Administration of Education Programs" (12.9 percent). Additional industries found to have CHWs among their personnel, although less often, included "Other Ambulatory Health Care Services" (8.4 percent) and "Office of Physicians" (5.3 percent).^[2]

The sizes of the organizations engaging CHWs are shown in Figure 5.1. The largest percentage (43 percent) were firms employing between five and 19 employees, 20 percent had between 20 and 49 individuals on the payroll, and another 19.1 percent fell in the 50 to 249 employees category. Few were "large" employers: 2.8 percent employed 250 to 499 individuals and 2.3 percent had 500 or more employees. About 12.5 percent of the firms had fewer than five employees.

[D]

Source: Study file of CHW employers whose industry affiliation could be verified -- N=744

The occupational characteristics of CHWs that have been motivating employers to hire them were identified by combining findings from the employers' interviews and information gleaned from the review of the literature.

Generally, employers have hired community health workers because they (a) learned about their successful utilization in professional journals,^[3] (b) believed that they were cost effective,^[4] (c) found that CHWs were capable of organizing communities in developing comprehensive health action plans,^[5] or (d) discovered that programs addressing health disparities were more effective when using one-to-one outreach by CHWs.^[6]

Community health workers were viewed as having contributed to more effective delivery of health-related services because they were (1) uniquely effective in gaining access to hard-to-reach populations that had been avoided by other health workers;^[7] (2) able to patiently coach clients in culturally appropriate terms and induce behavioral changes;^[8] (3) able to successfully communicate with clients, by developing trusting and caring relationships, to impart or gather information^[9] and motivate key decisions such as participating in immunization programs;^[10] and (4) able to address certain client needs such as adapting health regimens to family and community dynamics.^[11]

Networking has been the recruitment strategy used most often by employers (74 percent).^[12] Churches and local businesses have been successful intermediaries in attracting qualified candidates, and clinic-based programs have recruited among patients.^[13] Other recruitment methods ranged from mass mailings^[14] to partnerships with existing volunteer organizations.^[15] Fifty percent of the respondents to the CHW/NEI reported referrals by community members or CHW staff. Many employers (69 percent) complemented networking with traditional advertising.

Consistently, in the national Inventory, in employers' interviews and in the literature, the prevalence of short-term funding and the necessary reliance on multiple funding sources were cited by employers and other observers as a major barrier to the development of the CHW workforce.^[16] Figure 5.2 shows that 66 percent of the employers surveyed for the national Inventory reported two or more sources of funding.

[D]

Source: CHW National Employer Inventory (CHW/NEI) (2006), N=527

Figure 5.3 shows the percent of employers by the type of agency that gave financial support to the CHW programs. Federal and State governments provided most of the funds. Private organizations, local governments, and other sources supported about one-third of the employers. Similar patterns of funding were found in most recent State and local workforce studies on CHWs.^[17]

[D]

Source: CHW/NEI (2006), N=527 - multiple responses permitted

The NFME study predicted that charitable foundations, government grants, Medicaid, State/Federal government general fund appropriations, and private companies will be the major potential funding sources of the future.

The most successful CHW programs, reported the NFME researchers, are those that (1) have the mission of providing specific services to underserved target populations, (2) address the delivery of health care holistically, that is, attending to the total health needs of the population being served, (3) have clearly identified unmet health needs and intervention strategies, (4) can document outcomes with solid data indicating favorable changes in access, cost, or health status, (5) are able to attract the assistance of "champions" who have leverage for winning support for CHWs, and (6) can offer training to the CHWs on the specific services needed.^[19]

Sources of Long-term Support

Health Resources and Services Administration (HRSA)

HRSA funding has supported many CHW programs nationally, principally through Federally Qualified Health Centers of the Bureau of Primary Health Care (BPHC) and Healthy Start Programs of the Maternal and Child Health Bureau (MCHB). Some of the programs supported by the HIV/AIDS Bureau included CHWs as "peer educators" or "peer outreach workers." About one-fourth of employers responding to the "funding" section of the national Inventory survey reported receiving funding from HRSA or having a HRSA-sponsored program (26 percent, N=634). A 2002 report from the Health Resources and Services Administration, MCHB listed examples of programs from four Bureaus, and a partial list of shorter-term project grants from the Office of Rural Health Policy.^[20]

The Health Education Training Centers (HETC) program of the Bureau of Health Professions (BHPr) was the only program in HRSA with a specific legislative mandate to support the CHW workforce. A report for the 2004 National HETC Annual Meeting described 42 CHW programs supported by HETCs as "best practices."^[21]

In conducting the in-depth investigations of the selected States reported in Chapter 8, the following examples of HRSA support were found.

