CHWs at MA Audubon 3

Community Health Workers (CHWs) and other team members from the Worcester Partnership of the Prevention & Wellness Trust Fund head out for a hike at the MA Audubon Society at Broad Meadow Brook in Worcester.


In January 2014, the City of Worcester’s Division of Public Health (WDPH) was awarded nearly $6 million from the Massachusetts Department of Public Health (MDPH) Prevention and Wellness Trust Fund (PWTF) to engage community and clinical partners throughout Worcester in an effort to address and reduce pediatric asthma, uncontrolled hypertension, and prevent senior falls. Over the next three years, this innovative, evidenced-based program will create an opportunity to develop novel linkages and engage community health workers (CHWs) in bridging gaps in health care. Over the past several months, clinical and community organizations across the City have built capacity by collaborating on building unique partnerships and models of care under this new program.

Looking ahead in the New Year, the Worcester Partnership for the Prevention & Wellness Trust Fund will implement comprehensive approaches to address the three identified major health conditions that prove costly and often life-threatening. Led by the Pediatric Pulmonary Department of UMass Memorial Medical Center, under the pediatric asthma CHWs at four clinical sites will connect with high risk patients eligible for home-based multi-trigger, multi-component assessment and intervention. In addition, they will work with the Worcester Public Schools to educate school nurses and parents on pediatric asthma management. These interventions have the potential to reduce costly asthma-related emergency department visits and improve the quality of life for asthmatic children and their families.

The Family Health Center in Worcester has created a falls clinic to refer seniors who have been identified as high-risk for falling through a comprehensive falls assessment and follow-up. This clinic will follow the evidence-based STEADI protocol as outlined by the Centers for Disease Control and Prevention.  In the community, the Worcester Senior Center will serve as the referrals hub for the senior falls intervention, using their expertise in this field to connect seniors with fall prevention services, such as falls risk home assessments and modifications and A Matter of Balance and Tai Chi classes.  Last fall, senior health promotion events were held by funding partner Fallon Health and the Worcester Senior Center.  In addition, the Worcester Senior Center distributed 10,000 falls prevention calendars throughout the community.

Finally, clinical and community partners will engage patients with uncontrolled hypertension by teaching them to self-monitor the changes in their blood pressure. Patients will also learn about healthy living through Stanford Model Chronic Disease Self-Management Programs (CDSMP) at local community-based organizations led by Mosaic Cultural Complex.  For example, the Mass Audubon Society at Broad Meadow Brook will train PWTF CHWs about where clients and patients can walk in Worcester, including identifying free, safe areas throughout Worcester that are suitable for year-round outdoor exercise and offer walking groups from Family Health Center and Edward M. Kennedy Community Health Center.  Both WDPH and MDPH are eager to learn from them while they develop and implement these unique and inventive approaches.

A full list of partner organizations includes: Central Massachusetts Area Health Education Center (AHEC), Community Legal Aid, Edward M. Kennedy Community Health Center, Inc., Fallon Health, Family Health Center of Worcester, Inc., Head Start, Mass Audubon Society, Mosaic Cultural Complex, UMass Medical School, UMass Memorial Medical Center, Worcester Public Schools, and Worcester Senior Center.

For more information, please contact Tracy Kennedy, Project Manager for the Worcester PWTF Partnership, at the Division of Public Health at 508-799-1309 or

WDPH sees the PWTF as an important step in building a healthier community. This project will reduce health care costs and health disparities in the City by addressing the most prevalent and preventable health conditions. It will foster lasting change in the health of the community, supporting the vision of being the healthiest city in New England by 2020!