Member of Care Delivery Team Model
In this model, community health workers (CHWs) may collaborate with or work alongside medical professionals on a
clinical care team. The Community Preventive Services Task Force (CPSTF) has determined there is strong evidence to support the
integration of CHWs on clinical care teams. Research has demonstrated the effectiveness of engaging CHWs
to promote and increase cancer screenings, prevent cardiovascular disease, and prevent and manage diabetes. The
CPSTF also recommends interventions
that engage CHWs in a team-based care model to improve blood pressure and cholesterol to prevent
CHWs may work in a variety of practice settings, such as Federally Qualified Health Centers (FQHCs), Rural
Health Clinics, primary care offices, dental practices, and pharmacies. CHWs may also work with medical
professionals to conduct home visits. In this model, the members of the care delivery team will differ across
When collaborating with medical professionals, CHWs may offer a number of different services including:
- Take vital signs
- Body mass index calculations
- Disease screenings
- First aid care
- Medication counseling
- Chronic disease self-management
- Patient navigation to increase access to healthcare services
- Other basic services
CHW programs using this model may also integrate a more holistic approach or a medical
home model. Within a medical home, CHWs may work alongside a care team comprised of physicians, nurse
practitioners, and allied health workers to deliver a range of services, including navigation, outreach,
education, or referrals.
Examples of Rural Member of Care Delivery Team Models
Community Connections program of the
Northeast Vermont Regional Hospital (NVRH) integrates CHWs as part of a diverse team of healthcare
professionals, including physicians, nurses, behavioral health specialists, chronic care coordinators, and
dietitians. The CHWs provide services that align with other CHW models, including meeting with patients,
linking them to services, and enrolling them in insurance.
Hidalgo Medical Services – Family Support
Program uses Provider-Integrated Care Team Coordinators (CHWs) to work with clients who have, or who
are at risk for, developing diabetes.
In the Prevention through Care Navigation
Outreach Program, CHWs provide biometric screenings, assess and refer clients to services, and
provide peer support to increase coordinated care in rural Colorado.
A CHW-Based Chronic Care Management (CCM) program
for patients with high health care costs was implemented in three Central Appalachian states. The
program enrolled patients with diabetes, heart disease, and chronic obstructive pulmonary disease. CHWs
worked with a mid-level provider and a nurse. CHWs conducted home visits and helped patients with their
self-management goals, medications, and other social needs. Patients in the program had better outcomes and
the program had an annual cost savings of $384,000.
Health Core Health Program is a 12-month program for underserved populations with chronic diseases
in rural Michigan. Nurses and CHWs work together to conduct home visits to help patients manage their
chronic disease. A 2018 study of the Core Health
Program in two hospitals in rural Michigan showed improved health outcomes and a positive return on
When seeking to integrate CHWs into healthcare teams, it is essential to create a clear plan. This includes
identifying the specific role of the CHW and how their role relates to the other members of the care team. Other
implementation considerations for this model are described below.
Programs may experience barriers integrating CHWs into the care delivery team. Some providers may be less
willing to work with CHWs, particularly if they do not recognize the value of CHWs to the care delivery team.
Further, CHWs must be sure to maintain their ties with the communities they serve. Successful integration relies
on communication and collaboration. One strategy for achieving this is by co-locating CHWs and members of the
care delivery team.
A major consideration for implementing this model is identifying a funding source. Funding for incorporation of
CHWs into care-based teams can come from grants, but increasingly, states are implementing reimbursement for
CHWs in medical settings. In some states, reimbursement for CHW services is provided by Medicaid programs. In other states,
public health plans have begun reimbursing for CHW services or using teams of in-house CHWs. Healthcare
providers may also develop other internal financing strategies to support CHWs. For more information on funding, see
Funding and Sustainability Strategies.
When CHWs offer some direct health services, there can be liability concerns regarding any mistakes or
negligence that may occur. In some states, including Virginia, there is a Good Samaritan statute addressing
civil liability issues for CHWs. For example, people voluntarily performing certain types of care in good faith
are immune from civil liability for acts or omissions resulting from that care. However, if a volunteer or paid
CHW is negligent, the organization or employer may still be liable.
Many CHW programs recognize these liability issues but few have formal policies. Programs should explore whether
their state has relevant laws to understand the broader context of their activities. Programs should also assess
Do CHWs drive their own vehicles to appointments and/or transport patients in their vehicles?
Is the employer responsible for a CHW who is injured on the job?
Does the employer's liability change if the CHW is a paid versus volunteer employee?
Organizations hiring CHWs may consider acquiring malpractice insurance and should educate CHWs about their scope
of practice and responsibilities.
Program Clearinghouse Examples
Resource to Learn More
Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care
Offers healthcare administrators, providers, and others guidance and recommendations when developing CHW
programs. Addresses hiring, training, supervision, evaluation, and integration of CHWs into healthcare
Author(s): Kapheim, M. G. & Campbell, J.
Organization(s): Sinai Urban Health Institute
Bringing Community Health Workers into the
Mainstream of U.S. Health Care
Focuses on the integration of CHWs into team-based primary care. Identifies promising CHW programs, evidence of
CHW effectiveness, and obstacles to their implementation. Offers recommendations for advancing integration.
Author(s): Pittman, M., Sunderland, A., Broderick, A., & Barnett, K.
Organization(s): Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and
Community Health Representative Program
Describes activities providing outreach healthcare services and health promotion/disease prevention services to
American Indians and Alaska Natives within their communities.
Organization(s): Indian Health Service
Focus: Integrating Community Health Workers into Care Teams
Describes healthcare organizations that have integrated CHWs into multidisciplinary teams.
Author(s): Hostetter, M. & Klein, S.
Organization(s): The Commonwealth Fund
Integrating Community Health
Workers on Clinical Care Teams and in the Community
Provides guidance for integrating CHWs on clinical care teams in order to increase patient knowledge and
medication adherence in a variety of primary care settings.
Organization(s): Centers for Disease Control and Prevention
How CHWs Help Dental Providers
Describes the contributions CHWs can offer to help dental providers and to address dental health
Organization(s): Minnesota Community Health Worker Alliance
Community Health Workers into State and Local Chronic Disease Prevention Efforts: Program and Financing
Describes how CHWs can be integrated into clinical chronic disease prevention and health promotion activities,
using Washington state's Medicaid Transformation Demonstration Project as an example.
Author(s): Spencer, A.
Organization(s): Center for Health Care Strategies
Integrating Community Health
Workers into Health Care Teams Without Coopting Them
Describes the potential challenges of integrating CHWs into healthcare teams, including the risks of
medicalizing their position or modifying workflows to better suit existing clinical patterns.
Author(s): Garfield, C. & Kangovi, S.
Citation: Health Affairs Blog
Integrating Community Health Workers into Complex
Care Teams: Key Considerations
Discusses the critical elements of maximizing the impact of CHWs within a healthcare setting including
recruiting and hiring, training and career advancement, team integration, and support and retention.
Author(s): Lloyd, J. & Thomas-Henkel, C.
Organization(s): Center for Health Care Strategies
Guide to Implementing a Community Health Worker (CHW) Program in the Context of HIV Care
Identifies CHW best practices from Ryan White HIV/AIDS Program (RWHAP) and state and local CHW association
standards. Discusses the key considerations for using CHWs as part of the healthcare team to improve outcomes
for people with HIV along the continuum of care: patient engagement, retention in care, adherence to treatment
and viral suppression.
Author(s): Rajabiun, S., Falkenberry, H., Downes, A., et al.
Organization(s): Boston University