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  1. Gunderson, Jean M. DNP
  2. Wieland, Mark L. MD, MPH
  3. Quirindongo-Cedeno, Onelis MD
  4. Asiedu, Gladys B. PhD
  5. Ridgeway, Jennifer L. PhD
  6. O'Brien, Michael W. MSW
  7. Nelson, Tara M. CHW
  8. Buzard, Ron MDiv
  9. Campbell, Chad MPA
  10. Njeru, Jane W. MB, ChB


Community health workers (CHWs) bring their unique capacity as liaisons for patients, communities, and health care systems to health care teams. We describe the collaborative development of a community-based CHW program to address the social determinants of health that affect patients. This cosupervisory, generalist CHW model provides an innovative template for cocreation of patient-centered infrastructure and resourcing within an evolving and replicable holistic care continuum across patient ages, diagnoses, health care payers, and communities to promote health equity. The program has been effective in decreasing health care utilization and cost.