Dual Certification Of Community Health Workers And Certified Peer Support Specialists Can Better Address Syndemics

Public health crises often converge, creating syndemics that exacerbate their collective impact. The intersecting challenges of HIV, hepatitis C (HCV), and opioid overdoses illustrate this phenomenon, disproportionately affecting marginalized populations and accentuating deep systemic inequities. Addressing these crises requires innovative, multifaceted strategies to enhance prevention, intervention, and recovery efforts.

The United States has made significant investments in community-based health care workforces to reduce health disparities and expand care access. In 2022, the Biden administration awarded $225 million in training grants to develop the community health workforce. Community health workers (CHWs) and peer support specialists (PSSs) are central to these efforts, bringing unique expertise to their respective fields. While these roles are distinct, they share complementary elements that can function in tandem to address syndemics. This article explores the overlapping scopes of CHWs and PSSs, with an emphasis on the benefits of a dual-certification model to address syndemics.

National Coverage Of CHWs And PSSs: Scopes Of Practice

CHWs and PSSs play distinct but complementary roles in health care delivery, each addressing critical needs in their respective domains. CHWs focus on promoting health education, assisting with resource navigation, and addressing the social determinants of health that impact access to care. They are often culturally and demographically representative of the communities they serve, creating trust and relatability. This unique positioning enables CHWs to act as vital links between individuals and general medical care systems, ensuring that underserved populations can access and benefit from essential health services.

PSSs, on the other hand, bring the powerful perspective of lived experience in mental health or substance use recovery. By openly sharing their journeys, PSSs foster trust and reduce the stigma that often hinders recovery and engagement with health care. Their work is rooted in behavioral health, with a strong emphasis on promoting recovery, resilience, and overall wellness.

Although CHWs and PSSs share the overarching goal of improving community health, their approaches and areas of expertise differ. CHWs often form connections based on cultural or geographic commonalities, acting as relatable advocates for their communities. In contrast, PSSs create bonds through shared experiences of overcoming illness or addiction, serving as tangible examples of hope and recovery. Despite these differences, both roles contribute significantly to prevention efforts, health education, and facilitating access to treatment services, solidifying their essential place in the health care system.

A Syndemic Framework For Workforce Development

The theory of syndemics was first introduced by Merrill Singer in 1996, to inform the understanding of public health practices in the context of biosocial influences. While Singer’s later work focused on the SAVA (substance abuse, violence, and AIDS) syndemic, the Centers for Disease Control and Prevention’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP) division adopted their NCHHSTP Syndemic Approach in 2004—using Singer’s definition of syndemic as a “population-level clustering of social and health problems.” Around the same time period, the opioid crisis began to take center stage, with more than half a million American lives lost to opioid-involved overdoses from 1999 to 2020. The demonstrated association among opioid use disorder, communicable disease, and socioeconomic factors supports taking a syndemic approach in addressing these interrelated public health crises. While rates of HCV have decreased and national overdose fatalities are predicted to continue declining, HIV incidence rose by 5 percent in 2022. Social determinants of health, including housing instability and economic inequities, continue to exacerbate these crises. A syndemic approach acknowledges the interplay between multiple health crises and their shared social determinants, such as poverty, stigma, and inadequate access to care. CHWs and PSSs are uniquely positioned to address these challenges within a syndemic framework. Integrating their roles through dual certification can equip paraprofessionals with the skills needed to address co-occurring conditions holistically.

For example, the Community Education Group’s CHAMPS (Community Health and Mobilization Prevention Services) program trains CHWs in the Appalachian region, an area severely impacted by the opioid crisis and associated health disparities. In 2023, 53 percent of CHAMPS graduates had lived experience with a history of substance use, making them ideal candidates for dual certification as PSSs, which would expand their capacity to address both physical and behavioral health needs.

The Case For Dual Certification: A Syndemic-Informed Strategy

To become certified as either a CHW or PSS, candidates must complete training programs under state-approved curricula that require both core competencies and a minimum amount of hours of coursework. While certification requirements vary by state, both professions share a common framework: the promotion of health through helping individuals navigate the health care system and addressing social determinants of health. Dual certification, through a unified training model that meets the requirements of each profession’s training program, offers a progressive opportunity to integrate the complementary strengths of CHWs and PSSs, thereby enabling a more holistic approach to care. By incorporating peer support principles into their practice, CHWs can expand their impact on behavioral health issues while maintaining their focus on physical health. Conversely, PSSs equipped with CHW training gain the skills to address physical health needs, creating a seamless blend of support that addresses the full spectrum of health challenges individuals face.

