Scaling a Statewide Medicaid Community Health Worker Model Across 14 Organizations
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.
* First-year grantee organizations
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
Approach
Owned the enterprise relationship with TennCare and led the end-to-end implementation strategy across participating organizations.
Key actions included:
Designed and operationalized standardized, evidence-based CHW care coordination workflows
Guided organizations through strategic planning, implementation, and long-term sustainability planning
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
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