Centro Familiar de Salud San Vicente in El Paso, Texas, was a Federally Qualified Health Center supporting promotor(a) de salud (CHW) services in part from its Public Health Service Act (PHSA) Section 330 funding. San Vicente's "Puente de Salud" (Bridge of Health) program received a 2003 Border Models of Excellence award from the U.S.-Mexico Border Health Commission. Promotoras served primarily Hispanic residents who were economically disadvantaged and uninsured by providing community outreach education, access to referral services, counseling, and group presentations.^[22]

Three Healthy Start grantees (HRSA/MCHB) in Texas provided examples of how the same funding source could support different locally determined objectives and approaches.^[23] In Dallas, the objectives included reduction of infant mortality, low birth-weight and teen pregnancy. "Outreach Care Workers" (another term for CHWs) were used for case-finding, enrollment and follow-up visits. Fort Worth's objectives involved improving care coordination, increasing rates of early prenatal care, and increasing rates of immunization and screening for post-partum depression; there, the role of Outreach Workers was limited to case-finding and enrollment in informal community settings. In San Antonio, the objectives included those adopted by Dallas and Fort Worth, plus maintenance of participants in interconceptional care^[24] for up to 24 months post-delivery.

The New York State Department of Health managed several streams of HRSA funding including maternal and child health services grants and maternal and child health community-integrated services funds.^[25] The programs employed CHWs for outreach to pregnant and parenting women, to newborns, and to young children. The New York State "Community Health Worker Program," addressing maternal and child health, was perhaps the most widely recognized CHW program in the State. This may have been due to the fact that the program had long-term funding.^[26]

The AIDS Institute of the New York State Department of Health (NYS DOH) managed Federal funds from the Ryan White CARE Act through contracts with community agencies throughout the State. The Finger Lakes Migrant Health Project in Rushville, New York, employed CHWs in a promotor(a) model, recruited from migrant camps. The program was originally funded by the March of Dimes and later by a Medical Expansion Grant administered by HRSA. CHWs worked in prenatal clinics to provide education on infant and women's health issues and assisted in outreach services to migrant camps.^[27]

Community health centers of Franklin County, Massachusetts, received a Health Center Cluster grant under the Section 330 Healthy Communities Access Program (HCAP) from HRSA. The health center employed two full-time "outreach representatives," both of whom were bilingual.^[28] One of the CHWs worked with seasonal migrant farmworkers for half of the year, dedicating the other half to the general population of the health center. The outreach worker assisted migrant workers by providing transportation to health care appointments. Outreach to the community was conducted to inform residents about multiple issues including insurance enrollment, housing, nutrition, and other social and health service needs.^[29]

Community health centers in Arizona received funding from HRSA for services that included CHWs. The Mariposa Community Health Center's Women's Health Program was partially funded by HRSA/MCHB. Its CHWs provided linguistically and culturally appropriate health information, education, and referral, and led activities with community members, especially new community members, aimed at changing health behaviors.^[30] The CHW programs at Chiricahua Community Health Center and other community health centers in Arizona provided health education and home visitation.^[31]

The Office of Family Planning of the Office of Population Affairs (OPA), United States Department of Health and Human Services (USDHHS)^[32]

The Family Planning Program is administered within the OPA, although its budget line is located within HRSA. In addition to family planning services and related counseling, Title X^[33] supported clinics and provided preventive health services. For many clients, Title X clinics were the only continuing source of care and health education. The program supported a nationwide network of approximately 4,600 clinics delivering reproductive health services to approximately 5 million persons each year.^[34] Planned Parenthood was an example of a Title X Family Planning Delegate that received funds and employed CHWs at clinics throughout the country, including California, New York, and Texas.

