Organizational Readiness Forms Organizational Readiness Full Name First Last What is your title at your organization?Email(Required) Name of your organization(Required)Address of your organization:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What is your organization type?(Required) Community clinic Community-based organization Educational institution Faith-based organization For-profit organization Hospital/health system Local public health agency Managed care organization Medical clinic Mental health provider Oral health provider Social services agency State agency Substance use organization Other Please list your organizations population(s) of focus and vulnerable populations served at your organization.(Required)What year did your CHW program start?Before 200020002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025Do you currently have CHWs employed at your organization? Yes, certificate holding CHW(s) Yes, non-certificate holding CHW(s) Yes, both certificate holding CHWs and non-certificate holding CHWs No, we have a CHW position, but no one has been hired No, we do not have CHWs working in the organization and we do not have a CHW position Other How many CHWs are currently employed at your organization?Please enter a number from 1 to 30.How many CHW positions are currently open at your organization?Please enter a number from 1 to 10.Please select items that are present on your CHW Job Posting(s):(Required) CHW job posting is specific to the CHW role (e.g. not a template from another role like a MNSure Navigator, WIC Health Educator etc.) CHW Certificate is preferred. CHW Certificate is required. CHW Certificate is required within 1 year of hire. GED or High School Diploma required. Undergraduate degree preferred. Undergraduate degree required. Lived experience and community connection is emphasized in lieu of higher education and professional experience. Meaningful salary range Please select all the recruitment and interviewing elements that currently exist:(Required) Recruitment via community events Recruitment via culturally specific media Recruitment via organizational partnerships, specifically organizations who have relationships with communities you hope to serve with your CHW program. Specific definition of CHW role during recruitment and interview process Community involvement (e.g. community debriefs, letters of recommendation, community info-sessions about the job). Ample time for recruitment of the right candidate (3-6 months) Current CHWs play active role in recruitment Current CHWs are present during the interview Current CHWs are present during interviews and give feedback for candidate selection Please select all of the onboarding and training elements that currently exist:(Required) Universal organizational trainings (e.g. data security, HR policy etc.) Online modules that are not specific to the CHW role but cover things like home visiting Online modules specific to CHWs Informal introduction to internal team Formal introduction to internal team Informal introduction(s) to external partners Formal introductions to external partners Explanation of CHW role on the team internally Shadowing CHWs in the field (-3 encounters). Shadowing CHWs in the field (3+ encounters) Supervisors or CHWs shadowing new CHW Integrated in the CHW Certificate program Other How many hours of training do you provide (or plan to provide) during the first year employment of a CHW? Unknown, we are still in the planning phase Less than 8 8-24 24-40 40-56 56-80 80+ Other Of the hours listed above, how many of those hours are (or will be) safety training (e.g. blood born pathogens, OSHA, home visiting safety etc.)? Unknown, we are still in the planning phase 1-8 8-16 16-24 24-32 32-40 40-50 50+ Of the hours listed above, how many hours are trainings specific to the CHW role in general or at your organization? Unknown, we are still in the planning phase 1-8 8-16 16-24 24-32 32-40 40-50 50+ Other What does your organization do (or plan to do) to support CHWs in getting their CHW Certificate while employed with you?(Required) None, we only hire CHW Certificate holders None, we do not require that our CHWs have their certificate Secure funding to pay for part of the program cost Secure funding to pay for the entire program cost Allow paid time to complete classwork Allow CHWs to use office space/supplies (e.g. work computer, desk, internet etc.) to complete class work Act as the CHW’s Field Placement Site for their Certificate Reduce FTE for CHWs completing the program Other What kind of CHW Peer support does your program have or plan to have?(Required) Paid time to participate in CHW Learning Circle and other statewide CHW peer support groups Internal CHW group (Community of Practice) meetings held quarterly Internal Community of Practice meetings held monthly Internal Community of Practice meetings held weekly Paid time to attend regional or local CHW peer meetings or conferences. Paid time to attend statewide CHW conferences. Do CHWs at your organization have well defined pathways for professional advancement?(Required) No, there is no formal structure. There is not a formal structure, but some CHWs have advanced in my organization. Yes, there is a formal structure for CHWs to advance professionally. Other What aspects of your CHW Program currently exist?(Required) A formal referral structure Referral structure includes workflow for internal referrals A formal enrollment process A formal discharge protocol CHW Caseload limits Documentation protocol used by all CHWs Documentation software is integrated with the rest of the organization (e.g. CHWs use the same EMR as clinicians) Documentation software is not integrated with the rest of the organization HIPAA compliant documentation software Internal care team coordination and communication protocol Nationally recognized evidence-based model (e.g. IMPaCT or PCHI) Health Education modules SDOH screening Mechanism for CHW feedback to change program structure and/or specific protocols Patient/client/participant advisory board CHW program is integrated into other programs at my organization CHWs are present in the Organization Chart There is no CHW program at my organization, we are in the planning phase. Is the CHW role dipicted on your Organizational Chart? N/A we do not have CHWs No, our Organizatonal chart is limited to leadership No, but we plan to include CHWs in the future Yes, they are included with another team under the same supervisor (e.g. Care Coordination Nurses) Yes, the CHW program and its connection with other programs is clearly articulated in the Organizational Chart Do the CHW(s) and other professionals on your team (e.g. social worker, therapist, care coordination nurse, dietitian, interpreter, case manager, MNSure Navigator etc.) have a strong understanding about each team members role, how and when to refer, and how to work collaboratively?