Enabling and Elevating Community Health Workers across the US: Insights from MHP Salud’s Impact Delivery Approach to Technology

This transcript was generated by AI and may contain typos and inaccuracies.

Amie Vaccaro: Welcome to High Impact Growth, a podcast from Dimagi about the role of technology in creating a world where everyone has access to the services they need to thrive. I'm Amie Vaccaro, Senior Director of Marketing at Dimagi and your co-host, along with Jonathan Jackson, Dimagi's CEO and co-founder. We've heard a lot on this podcast about community health workers and the important role they play in global health, but we haven't talked about CHWs in the context of the US, where they're just as essential in creating more accessible services. Today, we're joined by two incredible women, Dr. Maggie Dante, CEO of MHP Salud and Rachel Udow, Data and Evaluation Analyst at MHP Salud, to hear how one organization is championing community health workers across the US, both within their organization and also training and consulting to other organizations on how to best integrate CHW programs. This is an organization that's been around for 40 years and has been on a

decade-plus journey of digitization to improve service delivery. MHP Salud really models so many of the best practices in leveraging digital to deliver impact at scale that we see across organizations. So if you're at any point in your digitization journey, this episode will be inspiring for you. Enjoy. Welcome to the podcast. So we've got a really great conversation in store for today. I'm here with my co-host and Dimagi's CEO and co-founder Jonathan Jackson, as always, and we have two esteemed guests, Dr. Maggie Dante, CEO of MHP Salud and Rachel Udow, Data and Evaluation Analyst at MHP Salud. So I'd love to start with a quick intro to each of you.

Maggie, do you want to kick it off with an intro? Sure. So I've been with MHP Salud a little over a year now, and previous to that, I have about 30 years of experience in social services. So child welfare, behavioral health. I am a licensed clinical therapist, so I've done a lot of work in the community with underserved and underrepresented populations doing maternal health and working with children and families. So I came to MHP Salud with a well-rounded kind of background to help this community, so I'm super excited about being here. Awesome. Great to have you on. And Rachel, over to you. Thanks for having us on. I was mentioning this to Amie earlier, but I'm just really a huge fan of CommCare, and Dimagi is a company, and it's an honor to be part of this conversation. I've worn various hats at MHP Salud over the years, but my current position is Data and Evaluation Analyst, so in that role, I'm collaborating with our evaluation department

and programming just to help ensure that the work we're doing is high quality and has a measurable impact. And I'm also one of four members of our CommCare team, and I've had the pleasure of witnessing the app's growth and evolution since its inception. Well, we're really excited to have you both, Maggie and Rachel, and we've known each other as organizations for a very long time at this point, but for our audience, quick background on the amazing work that MHP Salud has done and is now doing, because I know there's been a lot of growth as well in what the organization provides.

Absolutely. So MHP Salud is a national organization that provides training and consultation services to organizations interested in creating a CHW program or supporting current CHW programming. But we also have boots on the ground. CHW is in Texas and Florida, and that's where a lot of our growth has come from. We do provide services such as access to health care, health education, to adults and seniors. We also support and provide education to parents and their families. And so that has been where you see the most growth in those two areas.

MHP Salud now is like an $8 million organization with 70 employees, but we're celebrating 40 years this year, and we were born really out of necessity by two Catholic sisters in Michigan. They were working with migrant workers, and they were seeing the struggles of accessing health care, and that's kind of how the first CHW program was born. So we're really excited about how we've expanded over the years, and we've expanded from Michigan to Florida and Texas, but then nationally supporting other CHW organizations has been really, really great.

That's so cool. And Maggie, I was really excited to speak with you because I think that we hear so much about community health workers in the context of global health, and Dimagi does a lot of work supporting and enabling community health workers around the world, but we really don't hear about community health workers much in the U.S. context, or at least I don't. I'd love to hear from both of you. What is the status of community health workers in the U.S.? What trends are you seeing? I'm happy to kick that off, and then Maggie can jump in anytime. CHWs have been around in the U.S. for many years, but often referred to as other things, so Promotoras de Salud, lay health educators, community health representatives, and that may be true internationally as well. CHWs have formally been a part of Health and Human Services Systems in the U.S. since, I think, the 1950s and had a presence in the American Public Health Association since

the 1970s, so their history in the U.S. is pretty long and rich, but I think what's really been changing in recent years is this shift from CHWs as primarily a grassroots role in this country to really more of a formalized profession, and I think according to the Bureau of Labor Statistics, at this point there are over 125,000 CHWs in the U.S., and this is a profession that's growing at a much faster rate and expected to grow at a faster rate than other professions in this country over the next decade, and you can kind of see evidence of this in other places as well.