Community Health Representative (CHR) Program of the Indian Health Service (IHS)

This program is the largest and the longest standing in the United States. The CHR Program was initially funded by the Office of Economic Opportunity (OEO) in 1967 as the Community Health Aide Program, and was transferred to IHS gradually from 1969 to 1972. The original intent of IHS, modified somewhat through the years but retaining its general goal, was for the community health representatives (the term used for CHWs) to become community health promoters, educators, advocates, and health paraprofessionals who would regularly visit the homes of clients, conduct health assessments, and provide transportation when needed. Today, the CHR Program has grown to more than 1,400 CHRs representing more than 250 tribes in 12 service areas.^[35]

Annual State Appropriations

A few programs were found to be supported by annual State appropriations. The largest of them were the Kentucky Homeplace/SKYCAP^[36] and the Arizona Health Start Program.^[37] Few local health departments employed CHWs paid from ongoing revenue streams.^[38]

Medicaid, State Children's Health Insurance Program (SCHIP), and Medicare

While some outreach programs have been supported by Medicaid administrative dollars, only a few programs involving CHWs were established under Medicaid services funding, generally under waivers or under Medicaid-managed care plans. Of those employers responding to the Inventory, 18.0 percent included reimbursement by Medicaid and/or SCHIP.^[39] Perhaps the largest identified CHW programs funded under Medicaid waivers have been California's Family PACT Program, which provided, among other services, family planning under a waiver,^[40] and Alaska's Community Health Aide/Practitioner (CHA/P) Program, primarily funded by the Indian Health Service CHR Program and authorized to bill Alaska Medicaid for CHA/P services.^[41]

Many community-based programs had contracts with Medicaid and SCHIP managed care organizations (MCOs) to provide CHW services. Some specific programs were identified in rural New Mexico^[42] and Rochester, New York.^[43] Medicaid and SCHIP MCOs typically have wide latitude in the use of funding received as capitation payments. At least one Medicaid MCO had directly hired 50 CHWs on the basis of internal return on investment.^[44] Another (CareFirst) received recognition in 2006 from the National Committee for Quality Assurance (NCQA) for its "Closing the Gaps" program, which utilizes CHWs, as an example of innovation in serving linguistically and culturally diverse populations.^[45] A 1997 study by Seedco for the Annie E. Casey Foundation suggested that Medicaid-managed care organizations (MCOs) would be amenable to contracting for CHW services with community-based agencies if agency capacity and CHW skills standards were sufficiently high and, further, that this "could provide substantial revenues to support" CHW positions.^[46]

Other Medicaid support of CHW services has followed different paths. For example, the New York State Department of Health funded local CHW services in 41 sites in 2006 under its Prenatal Care Assistance Program, which is part of the Medicaid Program.^[47] Billing guidelines for HIV case management programs funded by the State of New York, as in other States, were specific in requiring that only the services of the case manager and the case management technician on the service team were directly billable to Medicaid. However, program guidelines allowed the services of a community follow-up worker (the equivalent of a CHW).^[48]

Pilot projects for CHW Medicaid services in Texas were authorized under House Bill 1864 in 1999, and the State Department of Health committed $1 million per year in combined Federal and State support for five sites in 2001.^[49] The State sought and obtained approval from the Centers for Medicare and Medicaid Services (CMS) in 2003^[50] to use private matching funds for one pilot site in Houston, but none of the other sites received funding. A similar situation arose for the "Community Connectors" program serving mainly the African-American elderly in rural Southeastern Arkansas; the pilot program was initially supported under Medicaid administrative funding with private foundation matching funds used for the Federal share of funding.^[51]

In 2006, the CMS funded six Cancer Patient Navigator demonstration sites for assistance to minority cancer patients on Medicare fee-for-service benefits, although navigator services were not a regular feature of fee-for-service Medicare.^[52] No other examples of Medicaid, SCHIP, and Medicare financing of services were found.

For-Profit Firms

A growing area of support for CHWs was found to be for-profit firms, both through outsourcing and direct employment. The increasingly large chronic disease management industry has changed both the structure of health care finance^[53] and the practice of medicine.^[54] In 2005, two for-profit disease management firms known to be actively pursuing the use of CHWs were among seven firms receiving annual excellence awards from the Disease Management Association of America.^[55] It is also conceivable that for-profit health insurers in the Medicaid, Medicare, and SCHIP programs may follow the lead of non-profit insurers in utilizing CHWs. However, most of the information on the utilization of CHWs by for-profit organizations has been treated as proprietary, sensitive from a competitive viewpoint, and has not been available for public dissemination.

Finally, private insurers may be considering utilizing CHWs. They are already investing heavily in wellness incentives, care management, and the use of paraprofessionals. It is likely that, as CHW capabilities and potential become better known and documented, models of CHW utilization may be considered for health benefit plans for industries with a high percentage of low-wage jobs. However, no current examples of this type of CHW employment could be located.

