CHWSD (RHT) Technical Assistance and Support Application

As the funding source for CHWSD Technical Assistance and Support has changed, all CHW/CHR programs receiving support need to complete this short form in order to continue to receive support. This allows the CHWSD to track grant metrics.

Organization Legal Name

Primary Contact Person

First NameLast Name

Organization Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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 CHWSD defines 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?

Have you received organizational support to begin/expand a CHW Program?

Organization Type

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

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

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)

Do you have CHW(s) currently employed?

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

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

Organization Signature

This contract is supported by the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $399,013.00 with 100 percent funded by CMS/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS, or the U.S. Government.

CHWSD Request for Technical Assistance and Support Application

1: Organization Information

Position Development

CHW Program Sustainability