Building the Infrastructure Behind URAC CHW Program Accreditation
A regional health system with 28 embedded community health workers had results but no documented program structure. Payer partners were asking questions the organization could not answer with evidence. This is how IHS helped them build what accreditation requires — and what their CHW program actually needed.
The Situation
The health system had built a CHW program organically over three years in response to rising readmissions and emergency department utilization in its highest-risk patient populations. The program had grown from a single pilot site to 28 CHWs embedded across six hospital and ambulatory settings.
The program was producing results. Post-discharge follow-up had reduced 30-day readmission rates in the target population. Blood pressure control improved among CHW-managed chronic disease patients. Emergency department utilization dropped in the neighborhoods the program served. Leadership knew the program worked — but they could not document how it worked in a way that satisfied external scrutiny.
Three events converged to create urgency:
- A managed care organization that was the health system's largest Medicaid payer partner asked for formal documentation of CHW program quality standards as part of annual contract review.
- The state Medicaid agency announced it was developing CHW billing codes and indicated that quality standards documentation would factor into program eligibility.
- A federal community health grant application required applicants to demonstrate "structured quality management infrastructure" for CHW programs — language the health system could not document to the required specificity.
The program director reached out to IHS after the third event. The question on the table: "We know our program works. How do we prove it in a way that meets URAC standards?"
What the Gap Analysis Revealed
IHS conducted a structured gap analysis across all ten URAC CHW Program Accreditation standard domains in the first four weeks of the engagement. The findings were consistent with what IHS observes in most organically grown CHW programs: strong operational results, weak documentation infrastructure.
Scope of Practice — Critical Gap
The health system had no written CHW scope of practice document. CHWs at different sites were doing different things — some conducting home assessments, some primarily doing post-discharge phone outreach, some embedded in clinical team huddles, some not. No documentation defined what CHWs were authorized to do, what fell outside their role, or how role boundaries were communicated to clinical partners.
URAC standard implication: Scope of practice is a defined standard domain. Reviewers look for written role definition, clear boundaries, and evidence that the organization has communicated scope to care team partners and to CHWs themselves. The absence of any documentation was an automatic deficiency finding risk.
Quality Management — Significant Gap
The program tracked outcomes — readmission rates, blood pressure control, ED utilization — but the data was held by the analytics team, not owned by the CHW program. No quality improvement process existed at the program level. No regular review of CHW-attributed outcomes against targets. No corrective action mechanism when performance dipped. Quality happened incidentally; it was not managed.
URAC standard implication: URAC's quality management domain requires a formal QI infrastructure: defined metrics, regular data review, documented improvement cycles, and evidence of leadership oversight. The outcomes existed; the framework for systematically managing and improving them did not.
Workforce Development — Moderate Gap
CHWs had received training — but it was undocumented, inconsistent across sites, and not tied to defined competencies. Onboarding varied by supervisor. No formal competency assessment existed. Career development pathways were informal and depended on individual manager relationships. Compensation varied across sites without a documented equity framework.
URAC standard implication: Workforce development standards require documented training curricula, competency assessment, supervision frameworks, and equitable compensation structures. Informal practices that produce good outcomes are not the same as documented systems that can be evaluated and replicated.
Leadership Engagement — Moderate Gap
The CHW program had a director but no formal governance structure. No executive sponsor was defined. No board-level or senior leadership reporting mechanism existed for the program. Leadership was aware of the program — but awareness is not governance, and governance is what URAC evaluates.
URAC standard implication: Leadership engagement standards require documented accountability structures: defined executive sponsorship, defined reporting lines, evidence that leadership receives and reviews program performance data, and evidence that leadership is accountable for program outcomes.
DEI Integration — Addressable Gap
The program hired CHWs who reflected the communities they served — a strong DEI practice. But the practice was informal and undocumented. No written DEI policy governed hiring. No documentation demonstrated how the program ensured culturally responsive service delivery across all six sites. No DEI data was tracked at the program level.
URAC standard implication: URAC embeds DEI throughout all ten standard domains. A good DEI practice that is not documented and not systematically operationalized does not satisfy the standards. The gap was not about values — it was about infrastructure.
Program Sustainability — Emerging Gap
The program was funded through a combination of grant funding and a hospital community benefit budget allocation. No Medicaid CHW billing had been implemented despite the state's CHW billing codes being available for 18 months. No billing sustainability strategy was documented. The program's financial future depended on grant renewal cycles.
URAC standard implication: Program sustainability standards require documented funding strategy, billing infrastructure planning, and evidence that leadership has a plan for long-term program viability. Grant-only programs without billing strategy fail this domain.
What IHS Built
The engagement ran nine months from gap analysis through mock review. IHS worked directly with the program director, the analytics team, HR, and senior leadership. The work was organized in four phases.
