Request for Application (RFA) for the Mississippi Delta Health Collaborative Clinical Community Health Workers Initiative

The Mississippi State Department of Health (MSDH) is seeking applications from eligible healthcare systems to participate in the Clinical Community Health Worker Initiative (CCHWI) and the Mississippi Alliance for Cardiovascular Health (MACH) Learning Collaborative. The goal of this initiative is to improve cardiovascular health outcomes among adults and older adults with hypertension and high cholesterol in the Mississippi Delta region. Participating healthcare systems will be required to establish and maintain an interdisciplinary care team, secure Community Health Workers (CHWs) to serve as liaisons between patients and healthcare providers, and participate in the MACH Learning Collaborative. Key activities include: • Identifying and recruiting eligible patients • Utilizing CHWs to support patient engagement and care coordination • Conducting standardized screening and referral activities to address social determinants of health • Demonstrating the ability to utilize an electronic health record (EHR) or other approved health information technology system • Collecting, monitoring, and submitting required programmatic, clinical, and social determinants of health (SDOH) data • Participating in monthly case review meetings, interdisciplinary team meetings, and other required activities The initiative aims to strengthen community-clinical linkages, improve care coordination, and support team-based approaches to improve cardiovascular health outcomes.