This session spotlights real-world models for embedding Community Health Workers (CHWs) into care delivery to address non-medical drivers of health. Presenters will share how two health systems integrated CHWs into clinical and community workflows using interoperable technology to screen for social needs, coordinate referrals, and close care gaps through cross-sector collaboration.

One model leveraged a Health Information Exchange (HIE) platform to enable real-time, bi-directional data sharing between healthcare providers and community-based organizations. Another built a statewide community resource library within the electronic health record and transitioned from grant-funded to sustainable operations through CMS’s Community Health Integration reimbursement. Both initiatives addressed key needs such as food insecurity, housing instability, and transportation access, while improving care coordination and reducing avoidable hospitalizations.

Attendees will learn practical strategies for designing and scaling CHW-led programs, integrating community partnerships, and aligning workflows to support whole-person care. Presenters will also share key outcomes—including improved clinical indicators, reduced emergency department utilization, and resolution of social needs—along with lessons learned around privacy, consent, and interoperability.