Phase 1: Documentation Architecture (Months 1–2)
IHS drafted the foundational documents the program lacked: a CHW scope of practice framework defining authorized activities, role boundaries, and communication requirements for clinical partners; a workforce development policy covering onboarding requirements, competency assessment, supervision cadence, and compensation equity principles; a DEI policy governing hiring practices and culturally responsive service delivery standards; and a governance structure document establishing executive sponsorship, reporting lines, and leadership review requirements.
All documents were written to reflect actual operations — informed by interviews with CHWs, site supervisors, and clinical partners — not aspirational standards the program had not yet implemented. The distinction matters: URAC reviewers evaluate whether documentation matches practice, not whether the documents sound good.
Phase 2: Quality Management Infrastructure (Months 2–4)
IHS designed a CHW program quality management framework: defined performance metrics tied to CHW activities (not just organizational outcomes), a monthly data review protocol, a quarterly QI committee process, a corrective action mechanism for performance below threshold, and a reporting template that surfaced program data to executive leadership quarterly.
Critically, IHS worked with the analytics team to restructure outcome attribution — not just tracking that outcomes improved in a population, but tracking which outcomes were CHW-attributed and documenting the CHW activities that drove them. This distinction matters for both accreditation and for Medicaid billing credibility.
Phase 3: Sustainability Planning (Months 4–6)
IHS developed a CHW billing implementation roadmap: analysis of the state's available CHW Medicaid billing codes, identification of which CHW activities mapped to billable codes, documentation requirements for billing compliance, and a 12-month implementation timeline. IHS also documented the program's existing funding mix and drafted a sustainability narrative for grant applications and payer contracting use.
Billing implementation was not completed during the accreditation engagement — that is a separate operational project. The accreditation standard requires demonstrated planning and organizational commitment to sustainability; IHS built the documentation that satisfied that standard.
Phase 4: Mock Review and Survey Preparation (Months 7–9)
IHS conducted a structured internal review replicating how URAC evaluators assess documentation. Every standard domain was reviewed for both documentation completeness and operational alignment — the two most common sources of deficiency findings. IHS identified three remaining gaps in the training documentation and one gap in DEI data tracking, which were corrected before submission.
Staff interview preparation covered the questions URAC reviewers most commonly ask CHW program staff: how their role is defined, how they are supervised, how they document their activities, how they interact with clinical teams, and what happens when they encounter a situation outside their scope. CHWs and supervisors at all six sites participated in preparation sessions.
Outcomes
Accreditation Achieved
The organization received URAC Community Health Worker Program Accreditation with no deficiency findings requiring corrective action. The desktop review and staff interviews reflected a program whose documentation matched its operations — the baseline URAC evaluates against.
Payer Contract Renewed
The managed care organization that had requested quality documentation renewed the contract and referenced the accreditation as a factor in the decision. The health system used the accreditation documentation package to respond to the payer's quality standards inquiry — a response that previously did not exist.
Grant Application Strengthened
The federal community health grant application was submitted with the accreditation documentation as an attachment to the quality management narrative. The "structured quality management infrastructure" requirement was satisfied with documented evidence rather than narrative assertion.
Medicaid Billing Positioned
The billing implementation roadmap IHS developed became the basis for a subsequent internal project to activate state Medicaid CHW billing codes. The sustainability documentation built for accreditation directly supported that operational initiative — work that would have had to be started from scratch without the accreditation engagement.
Program Infrastructure Strengthened
Beyond accreditation, the quality management framework IHS built gave the program director tools to manage the program that had not previously existed: regular data review, outcome attribution, corrective action process, and executive reporting. The program did not just pass an accreditation review — it became a better-managed program.
What This Engagement Illustrates
Three patterns from this engagement recur across CHW programs IHS works with:
- Good outcomes do not substitute for documented systems. This program had real results — reduced readmissions, improved chronic disease management, lower ED utilization. None of that satisfied the accreditation standards without the infrastructure to demonstrate how the program produced those outcomes systematically. URAC evaluates systems, not anecdotes.
- The documentation gap is almost always larger than the operational gap. This program was not poorly run — it was underdocumented. The work of accreditation preparation was primarily building the written infrastructure that reflected what was already happening in the field. Organizations that think "we already do all of this" frequently find that they do much of it but have documented little of it.
- Accreditation preparation builds program capacity, not just accreditation paperwork. The quality management framework, the scope of practice documentation, the workforce competency tools, and the sustainability planning IHS built served the program beyond the accreditation submission. Programs that approach accreditation as a documentation exercise miss the value of building infrastructure that lasts.
Does Your CHW Program Have the Infrastructure Accreditation Requires?
Most established CHW programs have results. Fewer have the documented systems that URAC evaluates. A discovery session with IHS maps your current program against all ten standard domains and identifies the gaps between what your program does and what your documentation demonstrates.
Thomas G. Goddard, JD, PhD — the former Chief Operating Officer and General Counsel of URAC — leads every engagement. That means you work with someone who helped build the institution that created these standards.
Schedule a Free Discovery SessionLast updated: April 2026