Community Health Workers

Research: Community Health Workers (CHWs)

Integrating Community Health Workers into Primary Care Practice

A Resource Guide for HCH Programs


CHWs and HCH (link)
CHWs Roles and Responsibilities (link)
Hiring CHWs (link)
Training CHWs (link)
Supervision of CHWs (link)
CHWs Integration and Support (link)

“Being a CHW has made me a better person in a very real sense. I’m more patient, understanding, and friendly in general – maybe it’s just doing a job I love.”

~ Community Health Worker



What are CHWS and what is this guide about?

Listen to the recording:

In June 2015, the National Health Care for the Homeless (HCH) Council completed a 3-year pilot project funded by the Center for Medicare & Medicaid Innovation (CMMI) through a Health Care Innovation Award (HCIA). The project aimed to connect individuals experiencing homelessness who were also high users of hospital services with Community Health Workers (CHWs) in order to increase utilization of primary care and reduce unnecessary utilization of emergency services.

CHWs were employed by and stationed at Health Care for the Homeless projects. Partnering hospitals referred high utilizers to CHWs on an individual basis or the HCH project notified CHWs when a high utilizer was in the clinic (based on a high utilizer list shared by a partnering hospital). Over the course of 3-years, CHWs enrolled 355 high utilizers into the project.

This project not only demonstrated the significant impact CHWs can have on the lives of people experiencing homelessness but also presented an opportunity to assess effective practices in recruiting, supervising, and supporting CHWs as part of a health care workforce.

The National HCH Council developed this resource guide to share experiences and successful recruitment and supervision strategies with other HCH projects looking to employ CHWs. This guide incorporates current research and uses feedback from administrators, supervisors, CHWs, hospital staff, community members, and clients involved in the HCIA project.


The Council contracted with 12 HCH projects who are also members of the HCH Practice-Based Research Network (PBRN). The 12 HCH participating sites partnered with local safety net hospitals to administer the project. At these 12 sites, 15 CHW were employed. Depending on the need, some sites employed one CHW, where other sites employed two CHWs. The CHWs were notified by hospital or HCH staff when a client from their high-utilizer list was available in either setting for consult. If the client agreed to participate in the study, the CHW worked closely with the client to identify and address unmet needs. The CHWs served as outreach workers, case managers, and peer navigators and developed trusting relationships with clients based upon their similar backgrounds, shared experiences of homelessness, and an understanding of issues experienced while homeless. The project period was July 1, 2012 – June 30, 2015. Primary responsibilities of the CHWs participating in the project:

  • Conduct targeted outreach to unstably housed individuals who are high users of ED services and in need of a medical home.
  • Plan and prepare connections to primary care with HCH and ED staff.
  • Assist clients in gaining access to and navigating a primary health care medical home and other community-based social services (i.e. behavioral health services, housing, legal, etc.) This assistance included coordination of transportation for clients to/from appointments, accompaniment as needed, and follow-up with clients regarding appointments, care plans, and health goals.
  • Provide basic planning, casework, and health education services for clients while ensuring these services are both culturally and linguistically appropriate.
  • Comply with data collection and reporting requirements of the project including documentation from intake interviews, monitoring client progress, and maintaining outreach/engagement logs.
  • Develop relationships with area social services agencies to build knowledge of resources available to clients.
  • Advocate on behalf of clients in order to facilitate access to resources and inform local stakeholders of client needs.

Finding value in the work of CHWs, most HCH clinics identified funding to maintain their CHWs after the project period ended. Click here to learn more information about the National HCH Council’s CHW project.

CHWS Voices

This resource guide features a series of informative podcasts, “CHW Voices,” which illuminate different facets of the recruitment, supervision, support, and responsibilities of Community Health Workers. You can listen to the podcasts within our Resource Guide, or click the button to the right to access the series directly.

These podcasts feature the voices of the following CHWs and CHW supervisors, to whom we give thanks for their participation:

Sharon Agee

CHW: Healthcare for the Homeless – Houston |
Houston, TX

Patricia Cawley

Director of Case Management and Integrated Services: Duffy Health Center |
Hyannis, MA

Rodney Dawkins

CHW: Heartland health Outreach|
Chicago, IL

Sue Moore

Director of Homeless and Public Housing Health Services: Charles Drew Health Center |
Omaha, NE

For more information about this project, please contact Julia Dobbins, MSW.

This project is supported by the Health Resources and Services Administrators (HRSA) of the U.S. Department of Health and Human Services (HHS) under cooperative agreement number U30CS09746, National Training and Technical Assistance Cooperative Agreement, for this budget year’s total cooperative agreement award of $1,625,741.00, and 0% of this total NCA project financed with nonfederal sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

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