Across U.S. randomized trials and program evaluations, CHW-enabled team-based care consistently improves blood pressure control, medication adherence, and cardiometabolic risk among underserved populations (1–5). Findings prioritize U.S. evidence, with international examples flagged and paired with brief ‘U.S. translation notes’ to indicate how the practice would operate within American delivery and payment systems. Based on the evaluated studies, the evidence supports the use of CHW-led interventions, demonstrating improved outcomes across several underserved populations and communities with challenges accessing healthcare (6–8). The trusting relationship described enables CHWs to serve as intermediaries between health and social services, facilitating access to quality services through culturally tailored education (7, 9, 10). Across randomized and program evaluations, CHW-enabled team-based care improves blood pressure control and adherence, particularly in immigrant and underserved populations (11–14). In some regions of the world, CHW-led interventions have been associated with shorter hospital stays and lower mortality rates (1, 6, 15, 16). CHW-led interventions can be effective in both mental health and chronic-care models. Recent evidence also suggests that, for patients with comorbid cardiovascular and mental health conditions, CHW-delivered interventions can lead to greater medication adherence and improved quality of life (17). In addition to other conditions, the greater use of primary care services, secondary to more straightforward healthcare system navigation, has been associated with navigation-focused CHW interventions for patients with CVD (2, 10, 18). The Community Preventive Services Task Force (CPSTF) supports CHW-integrated team-based care models to improve education-based outreach and address potentially modifiable risks (19).

CHW-led interventions for screening and chronic illnesses, such as HIV, also enhance screening and treatment rates compared to standard care practices (10, 20–23). They guide individuals navigating complex health systems and collaborate with community members and health and social service entities to increase adherence and promote appropriate service use. Studies also indicate substantial cost advantages in cardiovascular disease prevention for specific populations, including HIV patients, potentially decreasing ischemic heart disease, strokes, and cardiovascular disease mortality by 9%–36% in West Africa (24).

A recent study in Rwanda demonstrated the effectiveness of CHW-led use of a body mass index risk tool in assessing CHWs’ ability to screen and identify community members at risk of CVD. These findings suggest a positive association between CHW-conducted risk assessments and those performed by nurses, indicating that CHWs can be effective and reliable sources to screen for CVD in high-risk communities (25). A secondary analysis of two patient-centered lifestyle interventions that involved CHWs among South Asians in New York City revealed a significant reduction in blood pressure among patients with both diabetes and hypertension. These interventions included a culturally adapted diabetes management initiative, the DREAM project, and a hypertension management program, Project IMPACT (14).

Economic evaluations increasingly support CHW models for CVD. In Colorado's statewide CHW program, a cost-effectiveness analysis found that the intervention was cost-effective compared to standard approaches, driven by reductions in risk factors achieved in community settings (26). These data align with the CPSTF's economic findings for team-based blood pressure care and inform scale-up through Medicare Community Health Integration (CHI) services (HCPCS codes G0019/G0022) and state Medicaid financing pathways (SPAs, 1115 waivers, MCO contracts) (27–29).

When recruiting CHWs from within a community without a specific order, several studies help identify and engage community members at the volunteer or paid work level (7, 21). Some of these methods directly focus on specific vulnerable populations through a partnership-based model of care (22, 30–32). For many middle- and low-income countries, CHW interventions often result from volunteer efforts. However, incentivizing CHWs with pay or other benefits is associated with better learning and overall performance (33–35). Therefore, recruitment efforts should focus on individuals from the target populations they will serve, preferably developed in partnership with community members with strong advocacy voices (3, 36). This process should involve assessing their understanding of community morals, ethics, perspectives, dynamics, concerns, and resources.

An organization should establish clear selection and commitment criteria, effective retention strategies, and adequate compensation when recruiting CHWs within communities. Networking with CHW associations, local health departments, non-profits, and community-based organizations, and faith-based organizations (FBOs) can enhance the benefits of CHW intervention and often expedite gaining trust at the patient level. Collaboration with community stakeholders is, therefore, essential. Health systems can utilize a variety of communication platforms, such as social media and radio, to raise awareness.

