Improving Diabetes Prevention and Management

Project Title

Advancing the Integration of Community Health Workers into Patient-Centered Medical Homes and Health Homes in New York State

Grant Amount


Priority Area

Improving Diabetes Prevention and Management

Date Awarded

January 31, 2012







New York State has embarked on implementing two models of care—patient-centered medical homes (PCMHs) and health homes to improve health outcomes and reduce costs by giving people the right care and support they need in the appropriate environment.

Columbia University Mailman School of Public Health and the Community Health Worker Network of New York City disseminated best practices on how to integrate community health workers (CHWs), who have been shown to reduce health care costs and improve health outcomes for people with chronic diseases, into PCMHs and health homes.

The New York State Office of Health Insurance Programs aims to get these health homes up and running quickly to leverage the temporary 90% Federal match rate for health home services specified in the health reform law. CHWs are well positioned to help find people who have been historically marginalized from the health care system and have multiple chronic conditions, and enroll them in PCMHs or health homes. CHWs can ensure both continuity of care and care coordination, as part of PCMH and health home models, for patients who are hard to reach and difficult to manage. Columbia and Network staff will assembled and disseminated the evidence for using CHWs in PCMHs and health homes, and make the case to health leaders to employ these workers. They also developed recommendations on the training and supervision of CHWs, and guidelines for when and how to incorporate CHW services into health home operations, and prodived technical assistance to health homes using CHWs.