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Community Health
Worker Program

Community Health Workers (CHWs) are frontline public health workers who are trusted members of and/or have an unusually close understanding of the communities served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. (Definition used by the Center for Disease Control and the American Public Health Association)

The Missouri Community Health Worker (CHW) Program


  • Improve patient engagement in preventative, chronic disease management, and self-management services in Federally Qualified Health Centers (FQHC)

  • Connect patients with community based services

  • Assist patients with addressing social determinants of health (SDOH) needs

  • Reduce potentially avoidable emergency room visits

  • Reduce hospital admissions/readmissions for ambulatory-sensitive conditions

Key Outcomes:

  • Improvement in health center clinical quality metrics for MO HealthNet population

  • SDOH (assessment, education, referral for community resources)

  • Improved Patient Satisfaction/experience

  • Improved patient engagement in care

  • Reduction of avoidable ER visits and inpatient ambulatory sensitive admissions/re-admissions for CHC patients with a focus on the MO HealthNet population

Core CHW Functions:

  • Empower, coach, and serve as a liaison with the patient, CHC clinical care team, and community partners.

  • Engage patients in their care including preventative care, chronic disease management, and self-management.

  • Assist patients in meeting their identified social determinants of health needs

  • Navigation to community based services