Organizations in value-based contracts, particularly those taking on Medicaid risk, have a mandate to reduce acute care utilization for high- and rising-risk patients—or face financial penalties. However, at-risk patients with multiple complex clinical and social needs can be difficult to manage at scale given the limited budgets of population health departments.
A community health worker (CHW) program is one sustainable approach to supporting complex patients. As defined by the CEO of City Health Works, Manmeet Kaur, a “‘community health worker’ is an umbrella term that means one thing: a non-clinical person hired from the community that they serve.” These lower-cost staff, often salaried by a provider organization, address social needs and support disease self-management. CHW programs offer substantial return on investment (ROI) when implemented effectively.
This toolkit outlines five steps for implementing a sustainable CHW program: Determine program scope, secure funding, source talent, create a retention plan, and demonstrate long-term performance. Each step is supported by sample resources including ready-to-use slides, recruiting guidelines, day-in-the-life summary, and sample performance dashboards.