Many states in the U.S. have started CHW associations, for example, or enacted legislation around CHWs or just engaging in the profession in other ways, and I think one really important milestone was that in 2019 we had a National Association of Community Health Workers that was finally established after a lot of planning and organizing by CHWs and allies in the U.S., so that was really important. I think there's a lot of factors that have contributed to this growth and professionalization over the years, but I can think specifically of the Affordable Care Act and the emphasis on improving health care, improving health outcomes, reducing costs that came from that, and also this growing body of evidence for the CHW profession in a lot of different areas. So those are some things that I can think of about what we've seen changing recently. Yeah, there's been a lot of talk about how do we sustain community health workers within

organizations, so that's been a hot topic for a while now where there's really not a lot of funding to keep them after we hire them, and so trying to find innovative ways, educating and advocating for CHWs and organizations, and really people talk about return on investment, but I always like to have the conversation about if you have a health center and you need a community health worker, they're the bridge. They're the ones that connect those people in the community to your organization, so when you don't have a community health worker, you know, these people in these communities, they're not going to trust you to get services from you, so you need that trusted individual in the community to help bridge that gap, and we've seen that not only nationally, but in our boots on the ground work that the reason that they do get services, the reason that there is an intervention is because our CHWs are talking to them, educating them, and working with

them, and so we really think that it's not a luxury anymore. It's something that we really need to consider when we're looking at health care and we're looking at access to care. How do we infuse CHWs and everything that we're doing? Building on that, within the U.S. market, certainly there's been a lot of work around topics like social determinants of health, health equity, access, needs issues, and we totally agree with you that CHWs are not optional. They're an integral component of how to achieve those goals. At the same time, as you said, CHW programs have historically been heavily project-based funded. You know, they have like three-year funding cycles that then churn, and it requires a lot of innovation, and I'm guessing you've done a lot as an organization on how to maintain consistent workforces across multiple vertical funding streams. With the partners that you're training, with the partners that you're supporting now having grown into this national

organization, are you feeling optimism that the funding is changing at the federal level or at the state level, or are people still pretty concerned that a lot of the funding and support, while I think the role of CHWs have been elevated and recognized as like a really powerful, critical workforce? Have you seen the systems financing and the ways that these roles can be funded move as well? So, it really depends on the state, right? So, you see movement in some states to get Medicaid reimbursement and other funding sources, and then you see some states that really don't have a mechanism in place to support CHWs. So, a lot of the work that we do is not only educating organizations on the importance of CHWs, but valuing their input and valuing their work. So, without, you know, getting on a soapbox, I really struggle when organizations tell me they have CHWs, but they're contracted workers and they're not getting paid a livable wage and they don't have

benefits. That to me is incongruent with what I feel is needed in the community, right? How are you going to be a community health worker and advocate for people to get services, do what's right for the community if you're not taking care of your people, right? So, you have to pay them a livable wage. You have to get them benefits. You really have to wrap yourself around your CHWs and make them a priority. When they're not first and in the forefront, they get lost. They're like, project's over. We're going to do a reduction in force. And that's not how we're going to be able to sustain CHWs long term. We really do need to talk about how we build them into budgets, how we build them into the infrastructure so that they're in the fabric of everything we do. And MHP Salud, you know, we've had our reduction in force. We're not perfect. We've had projects that ended and there wasn't funding to keep people. But I can genuinely say that out of the 70 employees

that we do have, over 60% are CHWs. They're fully employed. They have a generous and robust benefits package. And their feedback to us is that, you know, we do make them a priority in the organization. And we're very proud of that fact. And we're trying to educate other organizations to make them a priority as well. That's amazing to hear. And congratulations on being able to do that. I agree 100%. And we had previous guests on from the Yale Impact Coalition and others who would totally agree with your soapbox. So, you know, definitely get on it on our podcast, at least. And I think you mentioned this challenge of project-based funding and having to reduce staff once it ends. So, your 60% of 70, you know, 35 to 40 CHWs you're supporting, you've really grown your programs as well. So, how do you think about how busy the workforce is today? How to sustainably expand your offering of services in Texas and Florida? So, you know,

if a donor came to you or funder came to you and said, hey, we have two years of funding for this great high impact program, but then I don't know what's going to happen. Like, how would you think about what to do there? So, I'll give you an example. So, one of our priorities is to support families, right? To get them to be resilient and self-sufficient. And so, we've been looking at our lines of business and really looking at how we can tap into other types of funding that, you know, may be CHW or adjacent. So, as an example, prenatal work, maternal health. One of the grants that we just recently applied for in Florida, there is an area in Florida that is underserved and they have a very high rate of pre-term births, right? Moms with a lot of stressors, maybe some domestic violence, some abuse, etc. And they really need a support system. They don't have a support system.

And so, this particular grant that we applied for was not only to support them with parenting and education, but also building partnerships in the community where we can create that tribe for them, that village, where they can have a healthy birth and then support their family and their child long term. And so, instead of looking at a grant as, oh, it's a three-year program and we're going to provide some parenting education. Yes, we are going to provide some parent education.

And in that work, we're going to give them referrals and we're going to connect them to the food pantry and housing, etc. But the connections that we're making in the community, the partnerships that we're putting together, the advisory board that we're putting together, that's where the longevity is going to come in, right? Because we're going to start building partnerships with other organizations doing similar things, but not the exact same thing. So, my people, my CHWs, are going to be providing the support in the home, but then I'm going to bring in the OBGYN and I'm going to bring in the housing and I'm going to bring in the transportation and the respite child care. Because we know that it's not all about, oh, I'm going to do this intervention and I'm going to do these referrals. I need to follow up on those referrals. I need to support that family. And as you do that, as you make it an integral part of the work, other funding opportunities come up, right?

