Community Health workers as a part of the clinical team

The Healthy Heart Program in North Minneapolis has been in existence for 2 years.This partnership involves Northpoint Health and Wellness Center a multi-specialty agency providing medical, dental, behavioral health and pharmacy services. Northpoint Inc provides human services to residents living in Minneapolis Minnesota. The healthy heart program provides cardiovascular screenings, education and case management to women and girls ages 16 and older by a RNC and CHW. The Program serves populations who live in north Minneapolis which is an area known for Health disparities. The women are primarily patients of the clinic and referred to the program by their medical providers. The CHW/RNC is responsible for the initial visit which consists of screening the women's weight, height, Blood pressure, BMI, lipids, blood glucose, and tobacco cessation evaluation. The goal is to have women in for a visit with the CHW to discuss the results of the screening and a lifestyle Intervention Coaching session. The women are encouraged by the CHW to set goals based around physical activity, nutrition, and tobacco cessation.The CHW has follow-up visits with the patient every 30 days.The follow-up can be an office visit or an over the telephone encounter. The Program now has 65 women who are being case managed by a CHW. Some of the benefits to the program for the participants are health and fitness classes,nutrition education and tobacco cessation support from the CHW. The goal of this program is to have 200 women enrolled