The screening capabilities of a well-trained CHW are also crucial in identifying patients with the highest potential for success. However, to demonstrate effectiveness in reducing cardiovascular disease or modifiable risk factors, CHW-led interventions will require effective training methods for the continual need to address cultural beliefs or historical stigmas related to CVD. Ultimately, effectiveness should be characterized with outcome measures that adequately assess the intervention.

While most US states have certification and training programs, the lack of a standardized national training approach for CHWs becomes problematic when considering the scalability of various programs. Several entities provide CHW training, including local and state CHW organizations, public health departments, educational institutions, and Care-Based Organizations (CBOs). As of May 2024, 11 states—Arizona, Connecticut, Colorado, Kentucky, Massachusetts, Maryland, New Mexico, Ohio, Oregon, Utah, and Texas—had established credentialing and certification programs through their state public health departments. Six states (Florida, Missouri, Pennsylvania, Rhode Island, and Virginia) offer private programs led by independent credentialing boards, while six others (Arkansas, Indiana, Kansas, North Carolina, South Carolina, and South Dakota) offer programs led by CHW associations or individual CHWs (37). Five states (California, North Dakota, Illinois, Tennessee, and Mississippi) are also developing their programs. Some states, such as Louisiana, have focused on creating more comprehensive training programs rather than establishing credentialing and certification programs. While licensure is not required in many states, some require it for service reimbursement (37).

According to the National C3 Council, CHWs should possess 11 core skills: communication; interpersonal and relationship building; service coordination and navigation; capacity building; advocacy; enhancing individual and community capacity; personal and community assessment; outreach; professional skills and conduct; evaluation and research; and knowledge base (38). As communities have varying needs, CHW curricula should cover general and community-specific topics and use multiple modes of adult learning. This includes hands-on training, interactive role-playing sessions, team-based exercises, and various in-the-field resources, such as worksheets, modules, manuals, as well as in-field shadowing and internship opportunities (23, 39–41).

Training should also include information on local and state-specific regulations for certification and credentialing, as well as education on navigating the healthcare system and collaborating with healthcare professionals. Additionally, it should provide instruction on duty supervision, mentoring, and coaching (16, 36, 39, 42, 43). However, future research should focus on identifying the specific activities and core competencies that can be universally integrated into specialized CHW training programs, enabling regional flexibility.

CHWs can work for a variety of organizations, including healthcare organizations, public health departments, nonprofits, social service agencies, educational institutions, insurance providers, corporations, and faith-based groups (see Table 1). Approximately 80% are employed by nonprofit organizations, community clinics, and hospitals (7, 44). They are integrated into healthcare systems in four main ways: through community-based partnerships with clinics, team-based care in hospitals, payer-based models, and public health departments (3, 6, 7, 45). Integrating trained CHWs into the community for intervention purposes is often hindered by several factors, some of which are unique to each community. In a community-based partnership model, CHWs focus on outreach and referrals (Figure 2).

In team-based care, CHWs collaborate with other healthcare providers within a hospital, clinic, or facility, offering valuable insights into the barriers patients face in accessing care. Each setting requires a focused skill set or competency that CHWs must acquire. In payer-based models, insurance companies and state Medicare/Medicaid agencies utilize CHWs to support patients within their respective networks. The CHWs trained in this capacity must have a certain level of numeracy to guide patients. Therefore, a well-trained CHW for complex tasks may require education beyond high school. Similarly, public health departments engage community health CHWs to provide services to healthcare providers and entities. Consequently, strategies for successfully integrating CHWs into healthcare teams vary widely. However, this approach must focus on the maximal benefits of CHW interventions.