Evidence-based programming is a big deal across the country. And so, looking at how do we get trained in some of these evidence-based practices where funding is available for that. So, I'm going to send my CHWs to get trained in this evidence-based program and that's going to be the core of what I'm going to do for the grant. But then I'm going to find alternative funding to be able to support this long term so that when this three-year grant ends, I have a braided funding mechanism where I have other funding sources coming in to help support the families. I think that's just one example, but that's how you get creative in figuring out, I've identified the gap in the community. I've identified what these moms need and we're not going to be everything to them, but we're going to be a piece of this village that's going to help support this family.

I love that answer. I'm sure Amie's smiling in her head too because that approach is exactly what our kind of new vision around impact delivery is all about. You know, we know you're going to get this vertical funding for three years to do this program, but how do you do a really great program and lay the foundation you just mentioned? How do you create that community buy-in? How do you create that advisory board? How do you then bring in additional funding for those CHWs to provide other high impact interventions?

And as we think about how impact delivery really needs to work, I think there's three key components. You know, there's better impact, just doing a better job with technology, with the CHWs, with the training. There's more impact. How do you add additional programs, additional support for the household, connect them to all the resources you mentioned? And then critically, there's how do you sustain the impact? Right? So as we think about better and more and sustain those kind of the three pillars that we're trying to achieve with impact delivery, and Rachel, I know you're part of the CommCare team and have used technology around this. And so I'd love to hear how has MHP Salud thought about technology over the last decade? I know you've been using CommCare in a variety of ways over the years, and a lot of people are skeptical about introducing technology into this workforce, about whether it's going to help or hinder.

So I'd love to get your take. You know, what caused you initially as an organization to start trying to technology enable your workforce? How has it grown over the years? And how's it going? The original impetus for CommCare was just getting off of paper and pencil into electronic data collection. We were spending a lot of time coding paper forms, manually entering the paper forms into Excel. So it was kind of from an efficiency perspective. And just to give you a sense of where we were at in 2011, when we introduced CommCare, I think two of our CHWs at the organization had used smartphones at that point. And not that CommCare requires a smartphone, but that's how we were planning to implement it. So there was a big learning curve transitioning from paper and pencil to CommCare, not because of the app, which was actually quite intuitive and perhaps more intuitive than paper and pencil, but I think

just the shift to using technology for this function. And I can remember a lot of conversations at the time with CHWs about concern over introducing this device, the phone, into the interaction in a home visit and what was that going to do in terms of a trusting relationship. And I think now we're all used to, you're talking to someone and they're inputting stuff on their phone, but at the time it felt a little bit scary to do. But kind of to give you a sense of where we're at today, all of the CHWs in the organization are using smartphones and CommCare in a wide variety of hardware and software. And something really exciting that we've rolled out this year is incorporating the Tableau integration with CommCare. And this is at the request of CHWs wanting to have more real-time access to see their outcomes and characteristics of who they were serving from CommCare. So each CHW in the organization has a personalized dashboard,

their goals, who they're serving, and that's been really exciting. So these are all the really positive things, right? But I think we also have to be real and just share technology, comfort, and skills are mixed as well. There's some people for whom this is really exciting and very natural and others for whom it's a bit of a struggle. And I think that kind of ties back to that discussion of the professionalization of the workforce and also those core aspects of what it is to be a CHW.

One thing that's really important to us at MHP Salud is kind of reinforcing the idea and message that CHWs at their core are trusted members of the communities that they serve, shared language, understanding of the culture, and it's really from that place that they're able to do the incredible work and see the outcomes that they have. And so keeping in mind that is really the core strength and differentiator of CHWs. You have different roles and skills of CHWs. There's the CHW Core Consensus or C3 Project, which listeners could learn more about at c3.org or c3project.org, but with other CHWs and allies to find these core roles and competencies. And it's interesting that technology isn't one of those. It's a tiny bullet point under one competency, which is Professional Skills and Conduct. And for me, the key takeaway from that is we all know technology is super important in our work and it's going to continue to be more so,

but it's not the be all end all for a CHW, nor should it be the primary measure of success. And for that reason, I think it's just so important that we design technology for CHW programs that's intuitive and supports workflow as much as possible. And that is one of the reasons I love Dimagi because I know that that's a value that you hold and something that you emphasize and all that you do, seeing that it's not just a data collection tool, but really about supporting the work of CHWs. So those are some thoughts on technology in our work. And Rachel, if I could add to that, MHP Salud is embarking on becoming an apprenticeship employer for CHWs. And in that conversation where we had to build out a significant amount of training for CHWs, digital health, and teaching them how to not only work with technology, but how it can tell a story, how that data can tell a story is really, really important. So we want to teach our CHWs,

I don't want you to be afraid of technology. I want you to embrace it, but I want to show you what else it can do and how it can make your life better and how it can help you tell the story about what you're doing in the community. So that is one of the modules that we are expanding on so that our CHWs really have a good understanding of how technology is a friend, not a foe. I love that. This is such rich insights and experiences. I'm curious to hear, could one of you share with me, almost like give me like a day in the life of a CHW that's working for MHP Salud and how they're using technology and how it's kind of weaving in, and maybe there's no typical day. It's hard because we have so many different types of programming. Rachel, you can talk a little bit about our platforms and how they use all of them, but each one of our programs is a little different, so they may touch each of them a little differently.

