As the COVID-19 pandemic was dominating life in the region, Linda Flores began reaching out to Spanish-speaking families to talk to them about a new vaccine. The work was crucial to ensure members of the community, many who did not speak English, understood the importance of protecting themselves and how to get a shot.

She sometimes worked as many as six days a week for the Latino Health Initiative, getting multiple part-time gigs that helped her support her child and share the bills with her husband.

Now that the public health emergency is over, she works only one day with the initiative and has to go to multiple organizations to find work, jumping in when someone is sick or on vacation.

“There are months that are good, there are months that are not,” she said in Spanish.

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Community health care workers like Flores are often the only link between their own communities and health care and social services. They work for health care providers, health departments and nonprofits, but they typically toil under the public radar, grant-funded and temporary and so low-paid they often don’t have health insurance themselves.

Health care advocates fear that with the federal pandemic dollars ending this year and uncertainty around other sources of funding for their work, the workforce will become even more disjointed and many of the most experienced workers will be permanently lost to unrelated jobs. That means fewer of them would be available when new needs arise.

The advocates are now working on how to create a more permanent, well-trained and sustainably funded workforce.

“We learned during the COVID pandemic how cost effective community health workers are,” said Monica Guerrero Vazquez, executive director of Johns Hopkins University’s Centro SOL, which promotes outreach and access to health care to Baltimore’s Latino community.

“They were effective in engaging communities of color and immigrant communities, providing awareness, promoting better outcomes,” she said about linking people who didn’t initially want, or know how to get, tests, treatments and vaccines. “But once pandemic emergency funding ended, we lost that workforce.”

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Advocates said the workers need consistent and better pay and benefits to keep them on the job. Some already are under-employed for their training. Flores, for example, was a physiotherapist before moving from El Salvador in 2012 but hasn’t been able to use her degree. So she spent six months getting accredited to be a community health worker so she could stay in the health care field.

There are more like Flores, according to a report from the Comptroller of Maryland on the state of the economy from April, which estimated that 21% of the 35,000 immigrants with health-related degrees in Maryland are unemployed or working in “lower-skilled jobs.”

Flores wants the state to provide more training that could help her get a full-time, better-paying community health job with benefits.

Advocates point to evidence that the workers can improve health in marginalized communities and save the health care system money. A recent Abell Foundation report found the workers effectively overcome a host of barriers.

Some are practical, such as language or transportation, and others are entrenched, including racism and classism, wrote the report authors, Chidinma A. Ibe and Obie McNair, professors in the Johns Hopkins schools of medicine and public health.

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These groups frequently also have more negative so-called social determinants of health, including poverty, food insecurity and housing instability.

“Community health worker programs are a cost-effective solution that can help mitigate the impact of social determinants of health,” they wrote. Community health worker “programs improve health outcomes across a number of acute and chronic diseases.”

To stabilize the work force and create a steady stream of funding, they called for an appraisal of the city’s workforce to get a handle on gaps — no one was even sure how many workers there are in Maryland.

They called for more budgeted state and philanthropic funding, plus long-term financing through Medicaid, the state-federal health program for low-income residents. They also called for more public awareness of work done by community health workers so there is more buy-in from lawmakers and the public.

Dr. Sarah Polk, co-director of Centro SOL, said 18 states allow reimbursements through Medicaid. Other states use “rainy day” health funds in their budgets or hospital-related fees for community health workers.

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Advocates said Medicaid in some of those states allows some reimbursement when a community health worker assists in linking someone to care, but only after they have a specific medical diagnosis and a doctor is supervising. Many people in underserved communities, specifically some Black and Latino neighborhoods, however, don’t have a doctor or a diagnosis, and this excludes interventions to prevent illness.

Advocates want to allow home visits and other outreach, for example, to link women with obstetric services and medical visits for newborns, a need in Baltimore where maternal and infant mortality rates exceed the national averages.

In 2018, Maryland created a training and certification process that adds consistency to the workers’ qualifications and an accounting of the workforce. The certification, however, is not required, and some workers have found that it hasn’t boosted pay so they don’t bother, said Kelly Velazquez-Umaña, a public health consultant and founder of Umana Public Health Solutions.

Community health workers could do more data collection to understand needs and cultural differences, particularly as immigrants make up a bigger share of the state’s population and the labor force, according to a report this year from the state comptroller’s office.

Chase Cook, a spokesman for the Maryland Department of Health, said the state has certified 1,089 workers since legislation created the process. But he said understanding the total number doing the jobs of community health workers is difficult because many aren’t certified and they go by variety of titles, including promotores de salud, health coach, community health advisor or coach, and many more. Some are paid and some volunteer.

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He said the health department is working to boost the workorce and developing a community health worker profile, intended to be released later this year. Officials also are working to expand access to training. To boost funding, they are investigating Medicaid reimbursement.

“The state recognizes that a key strategy to promote health equity and meet our community’s health needs is engaging with community health workers as key partners,” Cook said in an email.