Community Health Workers (CHWs) work directly with patients who experience a higher prevalence of health disparities in four chronic disease states: Diabetes, Hypertension, Pediatric Obesity, and High Risk (any of the three listed above and coexistence of mental health diagnoses). CHWs are members and representatives of the targeted patient population(s). They act as care coordinators. Duties include maintaining regular ongoing contact with patients, including a minimum of: biweekly telephone contacts, in-person meetings every month, accompanying patients to appointments as needed, providing referrals, conducting home visits, monitoring health status, acting as patient advocates, and educating patients in self-management.

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