[1] The estimates and the Inventory are discussed in Chapter 3 and the methodologies employed in each are explained in Appendix B and Appendix C, respectively.

[2]

Employers identified during the National survey were matched against listings from the American Labor Market Information System USA-INFO through a special confidentiality agreement with the Texas Workforce Commission (TWC) that protected individual firm records and allowed the use of employers' information only in large aggregates. These records contained the North American Industry Classification System (NAICS) codes of employers as well as the number of total employees, thus allowing the identification of the industries engaging the majority of paid and volunteer CHWs and their average size. Of the verified employers in selected States, 57 percent (759 of 1,327) were successfully matched against the employer records database. For the successfully matched records, 92 percent (701 of 759) corresponded to the industries identified for inclusion in the estimates of paid CHWs. (Additional information on the estimation process, as well as the identification of employers' industry, is available in Appendix B.)

[3] Lam TK, McPhee SJ, Mock J et al. Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education. J Gen Intern Med 2003; 18 (7):516-24; Baier C, Grant EN, Daugherty SR et al. The Henry Horner Pediatric Asthma Program. Chest 1999; 116 (4):204S-6S; Butz AM, Malveaux FJ, Eggleston P et al. Use of community health workers with inner-city children who have asthma. Clin Pediatr 1994; 33 (3):135-41; Krieger JW, Takaro TK, Song L et al. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health 2005; 95 (4):652-9; Stout J, White L, Rogers L et al. The asthma outreach project: a promising approach to comprehensive asthma management. J of Asthma 1998; 35 (1):119-27.

[4] Findings from this study's 36 employer interviews (CHW National Workforce Study Interviews (CHW/NWSI)) conducted in four selected States. Note: See also Barnes K, Friedman S, Namerow P et al. Impact of community volunteers on immunization rates of children younger than 2 years. Arch Pediatr Adolesc Med 1999; 153 (5):518-24.

[5] Friedman AR, Butterfoss FD, Krieger JW et al. Allies community health workers: bridging the gap. Health Promot Pract 2006; 7 (2 Suppl):96S-107S. Note: In one example, seven local sites of a national asthma control program independently developed comprehensive community action plans. The plans varied in approach; all included significant roles for CHWs.

[6] Siegel B, Berliner H, Adams A et al. Addressing Health Disparities In Community Settings: An Analysis of Best Practices in Community-Based Approaches to Ending Disparities in Health Care. Final Report to The Robert Wood Johnson Foundation. Program In Health Services Management and Policy, Robert J. Milano Graduate School of Management and Urban Policy, New School University & The Robert Wood Johnson Foundation, December 20, 2001; Revised and Updated October, 2003.

[7] CHW/NWSI (2006); Love MB, Gardner K. The Emerging Role of the Community Health Worker in California. Results of a Statewide Survey and San Francisco Bay Area Focus Groups on the Community Health Workers in California's Public Health System. Community Health Works of San Francisco, California Department of Health Services, 1992.

[8] Staten LK, Gregory-Mercado KY, Ranger-Moore J et al. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. J Womens Health (Larchmt) 2004; 13 (5):547-56; Bone LR, Mamon J, Levine DM et al. Emergency department detection and follow-up of high blood pressure: use and effectiveness of community health workers. Am J Emerg Med 1989; 7 (1):16-20.

[9] Krieger J, Castorina J, Walls M et al. Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention. Am J Prev Med 2000; 18 (2):123-31; Becker J, Kovach AC, Gronseth DL. Individual empowerment: how community health workers operationalize self-determination, self-sufficiency, and decision-making abilities of low-income mothers. J Community Psychol 2004; 32 (3):327-42.

[10] Krieger J et al. (2000).

[11] Rodney M, Clasen C, Goldman G et al. Three evaluation methods of a community health advocate program. J Community Health 1998; 23 (5):371-81; Meister JS, Warrick LH, de Zapien JG et al. Using lay health workers: case study of a community-based prenatal intervention. J Community Health 1992; 17 (1):37-51.

[12] CHW/NEI (2006).

[13] Keyserling TC, Ammerman AS, Samuel-Hodge CD et al. A diabetes management program for African American women with type 2 diabetes. Diabetes Educ 2000; 26 (5):796-805.

[14] Andersen M, Yasui Y, Meischke H et al. The effectiveness of mammography promotion by volunteers in rural communities. Am J Prev Med 2000; 18 (3):199-207.

[15] Barnes K et al. (1999).