Of course, CommCare we've been talking about is really key for the work that CHWs are doing in the community. They're using that every day to document and guide the work, but in terms of other types of technology, things like mileage tracking or time sheets are just those basic day-to-day kind of things we're all doing electronically at this point. Our goal with a lot of these tools, and especially on the data side, just because that's where my focus is, kind of to Maggie's point, just trying to reinforce how this can be helpful. So taking the Tableau dashboards as an example, the idea is not for this to be another thing you have to look at, another thing that you have to do, but rather a tool to see, okay, here's a map. This is where I've done outreach. I know that I'm trying to cover the whole county, and I see that this code is blank, so maybe I want to focus here. Or, oh, I see that the average age of my participants is this, and

we're targeting this, so maybe I want to adjust. So just trying to make it as helpful as possible, and if it's not helpful, either scrapping it or rethinking how we can make it more helpful. I love that. And I think it's just that laser focus on what's going to be useful and actually making their jobs better. That really resonates with us. I'm also curious to hear, one of the things I love about your story is that you started with CommCare back in 2011, and you've been continually investing and upgrading and improving CommCare over those years. I'd love to hear a bit, and I think, Rachel, you've been really behind all those changes.

How have you thought about evolving technology to support the needs of your users and to support MHP Salud? Sure. So I think a lot of it has been learning as we go and trial and error, and then evolving into some more intentional planning as we've evolved. But like I was mentioning before, really 2011 when we got into CommCare, the idea was we just need to get off paper and pencil. So we came up with a pretty simple app structure, an app for each program, none of the advanced features like case management or things like that, just really basic. And I think some Dimagi folks actually traveled to our Texas office in the Rio Grande Valley to workshop and help us set it up.

So that was a very exciting time. And then we got to a point in 2017 when we were really evolving our evaluation structure as an organization, and it became important to focus on measuring changes over time in our program. So knowledge, behavior change, health outcomes from the beginning of a program to the end. And that was the point that we redid our app structure on our own into a single unified app that all programs shared, mega case management. And that worked beautifully for a few years until that app got really, really big. That's the thing we were kind of reaching a critical point around sustainability and decided to invest in some help from Dimagi's customer success team. Great investment, worked with Erin Quinn and Lorena Rosario, and they were amazing. And we listened deeply to what our journey had been and what our needs were and helped us identify an app structure that was going to be sustainable long term. Let us

bring our ideas to the table as well based on what had been effective in the past. Another really important thing from this project, which was last year, was just a lot of feedback from across the organization. All CHWs were involved in multiple rounds of feedback and pilot testing, managers, and even other departments just to really make use of this opportunity and come up with the best product possible. And I think we're all extremely pleased with the results and really happy about that. And then we were able to extend it this year to Tableau. So it's a kind of three key periods of evolution. And somewhere in there, we also developed this CommCare team structure, which I mentioned before. There's two of us from our evaluation team, myself and then our CommCare lead, Haley Burns. And then we have two CHWs, Maricela Zuniga-Campos and Hilda Robles. And they played an extremely critical role in providing input, feedback about what's working,

what are the pain points, kind of as representatives of CHWs, they're able to gather and share that feedback. And they're also involved in training new CHWs and doing refresher training, just technical support ongoing. So that structure's worked well for us. You bring up a good point, Rachel, that we include the CHWs, right? We don't claim to be the experts. We're giving them tools, but they shape how those tools evolve and how they're actually useful for them. So I think that's important to point out as well. The structure that you mentioned, Rachel, is great to hear and I think is critical to success with any technology. Making sure the users are involved, driving where they perceive the ability to create more programmatic value, particularly with CHW workforces, but in general in the healthcare sector. There's just this crushing burden of administrative data on everybody for each project they're doing,

for each performance indicator, and creating a product that really creates ultimately a better job for the CHW as opposed to making that job worse. That's helping your organization get the data. It's really challenging. And we see that all the time in the healthcare setting across so many different roles. And so it's just so cool to hear how you have been able to evolve over time and achieve that. I'm really proud of just hearing your journey. I think if you look at any piece of software that you've used for over a decade, you probably hate it by now. I know. I'm thinking in my head of it, the software we've used inside of Dimagi, that's 10 years plus old and either it's gone or we don't like it anymore. And it's just so great to hear, but also a testament to how you thought strategically about really using the software as a tool and creating a tool that the CHWs want, that not only is it even better than it was last year, but you're adding Tableau

to it. It's really empowering for the organization, but that's hard to pull off. I mean, that's a really sophisticated use of digital within any organization for any purpose, much less one that has the funding challenges and the project churn that we see in our industry. So just kudos on hearing that story. Thanks for that. And we've gotten a lot of great ideas from Dimagi along the way, even outside of customer success. I remember sitting in on one of Quinn's webinars on data democracy and just that whole concept, which really kind of blew my mind and got us thinking in a different direction. So even when we're not working directly with you, we've been kind of picking up these pieces and trying to incorporate them. And I remember before we started this big CommCare restructure project last year, I read a statistic that was like 50 percent of system implementation projects fail, which was mildly terrifying, but I think doing the best

