“Blaze the Path:” Creating an Integrated Chronic Disease Management Team Utilizing Community Health Workers

The Massachusetts Department of Public Health (MDPH) recognizes the unique role that community health workers (CHWs) play in chronic disease management (CDM). A CHW is a public health professional who applies his or her unique understanding of the experience, language and/or culture of the populations he or she serves in order to carry out a number of roles, including outreach, health promotion and education, care coordination, cultural mediation and advocacy.

In 2007, the MDPH procured community health worker services through a model of integrated chronic disease management teams stipulating the use of CHWs. This $1 million RFR sought to support efforts at Community Health Centers (CHCs) and Community Based Organizations (CBOs) to develop an optimal system of care with the input of CHWs. 11 CHCs and 2 CBOs were chosen to pilot this innovative program beginning November, 2007.

The teams address client needs inherent in chronic disease management. The CHW supports self-management of chronic diseases in a cultural context, creates linkages, and utilizes community resources.

A Cambodian CHW from Lowell Community Health Center and an MDPH administrator will share their “Lessons Learned” during this critical first year of development and implementation.

This pilot project is unique in its financial support by MDPH for CHW salaries, CHW and supervisor training, and evaluation of CHW team integration. Health centers are creating new multidisciplinary chronic disease management teams that include CHWs as equal members. Leadership from CHWs and input from their clients are the foundation of a successful program.