[16] Raczynski JM, Cornell CE, Stalker V et al. Developing community capacity and improving health in African American communities. Am J Med Sci 2001; 322 (5):269-75; Rico C. Community Health Advisors: Emerging Opportunities in Managed Care. Annie E. Casey Foundation, Seedco--Partnerships for Community Development, 1997; Rosenthal EL, Wiggins N, Brownstein JN et al. The Final Report of the National Community Health Advisor Study. Tucson (AZ): University of Arizona, 1998; Pew Health Professions Commission. Community Health Workers: Integral Yet Often Overlooked Members of the Health Care Workforce. San Francisco (CA): University of California Center for the Health Professions, 1994; National Fund for Medical Education. Advancing Community Health Worker Practice and Utilization: The Focus on Financing. San Francisco (CA): Center for the Health Professions, University of California at San Francisco, 2006; Brownstein JN, Bone LR, Dennison CR et al. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J of Prev Med 2005; 29 (5S1):128-33; Blue Cross Foundation. Critical Links: Study Findings and Forum Highlights on the Use of Community Health Workers and Interpreters in Minnesota. Eagan (MN): Blue Cross and Blue Shield of Minnesota Foundation, 2003.

[17] Cowans S. Bay Area Community Health Worker Study. [HED 892 - Final Report]. San Francisco (CA): San Francisco State University, 2005. 29 p; Results of the Southwestern Connecticut Community Outreach Worker Survey. Bridgeport (CT): Southwestern Area Health Education Center and Housatonic Community College, October 2000; Blue Cross Foundation (2003); Massachusetts Department of Public Health. Community Health Workers: Essential to Improving Health in Massachusetts, Findings from the Massachusetts Community Health Worker Survey. Boston (MA): Division of Primary Care and Health Access, Bureau of Family and Community Health, Center for Community Health, March 2005; Virginia Center for Health Outreach. Final Report on the Status, Impact, and Utilization of Community Health Workers. Richmond (VA): James Madison University, Institute for Innovation in Health and Human Services, 2006; New Mexico Department of Health. Senate Joint Memorial 076 Report on the Development of a Community Health Advocacy Program in New Mexico. Santa Fe (NM): Department of Health, November 24, 2003; Keane D, Nielsen C, Dower C. Community health workers and promotores in California. San Francisco (CA): UCSF Center for the Health Professions, 2004.

[18] NFME (2006).

[19] Ibid (p.7).

[20] Health Resources and Services Administration. Directory of HRSA's Community Health Workers (CHWs) Programs. Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services July 5, 2002. Note: Bureau of Health Professions, Bureau of Primary Health Care, HIV/AIDS Bureau, and Maternal and Child Health Bureau.

[21] Health Education and Training Centers (HETC) Community Health Worker Best Practices Compendium. National HETC Annual Meeting, 2004.

[22] United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Puente de Salud Model El Paso, Texas. El Paso (TX): United States-Mexico Border Health Commission, 2004.

[23] Project Abstract - H49MC00114, Fort Worth Healthy Start Initiative. Rockville (MD): Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 2001; Project Abstract - H49MC00101, San Antonio Healthy Start Project. Rockville (MD): Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 2001; Project Abstract - H49MC00157, Dallas Healthy Start: Eliminating Disparities in Perinatal Health (General Population). Rockville (MD): Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services, 2001.

[24] This refers to the care or services provided to women between a birth/infant death/fetal loss and a next pregnancy to address various health and social conditions.

[25] CHW/NWSI (2006).

[26] Ibid.

[27] Ibid.

[28] Ibid.

[29] Ibid.

[30] United States-Mexico Community Health Workers Border Models of Excellence, Transfer/Replication Strategy. Mariposa Community Health Center of Excellence in Women's Health Model, Santa Cruz County, Arizona. El Paso (TX): United States-Mexico Border Health Commission, 2004.

[31] AACHC Program Overview [Internet]. Phoenix (AZ): Arizona Association of Community Health Care; 2006 [updated 2006/cited 2006 May 10]. Available from http://www.aachc.org/programs.php.

[32] Office of Family Planning [Internet]. Rockville (MD): Office of Family Planning, Office of Population Affairs, Office of Public Health and Science, U.S. Department of Health and Human Services; [updated 2006 Sep 16/cited 2006 Sep 26]. Available from http://opa.osophs.dhhs.gov/titlex/ofp.html.