that we could was important. So, you know, Don mentioned our kind of impact delivery approach. One of the things we think about there is that technology is a really key component, but there's also just the people and the processes. And I think what I love from what you shared, Rachel, or one of the things I love, is how you talked about the team in place, right, that's owning CommCare and helping evolve it. I'm curious if you'd share maybe a little bit more about, you mentioned Haley, who kind of runs CommCare. How does that work and how do you set that up for long-term success and kind of continuously adding more value? Sure. So we're always evolving the CommCare team. So it's had different individual participants since we started that structure. I think that was like 2019 or 2020 that we started working that way. And that's been important to not just have it sit with the same one or two people, but bring in new people,

new ideas, and kind of have that cross-training as well. So Haley's been the CommCare lead as of January. I was the CommCare lead last year. There were other CommCare leads before that. And we've had, I think, maybe seven or eight different CHWs on CommCare team over time. So in terms of that structure, the lead is really the person who's kind of leading organization of our work and planning and setting up our meeting structures and things like that. But we're all in there collaborating, providing input. So we just kind of continue to evolve and involve as many different people as we can so that we're just getting new ideas and exposing people to what goes on on CommCare team. Maggie, you mentioned the growth in building an apprenticeship model within the organization, and you do a lot of external training as well. Technology, as you mentioned on the C3 websites, is one subcomponent. But I'm curious, how do you talk to the CHWs who

don't work for MHP about how to think about enablement when you're coaching other organizations that run existing CHW programs or aspiring to start new ones? How do you think about the role technology could or should play in those environments? And then also I'm curious just generally, how hard is it to craft training programs when there is such a huge difference in what people want to get or expect to get from CHW programs? So it's funny because we're all about transparency, right? So when I'm talking to an organization and we're doing some consulting, I always hit them with the bottom line. How much costlier it's going to be if you don't integrate technology into your work. I love to do an assessment and show them where their inefficiencies are and where their time suckers are. And nine times out of 10, it's all the spreadsheet, it's all the going back and, oh, I needed to share this document and go back. All of that

cost them money. And I love to show them how much it cost them and say, all right, I'm not selling a product, but you need to consider these products and you need to consider moving to, whether it's a project management system or using CommCare. I actually was working with an organization that didn't have anything. And I was like, let me talk to you about CommCare. Just because they were spending so much time on pencil and paper and they were spending so much time talking about things that really could have been captured with this platform, right?

And then kind of pimping out this tableau and saying, hey, let me show you the visual that goes with that, right? So doing some of that work, because the reality is that when you can talk to a CEO or a CFO and say, let me tell you what this is costing you by not going in this direction. Because the first thing they say is, oh, we can't afford technology. We can't do this. We can't do that. And then showing them where they can find some efficiencies, where they can afford it, where they can bring it in. And again, start small and work your way up there.

But it's interesting, and this is what I love about MHP, is that we do include our CHWs because we were talking to a bigger organization that utilizes CHWs. But when I saw their training and orientation schedule, I was really blown away by the high level expectation that they were going to need to have to just do the work. And I said, I want to be clear that if you're actually hiring CHWs from the community, you may have a language barrier. You most definitely are going to have a technology issue here. And we need to talk about how you're going to support them. Because even with our CHWs who primarily speak Spanish and English is not their first language, we do a lot of handholding with how to support them to be able to be on our platforms and do the work because things don't always translate the right way, right? And so when we're talking to health centers and we're talking to hospitals and they're like, oh yeah,

we want CHWs. And then I'm looking at what they expect them to do. I'm like, you're setting them up for failure if you're not going to sit here and really educate them on why technology is important, but also what are you going to create to help them be successful? Because that's a lift. And I think we think that, oh, everybody's tech savvy. No, they're not. So they're really, really not. So two things. One is anytime you want to sell CommCare, feel free. Don't ever worry about CommCare people. That's just something you should feel free to do. I'm so curious. Even 10 plus years ago, we were talking with your leadership team about demonstrating the ROI of these tools because MHP Salud knew even back then probably better than we did about like, you got to speak that language to get executive level buying for these things. One of the things I've experienced at least recently in the US market is a lot of people who kind of were like, yeah, I'd love to

set up a CHW program. It just seems really hard. It just seems too hard to do this. I imagine by the time you're contracted, they've overcome that and that's why they're hiring you. But in those initial discussions, when you're talking to an organization who believes in the premise of CHWs, but it's like, this just looks like a lot of hard work, like hiring and training and support and all the things you just mentioned. How do you walk organizations through that journey to create that buying of the CHW program in general? It's interesting because in theory, they think they know what a CHW is and what they should be doing. And I've always said, if you're going to put them in an office and they're going to push paper, they're not a CHW. So even when they come to me and they say, oh, I know the importance of a CHW. And there's a lot of conversation about, tell me what they're going to do. Tell me why you want them to do this, where you see the role. So yes,