The growing demand for the expedient integration of telemedicine and artificial intelligence (AI)-enabled tools has presented both opportunities and challenges. On one hand, training CHWs to utilize telehealth platforms, wearable devices, and AI-driven tools could revolutionize our concept of ambulatory medicine. Particularly for patients with CVD and other chronic conditions, the innovative use of CHWs in this sense would likely yield effectiveness and sustainability. In contrast, many communities with a higher SDOH burden also have limited broadband access, hindering community digital literacy, particularly among veterans, older members, and school systems (46, 47). Healthcare teams can also empower CHW-led programs by identifying team champions who can advocate for CHWs and their work. This advocacy includes ensuring that team members receive formal education on the unique roles and characteristics of CHWs. Additionally, standardized guides should be developed to help CHWs understand the healthcare system, including practitioners’ roles and responsibilities. As in any associated research, incorporating community health workers (CHWs) into the program's ongoing development and evaluation is crucial. Continuous professional and technical development for CHWs is essential, as is support in creating patient education materials. Professional development should emphasize core competencies, such as cultural sensitivity, updates in health education, practical role-playing skills, and ongoing supervision and observation by supervisors (3, 33).

These recommendations are explicitly U.S.-specific. They operationalize globally proven CHW practices through American payment (Medicare CHI/PIN; Medicaid SPAs, 1115 waivers, MCO contracts), credentialing, and data requirements (see Table 1). Despite CMS expanding CHW reimbursement, community-based programs not affiliated with health systems continue to face persistent funding challenges and insufficient resources for program design and evaluation, among other factors. Federal and local initiatives must focus on establishing sustainable financial solutions rather than relying on temporary grant funding (22, 36, 39, 40). Legislation that standardizes credentialing and certification while preserving the fundamental aspects of CHWs, encourages workforce development initiatives, and strengthens Medicaid coverage should be prioritized (3, 42). Mechanism-specific operational examples appear in Supplementary Table S3.

State Medicaid programs, although encouraged to reimburse comprehensive CHW interventions, have varying success rates (27, 40, 55). Medicare beneficiaries should have access to CHI programs and collaborate with Medicaid-managed care organizations to mitigate financial deficits, enhance coverage, facilitate care coordination, and increase patient engagement. (Figure 3) To address concerns about attrition, providing full-time employment opportunities with benefits, professional development, technical skills training, and supportive administrative and coaching services is essential. Collaboration with the National Association of Community Health Workers (NACHW) will ensure that CHWs play a vital role in the development, implementation, integration, sustainability, and management of CHW programs. CHWs must adapt to mixed environments where they work alongside other healthcare practitioners who may not fully understand the unique needs of CHWs (6, 9, 30, 42, 43).

CHWs, like other frontline public health workers, should not be overlooked in policy, legislation, and regulatory discussions. Instead, they should play prominent roles in conversations about capacity-building, structural sustainability, and implementation. Initiatives specifically focused on increasing access to community-based services, preventive care, obstetric care, and chronic disease management are more likely to succeed when strategically integrated by CHWs (7, 42, 45, 56). However, further research is needed to assess the cost-effectiveness of reimbursement models for CHW services (26). Comparative studies that assess value-based care vs. fee-for-service models could provide additional insight into the sustainability of CHW programs.

There is a vast array of research opportunities and continued clinical program development for CHW-led interventions to reduce adverse CVD outcomes (25, 27, 30, 50) (see Table 2). Collaborative partnerships, including various sectors such as Medicaid health plans, local health departments, CBOs, and academic institutions, are crucial in improving healthcare outcomes. By implementing and evaluating CHW-led health plan programs, these collaborations can be used to study the long-term impact on patient-centered outcomes. However, despite improved outcomes observed in local CHW-led interventions, evidence of long-term, longitudinal effects and sustained improvements remains limited. Future research efforts should explore the benefits of a standardized cardiac care-trained CHW. Through this coordinated effort, valuable evidence can be generated to inform effective resource allocation. Furthermore, these partnerships will engage CHWs as integral research partners, ensuring that their insights and experiences contribute to the evaluation process and promote a more inclusive approach to healthcare.

Few studies report long-term clinical and cost outcomes of specific CHW task bundles for CVD; standardized cardiac training modules and supervision models are variably described; and economic evidence remains sparse relative to implementation studies. Priorities include pragmatic trials and comparative cost-effectiveness analyses of clinic-embedded, community-based, and payer-based models, with equity-stratified outcomes. U.S. translation: each transferable global practice should be mapped to the U.S. scope-of-practice, supervision, documentation, and payment (27, 29, 55).