Scaling a Statewide Medicaid Community Health Worker Model

Context

Partnered with TennCare (Tennessee Medicaid) to design and implement a multi-year, $7M statewide initiative to build a technology-enabled Community Health Worker (CHW) infrastructure across 14 healthcare and community-based organizations.

This initiative represented a first-of-its-kind effort to standardize and scale CHW programs across a diverse Medicaid ecosystem.

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    The Challenge

    The initiative required aligning 14 organizations with significant variability in:

    - Organizational size, structure, and readiness

    - Clinical integration and care coordination maturity

    - Workforce models and staffing capacity

    - Technology infrastructure and data capabilities

    At the same time, the program needed to:

    - Align with Medicaid priorities and reporting requirements

    - Demonstrate measurable clinical and operational outcomes

    - Establish a sustainable model beyond initial grant funding

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    The Approach

    Owned the enterprise relationship with TennCare and led the end-to-end implementation strategy across participating organizations.

    Key actions:

    - Guided organizations through strategic planning, implementation, and long-term sustainability planning

    - Designed and operationalized standardized, evidence-based CHW workflows

    - Led technology selection and integration across EHR, care management platforms, and AI-enabled tools

    - Built performance management infrastructure, including dashboards and reporting frameworks tied to outcomes

    - Facilitated cross-organizational collaboration to drive alignment, shared learning, and consistent execution

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    The Impact

    9,650 Tennesseans served across 33 counties

    26,000+ social and clinical needs addressed

    29% reduction in hospitalizations, demonstrating measurable clinical impact

    Established a scalable statewide CHW infrastructure, enabling long-term program sustainability

    12 of 14 organizations renewed, with 2 expansions, validating program value and driving continued investment

TennCare’s proven Community Health Worker infrastructure has improved quality and saved $60.7M.