(Required) Yes, all Yes, most No Other Please select all of the people in your organization who have an understanding of the CHW Role and Scope of Practice: CHW(s) CHW Supervisors Internal care team members who work closely with the CHW (e.g. providers, RNs, Social Workers, Navigators, Care coordinators etc.) Director of the department where the CHW program is housed Organization Leadership (e.g. CEO, President, Executive Director) Board of Directors of the organization External partners who work directly with the CHW program External partners who do not work directly with the CHW program Please check all that apply to CHW Supervisors at your organization:(Required) CHWs meet with their supervisor at least twice per month CHWs meet with their supervisors at least once per week Supervisors have additional training in cultural humility, trauma and motivational interviewing Supervisors typically have experience working in the field as a CHW Supervisors are typically CHW Certificate holders Supervisors are licensed professionals (e.g. RN, MSW, LSW, pharmacist, DDS etc.) Supervisors are encouraged to engage in peer learning groups with other CHW supervisors and are able to do this during paid time Supervisors have understanding and experience with the communities being served by the CHW program Supervisors provide ongoing training and professional development opportunities to CHWs they supervise Please select all of the aspects of data, measurement and evaluation that currently exist:(Required) We do not have a CHW program, and our plan does not include concrete metrics of CHW impact. We do not have a CHW program, but our plans do include concrete metrics. No concrete metrics of CHW impact reported Qualitative data (e.g. success stories) Quantitative data Data collected at regular intervals (e.g. annually, quarterly, monthly). Data is used for program improvement Data is used for CHW performance improvement Data is used for Supervisor performance improvement. Data dashboards Please select the option that is closest to the current state reporting data collected from your CHW Program:(Required) Reported to funders Reported to health insurance payers Reported internally within our organization Reported back to the CHWs doing the work (e.g. for the purposes of program improvement) Reported to governing board Reported to advisory board Included in organization wide reports (e.g. annual reports) Reported to community leaders Reported to other stakeholders Reported to clients/patients Other Is your organization currently billing for CHW services?(Required) Yes, billing Medicaid Yes, billing Medicare Yes, billing Medicaid and Medicare No, but we want to learn more and explore billing No, we are not interested in billing Other What are your barriers to billing? (check all that apply)(Required) We do not currently have CHWs employed at my organization. Eligible provider requirement Covered services do not align with work of CHWs at my organization Registration with DHS CHWs at my organization are not certificate holders CHWs at my organization have certificates but do not have NPIs My organization does not have the infrastructure to submit claims Reimbursement rates (not worth it) Please select all of your current funding sources for your CHW program:(Required) No funding One short term grant (-2 years) Multiple short term grants (-2 years) One long-term grant (2+ years) Multiple long-term grants (2+ years) Billing Organizational funding for supervisors (e.g. FTE percentage) Organizational funding for CHWs (e.g. CHW role is included in annual organizational budget) Other Is your current funding sufficient to sustain your CHW program?(Required) Yes No, but we have a plan to increase funding No, and we do not currently have a plan to sustain the program Other What is the position of the highest ranking "CHW Champion(s)" at your organization? A CHW Champion is someone who has a deep understanding of the CHW role and scope of practice and advocates for CHWs in their organization.(Required) Our organization does not have a CHW Champion CHW/ Program Associate Coordinator Manager Director Executive Director or higher Everyone at our organization understands and values the CHW role, we are all CHW Champions. Other What is the position of the highest ranking CHW Certificate holder at your organization?(Required) Our organization does not have a CHW CHW/ Program Associate Coordinator Manager Director Executive Director or higher Other Leadership at my organization: (select all that apply) Are skeptical of the CHW role See the value of CHWs in a limited sense, See the value of CHWs and our CHW program Promote the CHW program with external partners Open to expanding the CHW program Prioritize sustaining the CHW program financially Constantly looking for ways to expand the CHW program. Other Do CHWs at your organization have, or will have, formal channels to provide feedback to your organization that have the potential to impact the CHW program and/or engagement with communities the CHW(s) work with?(Required) Yes, CHWs are welcome to bring feedback to program management. Yes, we solicit feedback from CHWs and there is a structure to communicate desicsions made by leadership based on CHW feedback Yes, CHWs have formal power sharing in decisions that affect CHW programs No, but we are open to it. No, we don’t see the value in this. Other What is the typical starting pay range for a CHW at your organization? Less than $15 per hour $15-$17 per hour $18-$20 per hour $20-$22 per hour $23-$25 per hour $25-$27 per hour $28-$30 per hour More than $30 per hour Other How long does the average CHW remain in the CHW position at your organization? less than a year 1-2 years 2-3 years 3-4 years 4+ years Other Of the CHWs who have left their CHW position at your organization, what percent have advanced in your organization? 100% 75%-100% 50%-75% 25%-50% 1%-25% None N/A we have not had any CHWs leave their position Other Δ