Our Services
Community Health Workers (CHWs) deliver services called community-based Care Coordination for the people who participate in our two programs:
Adult Health Care Coordination
CHWs work with adults referred by primary care practices, Medicaid health plans, and the community. CHWs work with program participants to complete a social and medical access assessment, then build and execute a plan to meet chronic disease self-management goals.
Pregnancy and Family Health Care Coordination
CHWs work with pregnant people and their families, providing education on topics such as breastfeeding, safe sleep, and smoking cessation. CHWs stay in contact with program participants throughout pregnancy and into [up to two] postpartum years, helping to ensure that the family has what they need to be healthy.
Community-based Care Coordination is about connection.
CHWs connect program participants with the resources and education they need to overcome barriers to good health outcomes. By developing genuine connections with program participants, CHWs work to identify and tailor solutions to their needs. CHWs act as the bridge between clinical and social services and the people they serve.
Barriers to good health outcomes that program participants may face include:
- Unstable housing
- Lack of transportation
- Misunderstanding medical instructions
