Three Tier Community and Public Health Delivery System

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Building a Sustainable Public Health Workforce: Elevating Community Health Workers (CHWs)

A sustainable public health workforce requires a layered, culturally grounded, and community‑rooted structure. While nurses remain the clinical and organizational leaders of the Community and Public Health Delivery System, Community Health Workers (CHWs) serve as the essential frontline workforce, the “boots on the ground” who bring public health directly into homes, neighborhoods, and cultural communities. It begins with Gen Z and other emerging workers, and describes how CHWs can strengthen the healthcare ladder, relieve workforce shortages, and elevate nurses into advanced leadership roles.

The Historical Role of Community Health Workers

CHWs have existed for decades across the world under various titles:

• promotoras
• peer educators
• village health workers
• outreach workers
• lay health advisors

Despite their long history and proven effectiveness, CHWs have often been:

• underrecognized
• underfunded
• inconsistently integrated
• limited in career mobility

The Community and Public Health Delivery System seeks to change this trajectory by institutionalizing CHWs as a core workforce, supervised by nurses and embedded within community Hubs.

CHWs as the “Boots on the Ground” of Public Health

CHWs are uniquely positioned to serve as the frontline workforce because they:

• live in the communities they serve
• share cultural, linguistic, and social identities
• understand local needs and barriers
• build trust more rapidly than external professionals
• provide navigation, education, and support in real time
• bridge gaps between healthcare systems and community life

In this model, CHWs are not auxiliary—they are central to community health delivery.

The CHW–Nurse Leadership Model

The system uses a tiered workforce structure:

CHWs: Frontline Workforce

• conduct outreach
• support chronic disease management
• provide health education
• assist with navigation and referrals
• document community needs
• support cultural and ceremonial activities

Nurses: Supervisors, Educators, and Leaders

Nurses provide:

• clinical oversight
• training and mentorship
• program coordination
• evaluation and quality assurance
• leadership in policy and system design

Advanced Practice Nurses: System Architects

Nurses with advanced degrees (MSN, DNP, PhD) serve as:

• program directors
• community health strategists
• policy advocates
• institutional leaders
•  “the next doctors in the house” in rural and underserved areas

This structure elevates nurses while expanding the workforce beneath them.

CHWs as an Entry Point for Gen Z and Emerging Workers

Gen Z is entering the workforce with:

• a desire for meaningful work
• interest in health, wellness, and social impact
• comfort with technology and digital tools
• openness to hybrid and flexible work models
• a strong sense of justice and community

The CHW role is an ideal entry point for this generation.

Low Barrier, High Impact

For individuals with college degrees, CHW certification requires:

• short‑term training
• competency‑based learning
• cultural and community engagement skills

This creates rapid employment pathways.

Career Mobility

CHW roles can lead to:

nursing (LPN, RN, BSN)

• public health degrees
• social work
• health education
• community leadership

The CHW role becomes the first rung of the healthcare ladder.

Addressing Workforce Shortages Through the CHW Pipeline

1 Nursing Shortage

By attracting Gen Z into CHW roles:

• more young workers enter the healthcare pipeline
• CHWs gain exposure to nursing practice
• many transition into nursing programs
• nurses can delegate tasks and focus on leadership

This relieves pressure on the nursing workforce.

2 Physician Shortage

Especially in rural areas:

•           advanced practice nurses (NPs, DNPs) can fill clinical gaps

•           CHWs support navigation, follow‑up, and chronic disease management

•           the CHW–nurse team becomes a community‑based primary care extension

This strengthens rural health systems.

3 Public Health Workforce Shortage

CHWs expand capacity by:

• supporting community assessments
• conducting outreach
• facilitating programs
• documenting needs and outcomes

This builds a sustainable, community‑rooted workforce.

CHW Competencies in the Community and Public Health Delivery System

CHWs in this model are trained in:

1 Core Competencies

• communication and cultural humility
• health education and literacy
• chronic disease support
• navigation and referral
• documentation and evaluation
• digital literacy and telehealth support

2 Community‑Specific Competencies

• cultural and ceremonial integration
• community mapping
• outreach strategies
• intergenerational engagement

3 System‑Level Competencies

• partnership coordination
• program implementation
• data collection for evaluation
• participation in quality improvement

These competencies align CHWs with the system’s architecture.

Training and Certification Pathways

1 Certification Programs

CHW certification can be delivered through:

• community colleges
• public health departments
• workforce development programs
• online and hybrid platforms

2 Nurse‑Led Training

Nurses supervise:

• clinical content
• chronic disease modules
• communication and ethics
• documentation and evaluation

3 Cultural and Community Training

Community leaders provide:

• cultural knowledge
• ceremonial practices
• local history and context

This creates a holistic, community‑rooted training model.

Integrating CHWs into the Community Hub

CHWs serve as:

• outreach coordinators
• program facilitators
• navigators and connectors
• cultural ambassadors
• documentation stewards

Their presence strengthens:

• trust
• participation
• cultural relevance
• continuity of care

CHWs become the heartbeat of the Hub.

Policy and Funding Implications

Scaling the CHW workforce requires:

• Medicaid reimbursement for CHW services
• state certification standards
• workforce development funding
• partnerships with educational institutions
• integration into public health modernization plans

Policy alignment ensures sustainability.

The Ripple Effect: A New Workforce Ecosystem

When CHWs are elevated:

• Gen Z enters healthcare
• nursing shortages decrease
• nurses move into leadership
• advanced practice nurses fill clinical gaps
• rural communities gain access to care
• public health infrastructure strengthens
• cultural relevance increases
• community trust deepens

This creates a self‑sustaining workforce ecosystem.

Summary

Building a sustainable public health workforce requires a layered, culturally grounded model that elevates CHWs as the frontline workforce under the leadership of nurses. By positioning CHWs as the “boots on the ground,” creating rapid pathways for Gen Z and emerging workers, and strengthening the healthcare ladder, the system addresses workforce shortages while expanding community capacity. This chapter establishes CHWs as essential to the future of public health and positions nurses as the leaders who guide, supervise, and shape the next generation of healthcare professionals.