most of them have gotten over part of that, but I try to find a commonality. So some health centers or hospitals use interns, right? So I try to give them something that they're familiar with and say, think of it like an intern. Think of it like this person just graduated high school. They don't know a lot and you're going to grow them into the CHW that you want to grow them into. And so you really do need to know what they want out of that. Sometimes organizations really get it and they infuse CHWs beautifully after we've had some conversation. And other times they're trying to fill a gap. And I was like, you can't put the square peg in the round hole, right? So you can't make a CHW something they're really not. And sometimes that's what they're trying to do to write them into the grant. So I really like to have that philosophical conversation of, why do you want a CHW? And what does that mean to you? And after you start having those dialogues

with them, then you can really guide them into how to build a CHW program that can again be sustainable, not just a short-term project. And I think jumping off what Maggie said too, there's just, as the profession evolves, so many resources that are out there and MHP Salud is one organization training on the CHW role for CHWs and supervisors, a website full of resources about implementing CHW programs and managing them over time and other organizations as well. So I think just letting organizations know that if it feels overwhelming and intimidating, there are resources and they just need to look. And we're always evolving. So even with our curriculum and our modules, we're always trying to figure out how to improve them, how to make them better, how to kind of stay innovative with what is needed and what we're hearing from the communities and what we're hearing from providers that we work with. So something that we might have had in our

curriculum 10 years ago, we don't have now because it's evolved into something else. So that's always important as well. You have to stay growing. You can't be stagnant. Absolutely. Yeah. I love that. I want to make sure before we transition from the topic of technology at a high level, we've talked a bit about some of the benefits, some of the challenges, but I want to make sure I've kind of heard in totality from both of you in terms of after being on this journey of 12 years, really leveraging technology deeply, what are the key benefits that you see to using technology day to day in your operations? And also what are the biggest challenges that people should be aware of as they're thinking about incorporating technology and really saving money with technology? Just thinking broadly, benefits in terms of efficiency and guidance for workflow. And thinking of CommCare, I'm also thinking of other things. I

think technology can be a lot smarter than paper and pencil, for example, just in terms of having a series of questions that if answered one way can guide you to do service in another way, dashboards being able to inform your work. So there's a lot of benefits that I think can help all staff, not just CHWs, sort of focus their work and do their work more efficiently with technology. I think the risk is leaving folks behind if you don't do it in an intentional way. And again, just going back to that role of what is a CHW, if your requirement is someone has to be a technology whiz, you're going to find somebody, but they might not have some of those core CHW qualities. And of course, in that Venn diagram, there are some really true CHWs who do have that skill. And I think just approaching it in a way where you're bringing people along for the journey, you're looking at people who have that community experience, that heart for the work.

And there will be varied levels of technology experience and just making sure that you're going at a pace that everybody can come along so that you don't end up with a CHW workforce that may be missing a lot of the heart of what that profession is in the first place, not mutually exclusive, just kind of making sure that all pieces are covered. Maggie, what do you think? Yeah, I always say we need to give people grace and mercy. If you're truly hiring a CHW and we know there's going to be a barrier to technology, you have to be very intentional, not just in the product that you're choosing, but also how you're going to roll it out and where you're going to make it a priority to bring them along.

And when they struggle, how are you going to support them? Because the reality is they're not going to get it the first, second or third time. And even after they've been using it, they're still going to make mistakes. So what are you going to do instead of saying they can't do it? What are you going to do to support them? We've actually evolved a position to support staff with platforms, one, because we have a few, but two, because they have those little questions where like, I'm stuck on this or I'm stuck on that or I don't remember how to do this and they need that support. So we had to craft a position specifically to support our workforce because they were struggling in some areas. And again, sometimes it's a language barrier and it looks different in their language or their dialect. So helping bridge that gap.

And the product is only as good as what you put in. So you give me the best platform, but it's only as good as the data that goes in it. And so you can't just throw it out there as a package and say, okay, we're going to do this now. And you haven't really made it a priority. And then they go back to the company and say, oh, you didn't give me a good product. You have to make it a priority to make sure we've trained people correctly and really support them along that journey. So Rachel's completely accurate that we have to bring people along. And if we go too fast, if we don't slow down sometimes, we will lose people. And that's not good for us. So we have to continue to remind ourselves that, hey, we're only as good as what they put in here. So we need to support them so that we can get the richest data possible. I love that anecdote. And I think in addition to that, making sure you have sufficient resources for support, we often overlook the need

to create the buy-in in the first place. Why CHW should believe this technology is going to be helpful to them. We often talk about CHW as this like the goal can do everything role. And it's like, that's true of every employee at every organization on every IT rollout. Right? Like, does anybody like when they get that email from the company being like, hey, new system? I was like, no, you got to convince me why I should use it. You got to convince me why it's worth taking time out of the day. It's particularly critical for CHWs who are in such a high empathy role, such a important role where you're taking culture into account, where you're taking local needs into account. It's even more important to make the case at a very individual level, right, as to why it's worth the effort and then making sure the support system is there for the people putting in the effort to be able to get through some of those inevitable challenges one's