[33] According to the Office of Family Planning (OFP), Title X is a Federal program solely dedicated to family planning and reproductive health with a mandate to provide a broad range of acceptable and effective family planning methods and services.

[34] Office of Family Planning [Internet]. Rockville (MD): Office of Family Planning, Office of Population Affairs, Office of Public Health and Science, U.S. Department of Health and Human Services; [updated 2006 Sep 16/cited 2006 Sep 26]. Available from http://opa.osophs.dhhs.gov/titlex/ofp.html.

[35] General CHR Information, History & Background Development of the Program [Internet]. Rockville (MD): Indian Health Service, U.S. Department of Health and Human Services; [updated 2006 Mar 30/cited 2006 Oct 21]. Available from http://www.ihs.gov/NonMedicalPrograms/chr/history.cfm.

[36] Center of Excellence in Rural Health - Kentucky Homeplace [Internet]. Hazard (KY): University of Kentucky Chandler Medical Center; 1999 [updated 2006 Sep 25/cited 2006 Oct 9]. Available from http://www.mc.uky.edu/RuralHealth/LayHealth/KY_Homeplace.htm.

[37] Office of Women's and Children's Health - Health Start [Internet]. Phoenix (AZ): Arizona Department of Health Services, Division of Public Health Services; 2006 [updated 2006 Sep 13/cited 2006 Oct 9]. Available from http://www.azdhs.gov/phs/owch/healthstart.htm.

[38] Fort Worth, TX; San Francisco and Berkeley, CA.

[39] CHW National Employer Inventory (CHW/NEI) (2006).

[40]

Gold RB. Special analysis: Medicaid family planning expansions hit stride. The Guttmacher Report on Public Policy 2003; 6 (4).

[41] Health Resources and Services Administration. The Alaska Community Health Aide Program: an Integrative Literature Review and Visions for Future Research. Office of Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services, March 2003.

[42] NFME (2006).

[43] CHW/NWSI (2006).

[44] NFME (2006).

[45]

Ten Health Plans Recognized by NCQA for Bridging Cultural and Linguistic Divides in Health Care [Internet]. Washington (DC): National Committee for Quality Assurance; 2006 [updated 2006 Sep 13/cited 2006 Sep 29]. Available from http://www.ncqa.org/Communications/News/CLAS_06.htm.

[46] Rico C (1997).

[47] Governor Pataki Announces $8 Million in Funding for Family Health Services, Perinatal Care. Initiative Supports Expanded Access for Women to These Vital Services [Internet]. Albany (NY): New York State Governor's Page; 2006 [updated 2006 May 4/cited 2006 Sep 26]. Available from http://www.ny.gov/governor/press/06/0504061.html.

[48] Welcome to the COBRA HIV/AIDS Case Management Website! Who are We? [Internet]. Albany (NY): AIDS Institute, New York State Department of Health; 2002 [cited 2006 Sep 26]. Available from http://www.cobracm.org/whoweare/.

[49] Promotora Program Development Committee: Promotora Program Development Committee Meeting Minutes - for 2000 (August 17, 2000) [Internet]. Austin (TX): Texas Department of State Health Services; 2000 [updated 2006 Oct 30/cited 2006 Sep 30]. Available from http://archive.tdh.state.tx.us/legacytdh/ppdc/minutes_2000.htm#August%2017,%202000.

[50] Nichols DC, Berrios C, Samar H. Texas' community health workforce: from state health promotion policy to community-level practice. Prev Chronic Dis [Serial Online] 2005; 2:1-7.

[51] Rush C. Conversation with: M. Kate Stewart. 2004 November 8. Mr. Rush served as a consultant to this project in 2001-2002 through the University of Arkansas for Medical Sciences, Center for Health Improvement.

[52] Awardees Cooperative Agreement Summaries - Cancer Disparities Demonstrations [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services; 2005 [updated 2006 Oct 18/cited 2006 Sep 26]. Available from http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/CPTD_Awardee.pdf.

[53] Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: Can costs be controlled while preserving quality? Ann Intern Med 2005; 143 (1):26-31.

[54] Casalino L. Disease management and the organization of physician practice. JAMA 2005; 293 (4):485-8.

[55] DMAA Recognizes Excellence in Disease Management [Internet]. Washington (DC): Disease Management Association of America; 2005 [updated 2006 Oct 18/cited 2006 Sep 26]. Available from http://www.dmaa.org/news_releases/2005/PressRelease10182005Excellence.html.