This resource describes a program in New Mexico that employs community health workers (CHWs) to address social determinants of health, as well as how that program was implemented and spread.
- CHWs are culturally and linguistically competent individuals from the communities served who focus on identifying and addressing adverse social determinants of health for patients.
- Almost a decade ago, the University of New Mexico hired a group of CHWs who helped patients understand their health care and social benefits and provided support for transportation to clinics.
- Patients are screened for adverse social determinants and referred to CHWs, who provide varying levels of support, depending on the patients’ needs.
- Screening data is used to better understand the social issues affecting the entire community, informing a broader community health improvement strategy.
- In 2017, New Mexico Medicaid required all of the state’s managed care organizations (MCOs) to increase their CHW contacts with clients by 20 percent. Since three of the four MCOs are national, the CHW model begun in New Mexico has now been deployed in 12 states.
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Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
- How can community health workers (CHWs) help address social determinants of health?
- How can clinical care integrate CHWs?
- What’s an example of a successful program?
Level of Evidence
PromisingWhat does this mean?