going to run into. And Meg, exactly to your point, these technologies, whether it's CommCare or Tableau or anything, they're only as good as the user-centered design you put into it and the value it's given back. And it sounds like that feedback loop you have with your CHW is amazing. And I hope a lot of the organizations that you're now able to provide your expertise to can learn from that lesson around how to make sure they're creating that buy-in and that approach. You've already touched on a few of these other ideas, but I'm curious for our audience globally or in the US who are thinking about CHW programs, thinking about how to improve ones they are already running or start new ones. Do you have other pieces of advice based on your amazing run as an organization and the growth of just how to think strategically about improving your CHW program, running your CHW program? I know recruiting is really hard for a lot of

organizations right now, but just any guidance you have for our listeners? I have to be honest that you had mentioned it about the why, right? So we do a lot of that, no matter what we're implementing, no matter what we're rolling out. I always go back to the staff and tell them why. If I can't do it, I tell them why. If I can do it, I tell them why. And then after I tell you why, then we have conversations about the importance of it. And then I go back and we have more department meetings and we talk to them again. So I don't roll anything out where we don't get that buy-in, right? And again, if you're trying to create a culture where everyone is going to feel valued, whether you're a CHW or not, you have to get that buy-in and that is a lot of work. And organizations need to understand that not just with CHWs, you have to talk about the why. And you have to talk about the why because if you do not get

buy-in, it will not succeed. And I don't care what you're trying to implement. Implementing it and saying, okay, this is what we're going to do now. And they don't get the journey. They don't understand why you're going there. You're going to lose that. And something that I can share that we're very proud of at MHP Salud is because we've focused in this strategic direction, right? To be less project-based and more of a service delivery model. When I came on last year and we did our first employee survey, that's how we created the CHW Advisory Committee. And one of the things that we looked at when I first got hired was the turnover rate. And MHP Salud was hovering between 40 and 47% in turnover every year. And I was like, something's wrong. We have amazing benefits. We have all this great work. What is going on?

And just by putting in the advisory committee, just by changing the way we did town halls, just by listening to staff and getting their buy-in, we finished the year last year. I started in April and by December we were down to a 23% turnover. And today, as of the end of July, we're at 11%. So we have to be doing something right with the culture and the buy-in that we've gone from 47% turnover to 11%. And I think that's because staff feel validated, they feel heard, and they feel valued that what they're doing is important and they're making a difference.

That's amazing. Congratulations on that improvement. And I think that point you made around feeling valued, I just want to stress on because we're asking community healthcare workers to go out in the community, connect with patients who might lack trust in the system, who might be resistant to being connected into the services that we're trying to connect them into. And we're trying to do that with a workforce that they themselves don't feel valued and therefore don't trust their employer or don't trust the system they're part of. Obviously, that's not going to be a very durable solution to the problem. And I think that's why it’s Dimagi’s top priority to support creating better jobs for better outcomes because if we start there and we start with the why of supporting this workforce, then lots of great stuff can happen from there. But if we undervalue this workforce, burden them with data collection, ask them to push paper, ask them

to do things that don't build that trust, don't build that sense of value, sense of importance, it's like a comically flawed theory of change for systems to think that that's going to result in better outcomes, I think. And you had brought up a good point about being a caregiver to others, right? To providing that service and what it does. And so a lot of organizations talk about burnout and self-care. And one of the things that I'm trying to implement at MHP Salud is to talk about compassion fatigue and how that is different from burnout and how you take on other people's worries because again, you're in the community. Let's say you're helping them get health insurance but you know that they don't know how to pay the rent this month, right? And so you're taking all that on. So it goes beyond burnout and really that compassion fatigue and how that weighs on staff and how they struggle to do appropriate self-care because they're taking that all in.

So when we work with the CHW Advisory Committee and they're talking about training and development opportunities, I talk to them about that and say, I know you say self-care but it's more than how do we get you to be able to process all of this stuff that you're hearing all the time and how do you be empathetic without taking it on and it affecting your every day, right? So I think that's really important as well. And it goes back to valuing your employee enough that you're creating a training and development program where you're looking at the whole person and not just checking the box. I love that framing Maggie. I haven't heard that phrase before about that compassion fatigue and that just sounds so real. I myself originally in college, I thought I wanted to be a therapist and I think I kind of then realized that the compassion fatigue that I would have and knowing myself as just a very sensitive individual, I was like, maybe I'm not going to be

able to handle that. And so I went into management consulting. But I'm curious, how do you think about supporting, combating that compassion fatigue and supporting your staff to build resilience, I suppose? Well, you have to give them the voice and the platform to be able to talk about it, right? You have to give them permission to tell you what's going on with them and acknowledge that it's a real thing and that they don't have to be strong and that they don't have to take it all on and that they can be a witness to the situation without absorbing. I can be empathetic to your situation. I can understand and I can be helpful without actually taking it in and absorbing.

So, you know, we use this scenario where it's like, okay, can you think about what's happening with this family and take a step back and just be a witness and not just absorb all those feelings? Because when you absorb all the feelings, then you get exhausted. Now you're tired and you're not going to be as effective. So just giving them permission to talk about it, giving them permission to just kind of trauma bond a little bit and vent it out a little bit plays a huge part. And then sharing what are some ways to take care of yourself. So one of the things that MHP Salud with our benefits is that flexibility, right? And saying, okay, you can turn it off now and flex the morning or because sometimes our CHWs are at health events or community events where they're going to work some weird hours or they're going to, let's say work Saturday. And so I always encourage the supervisors, make sure they're flexing, make sure they're taking Monday morning

or whatever it is that they want. But that's why we do give a generous wellness package and benefits package is because we want them to take the time off. Very intentionally, we have a use it or lose it vacation policy on purpose because I want them to use that time. I do not want it sitting somewhere. I don't want them cashing it out. I want them figuring out how to refuel and re-energize themselves. We get on social media and we see, you know, you can't drink from an empty cup. So that is a very true statement for our CHWs. And it's like, what are you going to do to be okay? What are you going to do to fill your cup so that you can give to other people? And so that's a constant that we're always talking about because we want them to feel like it's okay to talk about it. I love that. So just to kind of close this up, I'm curious to hear what's next for MHP Salud and also are there any kind of closing messages that you want to leave our

audience with? For sure, stability and sustainability for the organization is like a key priority for us in 2023 and moving forward. Historically, we have been very project-based. And so one of my visions for the organization is to move into this service delivery model where we have lines of business and we have braided funding models so that we can stay innovative and we can do some of that longer-term interventions that have more of a lasting impact. And so what I hope for this organization is that, you know, we're celebrating 40 years, but in the next 10 years, we're going to be seen as a leader in training CHWs nationally and supporting the CHW organizations so that they see us as an organization they can trust and that can help them build whatever CHW support they want to see. And with regards to key messages, genuinely as a CEO, I say this to other CEOs, your strategic plan and your vision are not a paper exercise, right? Like you must incorporate

this in everything you do. You have to walk the walk. You have to talk the talk. And sustainability is much more than just financial sustainability. It's about your relationships in the community. It's about organizational capacity and getting your house in order. So I always talk to other CEOs and say, do you have your house in order before you start applying for this other stuff? Because if your stuff isn't right at home, I assure you whatever grant you're applying for will fall apart and will not be sustainable because you have these inefficient processes or you have these inefficient platforms that you're not maximizing. So we're always looking at how we can integrate our platforms and integrate our processes so that we're working smarter and not harder.

And then lastly, human capital is your most valuable resource. You need to nurture them. You need to take care of them. You need to be supportive to them so they can be supportive to the communities that they serve. And I wholeheartedly believe that I'm not going to be successful at MHP Salud if I do not take care of my people so they can take care of the communities that, you know, were meant to serve. Thank you to Dr. Dante and Rachel. I loved hearing these experiences and think there's a lot that organizations looking at their technology strategies can take away. As Jonathan mentioned, a lot of what we heard from MHP Salud ties into our impact delivery approach for creating better, more, and sustained impact. So I want to break down some of my takeaways in those three buckets. Let's start with better impact. You need to design and roll out tech that's intuitive and supports the workflows of your CHWs and teams. Tech is just

one small part of everyone's role, especially community health workers. It should be easy and actually add to their experience. MHP Salud invested in creating strong feedback loops for their CommCare users to ensure it's continually improving. And they built this into the org structure by creating a CommCare team, rotating membership, and community health worker roles embedded on that team. Now, moving on to more impact, the second pillar of impact delivery. MHP Salud has successfully used one platform to enable all their varied programs with different applications for different users and scenarios. By streamlining workflows onto one platform, they offer an intuitive experience for their community health workers, but can also easily roll out new content, new programs, or even support new types of users. MHP Salud recently rolled out an integrated Tableau dashboard for all of their users so they can see their impact

in real time and be motivated to do more. And lastly, I want to touch on sustained impact. MHP Salud started using CommCare in 2011 and kept investing in the same platform. You heard Rachel describe the phases of their journey. Yes, there was definitely trial and error along the way, but by committing to a long-term partnership and looking at the ROI of technology over the long term, they're seeing increasing value over time. And amazingly, they're still fans of CommCare 12 years after we started our work together. Also on the sustainability note, you heard Dr. Dante speak to how she's ensuring that the organization itself is sustainable by overcoming the limitations and realities of project-based funding.

Dr. Dante describes creating a braided funding model. So while she may be receiving funding for one three-year project, she can weave that together with other funding sources to support the same families and programs. By doing this, she's able to move the organization from being project-based to more of an ongoing service delivery model for long-term impact. I also want to elevate the theme around processes needed to ensure an impact delivery approach.

Dr. Dante shares how important it's been to bring our teams along on the journey, explaining the why of what the organization is doing and trying to do, and getting their buy-in and not just throwing technology over the fence to their teams. And on top of that, she talks about being realistic about expectations and providing the support needed to fill any gaps. That's our show. Please like, rate, review, subscribe, and share this episode if you found it useful. It really, really helps us grow our impact. And write to us at podcasts at dimagi.com with any ideas, comments, or feedback. This show is executive produced by myself. Danielle Van Wieck is our producer. Sarah Strauss is our editor and cover art is by Sudhanshu Kanth. Thank you.