Looks at how the Keystone ACO partnership, serving residents of 41 primarily rural Pennsylvania counties as well as parts of New York, New Jersey and Maryland, is using community health workers to improve the quality and cultural competence of service delivery.

Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs. But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams.