EXAMPLE

STANDING ORDERS FOR

Providing Community Health Worker Services

Purpose: To build an individual’s capacity to self-manage chronic conditions through the delivery of
Community Health Worker (CHW) services, including culturally and linguistically appropriate health
education, addressing social determinants of health, helping recipients connect to or communicate with primary
care, connecting individuals to social services, and educating about blood pressure and blood glucose testing to
support self-management.

Policy: Under these standing orders, certificate-holding Community Health Workers will deliver diagnosis-
related patient education services to adults who meet the criteria below. CHWs will follow the Ohio Pathways
model (OR OTHER BEST PRACTICE PROTOCOLS OUTLINED BY AGENCY), and best practice
guidelines related to the client’s condition(s) attached to this standing order.

CHW Eligibility: For the purposes of this standing order, CHWs must have a valid certificate of completion
from a Minnesota Community Health Worker certificate program demonstrating that the CHW has completed
an approved community health worker curriculum. CHWs must also receive training on blood borne pathogens,
testing blood glucose levels, blood pressure screening and in health coaching techniques that CHWs can use to
support client self-management of pre-diabetes, diabetes and hypertension. An ordering provider must sign off
that the CHW is proficient in these areas.

Provide CHW services to adults meeting the following criteria:

1. Client is being served by (AGENCY NAME)
AND
2. At least one of the following:
a. Client has requested CHW support services for a clinician-diagnosed health condition (based on
self-report)
b. Client receives a score of 5 or above on the ADA prediabetes risk screening tool or meets criteria
for prediabetes (fasting plasma glucose of 100 mg/dl to 125 mg/dl
c. Client meets criteria for diabetes (fasting plasma glucose of 126 mg/dl or higher)
d. Client meets criteria for hypertension (>140-159/90-99 mm Hg)
e. Client’s Primary Care Provider has made a referral directly to (AGENCY NAME) for CHW
services

Provide Blood Glucose Testing to adults meeting the following criteria:

1. Client is being served by (AGENCY NAME)
AND
2. One at least of the following:
a. Client scored at or greater than 5 on the American Diabetes Association Type 2 Risk Test
b. Client’s Primary Care Team has made a referral directly to (AGENCY NAME) for ongoing
blood glucose testing assistance and self-management education

Required Documentation:
1. Document each client encounter and follow-up in the (AGENCY ELECTRONIC HEALTH RECORD).
2. Periodic (at least monthly) assessment of the recipient’s progress and need for ongoing CHW services.
3. The following information must be documented in (AGENCY ELECTRONIC HEALTH RECORD) for
each encounter:
a. Date of service
b. Start and end time for the service
c. Whether the service was group or individual and if group, number of patients present, summary
of the session’s content.
CHW service delivery activities may include:
1. Assisting individuals in understanding chronic disease diagnosis and adopting healthy behaviors
2. Providing information on available resources, health education, social support and informal counseling
3. Assisting the individual with connections to primary care and other health services
4. Addressing social determinants of health
5. Providing services such as training clients on testing their blood glucose and/or blood pressure to
support self-management of their conditions.

Provide all clients with a copy of the following documents:

1. Release of information
2. Culturally and linguistically appropriate health education materials
3. Notice of Privacy Practices

Patient Education Plan: The content of the patient education plan or training program must be consistent
with established or recognized health care standards. Curriculum may be modified as necessary for the clinical
needs, cultural norms and health literacy of the individual patients. Disease/diagnosis-specific education best
practices attached to this standing order must be included as part of the patient education or training plan.

Service Delivery: Provide all services face-to-face with the recipient (individually or in a group)

Time Requirements: Deliver CHW services in 30-minute units: limit 4 units per 24 hours; no more than 24
units per calendar month per recipient. Services can be delivered one on one and/or in group settings according
to patient preference.

Medical Emergency: In the event of a medical emergency, be prepared to follow the (AGENCY NAME)
written medical emergency protocol.

Standing Orders Authorization

This policy and procedure shall go into effect on _____________________________ and remain in effect for
all clients of the (AGENCY NAME) until rescinded or until __________________ (date).

Ordering Provider’s signature: _______________________________________ Signature Date: ____________

Minneapolis Health Department with funding from the Minnesota Department of Health and the Centers for Disease Control and Prevention