The potential of this integrated model is exemplified by Charlie Turner, a dual-certified CHW and PSS trained through the CHAMPS program. Turner’s journey through substance use recovery allowed her to detect a critical gap in advocacy for physical health among peers in recovery. While her peer support specialist helped her navigate the behavioral health system, Turner often struggled to find similar guidance for her medical needs. Recognizing this disparity, she pursued dual certification, equipping herself to bridge the divide between physical and behavioral health services. Today, Turner provides comprehensive care and advocacy, ensuring that individuals in recovery receive the holistic support they need to achieve lasting wellness.

Financial Implications Of Dual Certification

As of January 2024, Medicaid reimbursement for CHWs is available in 24 states, with rates for a 30-minute session varying significantly by location, ranging from $18.11 in Louisiana to $35.00 in New York. PSSs benefit from even broader Medicaid coverage, with 47 states and the District of Columbia reimbursing their services. Medicaid reimbursement rates also vary widely—ranging from $5.98 per 15-minute billing unit in South Carolina to $36.32 in Ohio—reflecting differences in state policies and funding structures.

The dual certification of CHWs and PSSs presents several compelling advantages within this reimbursement framework. By equipping paraprofessionals to operate in both physical and behavioral health settings, dual certification increases workforce flexibility, making these professionals more valuable to employers. Additionally, a unified training model for dual certification reduces redundancies and lowers overhead costs for employers, creating a more versatile and cost-effective workforce. Perhaps most significantly, dual-certified workers can access both CHW and PSS reimbursement streams, enhancing the financial viability of programs and expanding the reach of services to underserved populations. This integration offers a practical and scalable solution to optimizing workforce potential while addressing critical gaps in health care delivery.

Recommendations

To optimize the potential of CHWs and PSSs in addressing syndemic health crises, we propose several strategic recommendations. First, we need state-level comparative studies on CHW and PSS workforce saturation and their impact on syndemic outcomes to guide targeted workforce investment strategies. These analyses can detect the relationship between community-based workforce density and improved health outcomes, providing critical data to inform policy and funding decisions.

Second, training programs that integrate CHW and PSS competencies should be developed and implemented by training organizations. These dual-certification programs should prioritize individuals with lived experience, ensuring they are equipped to address both behavioral and physical health needs. Aligning these programs with state certification requirements will further streamline their implementation and effectiveness.

Third, we need policy advocacy from PSS associations, CHW associations, and community-based organizations that support both professions to promote Medicaid reimbursement policies that support dual-certified paraprofessionals. Such policies will ensure sustainable funding for these innovative roles, maximizing their reach and impact. Additionally, efforts must focus on equity by prioritizing the recruitment of paraprofessionals from marginalized communities. Addressing cultural and socioeconomic barriers to care through inclusive recruitment strategies will help bridge gaps in access and improve outcomes for underserved populations.

Conclusion

CHWs and PSSs are indispensable in tackling the overlapping public health crises of opioid use, HIV, and HCV. Their unique abilities to connect with individuals, whether through cultural and community ties as CHWs or lived experience and shared recovery journeys as PSSs, make them essential components of the public health workforce. However, the full potential of these roles remains untapped without strategies that integrate their strengths.

A dual-certification model presents a profoud opportunity for public health systems. By equipping CHWs with peer support skills and PSSs with the tools to address physical health and social determinants, dual certification fosters a more versatile workforce. This integration not only expands the reach of these professionals but also enhances their ability to provide comprehensive, patient-centered care that bridges gaps between behavioral and physical health systems. Such an approach ensures that individuals receive seamless support for their interconnected health challenges.

The dual-certification model also provides a scalable solution to systemic health inequities. It allows for more efficient use of resources by streamlining training and increasing the reimbursement potential of paraprofessionals. Moreover, it addresses workforce shortages in underserved areas, ensuring that communities disproportionately affected by syndemics have access to both prevention and recovery resources.

By investing in dual certification and embracing this innovative approach, public health systems can address syndemics more effectively, reducing disparities and fostering resilience in vulnerable populations. The integration of CHWs and PSSs through dual certification represents not just an advancement in workforce strategy but a critical step toward achieving health equity and improving outcomes for some of the nation’s most at-risk communities.