FY25 CHWSD Request for Additional TA&S

Organization Legal Name*

Primary Contact Person*

First NameLast Name

Site Champion*

First NameLast Name

Site Champion Title and Organization*

TitleOrganization

Organization Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

A requirement of this support is that all organizations must provide direct patient/client care and/or services. Please read the below definitions prior to continuing with this application.
The Centers for Disease Control and Prevention (CDC) defines direct patient care as hands on, face-to-face contact with a patient for the purpose of diagnosis, treatment, and monitoring. The SD DOH and CHWSD define direct patient/client services as current and/or proposed services that are provided by organizations that compliment direct patient/client care where a CHW position could compliment direct patient/client care by providing the services of the CHW scope of work.

Medical Clinical Example: A medical/clinical site may have medical providers seeing patients and providing diagnosis, treatment, and monitoring. Through this funding, a CHW could then be added to the team to provide direct patient services related to resource coordination and patient navigation, health promotion and coaching, and health education.
Community-based Example: A CHW could be added to aid existing direct client services related to resource/referral coordination and client case navigation, health promotion and coaching, and health education. CHW direct services should focus on individual/family, one-on-one services provided to coordinate needs related to social determinants of health (housing, education, economic stability, safety, healthcare access, neighborhood/environment, and social/community needs). Organizations that do not currently provide a basic-level of proposed CHW services (resource/referral coordination and patient/client navigation - related to social determinants of health needs, health promotion and coaching, and health education) are not eligible to apply for funding.

Given the above examples, does your organization provide direct patient/client care and/or services?*

Yes, Continue completing applicationNo, Unfortunately your organization is not eligible to apply for additional support at this time, please do not continue with this application

Please upload a CHW Toolkit Certificate of Completion:*

Or email the certificate to julie@chwsd.org.

Organization Type*

Medical/Clinic, (i.e. hospital, clinic)Community-Based Organization (i.e. social services, non-profit organizations)Tribal OrganizationsOther

Organization Status*

For-ProfitNon-ProfitOther

Please list the direct services your organization provides to patients/clients*

Approximately how many patients/clients per month do you serve?*

Please provide information on the population(s) your organization serves and the population(s) your CHW program plans to work with (i.e., disease-specific, community-specific, culturally specific, etc.)*

What technical assistance and support is your organization seeking from CHWSD? (Please select all that apply)*

If Other, please indicate what other Technical Assistance and Support needs your organization is requesting from CHWSD.

Please provide a short response (2-3 paragraphs)

Briefly describe your organization and how you envision utilizing a Community Health Worker. Include 3 specific objectives the CHW will accomplish.*

Please provide a short response (2-3 paragraphs)

Please briefly describe who will be responsible for managing and coordinating the work associated with developing the CHW program at your organization. *

Please provide a short response (1 -2 paragraphs)

CHWs must be able to record interactions and services provided to patients/clients. Please briefly document how your CHW(s) will document patient/client interactions and services provided. Does your organization currently have an EHR (Electronic Health Record)? Does your organization currently subscribe to client management software? *

Please provide a short response (1 -2 paragraphs)

Do you have CHW(s) currently employed?*

YesNo

Do you have CHW(s) trained and/or in-training?*

YesNo

Please indicate below how many individual CHW positions you are looking to add to your new CHW program within the next 6 months.

Scholarship opportunities may be available for individuals wishing to train as a CHW. These scholarships are offered to individuals associated with a developing CHW program. Please indicate below how many individuals would likely be applying for a CHW scholarship.

What 2-3 measures will your site track to assess your specific needs and issues. Examples in a health setting may be reducing emergency department visits, increasing appointment follow-through, or specific chronic disease measures, such as A1c or blood pressure. Examples in a community-based organization may be related to specific case management measures important to the agency. What 2 - 3 measures will your CHW program measure?*

Please provide a short response for your measures listing them separately as 1. 2. and 3. (if applicable)

Please provide a detailed plan for how your organization will sustain your CHW program well into the future. i.e. If your organization is planning to seek Medicaid and/or Medicare reimbursement for CHW services provided, please briefly summarize. Please list other funding sources your organization will pursue to sustain the CHW program after funding has ended.*

Please provide a detailed plan for sustainability

Upload your letter(s) of support below*

Organization Signature*

CHWSD Request for Technical Assistance and Support Application

1: Organization Information

2: CHW Toolkit Certificate

3: Organization Overview

4: CHW Program Narrative

CHW Position Development

CHW Program Development

CHW Documentation and Reporting

Position Development

Evaluation

CHW Program Sustainability

5: Letter of Support