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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

Learn more about CHWs

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Social Determinants of Health Assessment

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) has been a multi-year effort between the National Association of Community Health Centers (NACHC), the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures, along with a group of pioneer health centers and health center networks in Hawaii, Iowa, New York, and Oregon. PRAPARE was supported with funding from the Kresge Foundation, the Blue Shield of California Foundation, and the Kaiser Permanente National Community Benefit Fund at the Easy Bay Community Foundation.

  • national effort to help health centers and other providers collect the information needed to better understand and act on their patients’ social determinants of health

  • consists of a set of national core measures as well as a set of optional measures for community priorities

  • informed by research, the experience of existing social risk assessments, and stakeholder engagement

  • aligns with national initiatives prioritizing social determinants (e.g., Healthy People 2020), measures proposed under the next stage of Meaningful Use, clinical coding under ICD-10, and health centers’ Uniform Data System (UDS)

  • PRAPARE emphasizes measures that are actionable

  • PRAPARE Electronic Health Record templates have been developed or are currently under development

Resource Links
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