Community health workers meet around a table

Community health workers help patients—particularly those with multiple chronic diseases, including mental health and substance use disorders—to address barriers to their health including housing, safety, and understanding their medications. 

CHWs create trusting relationships, navigating patients to important appointments, making follow-up home visits, and closely communicating with the provider team. CHWs engage patients in setting their own goals and building their efficacy to take care of their health.

Patient navigators work with vulnerable patients needing help to receive preventive cancer screenings, make it to diagnostic specialty appointments and cancer treatment. Patient navigators specialize in addressing patients’ barriers to care, ranging from transportation to health literacy to fear. The navigators provide reminders, health education and support, and may accompany the patient to an appointment if needed.

Community health workers are the bridge between patients and the providers. We build relationships and help to bring the patient’s voice forward when we are a part of the care team.

Ana Cabral
Manager, Complex Patient Populations MGH Chelsea

How We Reduce Barriers to Care

Cancer Navigation Program

Our Cancer Navigation Program brings patient navigators to work with vulnerable patients needing help to receive preventive cancer screenings, make it to diagnostic specialty appointments, and cancer treatment.  Patient navigators specialize in addressing patients’ barriers to care, ranging from transportation to health literacy to fear.  The navigators provide reminders, health education and support, and may accompany the patient to an appointment if needed.

Complex Patient Population Community Health Worker Program

Community Health Workers (CHWs) work with patients who have multiple health issues and experience barriers to care.  Most CPP patients are immigrants or refugees who have limited English proficiency, little social support, and/or not familiar with the US medical system.  CPP CHWs meet patients where they are at in their care, help create and accomplish goals, and ultimately increase their connection to primary care.

Connect to Wellness

Connect to Wellness is a partnership between Massachusetts General Hospital and Boston Senior Home Care that began in April 2017 and offers on-site health and social services to residents living in three apartment buildings surrounding the hospital campus in Boston’s West End and Beacon Hill.  The objective of this community collaborative is to assist all residents in maintaining independence as they age in place by identifying social and health related needs and providing intervention.

Family Planning Program
The Family Planning Program provides confidential reproductive health services to adolescents, young women and men.  It ensures delivery of clinical family planning services at MGH Revere Pediatrics, MGH Revere School-Based Health Center, MGH Revere Adolescent Health Center, MGH Chelsea Pediatrics, and MGH Chelsea School-Based Health Center.
Food for Families

Food for Families identifies pediatric patients and their families in Chelsea who have experienced hunger and food insecurity and connects them to food resources.

Hepatitis C Program

Our Hepatitis C Program works to improve clinical care and increase the screening and treatment of Hepatitis C Virus (HCV) through treatment and patient education, and community outreach activities.

Helping Abuse & Violence End Now (HAVEN)

HAVEN offers direct services to help improve the health, safety, housing, employment and financial circumstances of Mass General patients, employees and community members who have experience intimate partner abuse.

Healthy Families America Home Visiting Program
Our Healthy Families America Home Visiting program provides home visiting services to vulnerable families to support healthy child and family development from pregnancy through 3 years of life.
Healthy Steps Family Home Visiting Program
We provide timely well-child visits and immunizations along with increasing parental knowledge of child development, healthy eating habits and obesity prevention.  In addition, the program seeks to improve access to care for all patients and their families.  Child development specialists in the Healthy Steps program conduct joint office visits with the pediatricians during well-child checks for children between the ages of birth and three years. Healthy Steps is offered to all first-time parents bringing their newborns to MGH Revere for pediatric care. 
Immigrant and Refugee Health Programs

Immigrant and Refugee Health Programs (IRHP) ensure the well-being of refugees by providing culturally responsive health care, assisting with the integration of children and their families into schools, and improving the cultural competence of future physicians.

Legal Initiative for Care (LINC)

Legal Initiative for Care (LINC) improves the well-being of immigrant and refugee families through legal advocacy related to public benefits, housing and immigration.

Living Tobacco-Free

Living Tobacco-Free works with Mass General community health care centers and community organizations to help people stop using tobacco products and to prevent youth and others from initiating tobacco use.

Medical Interpreters and Community Health Workers

The Medical Interpreters/Community Health Workers (MI/CHW) program aims to reduce barriers to health care for MGH Chelsea patients with limited English proficiency by providing high-quality linguistic and health system navigation services.

Pediatric Asthma Program

In the Pediatric Asthma Program, an asthma worker provides health education through in office visits, home visits and group teaching sessions. The patients’ understanding of chronic asthma and how to control it with daily medication is reinforced through follow-up and assistance managing triggers in the home. 

Prenatal Outreach Program
The Prenatal Outreach Program provides support, health education and referrals to the diverse Chelsea patient population during pregnancy and up to the first six weeks postpartum to ensure a healthy pregnancy and engagement in primary care for both mother and child. The Prenatal Outreach Program also encourages and engages fathers in prenatal care.
School-Based Health Centers

Staffed with Pediatric Nurse Practitioners and other clinicians, our School-Based-Health Centers (SBHCs) provide primary care and services in mental health, nutrition, health education, substance abuse prevention, violence prevention and assistance with health insurance enrollment to all students at Chelsea High School and Revere High School.  

Stay in Shape

Stay in Shape is a free after-school program designed to promote awareness and inspire healthy living to prevent childhood obesity among adolescent students in the communities served by MGH HealthCare Centers.

Suboxone Program

The Suboxone Program provides nursing case management and support for patients with substance use disorders, specifically opioid addiction. This program provides an innovative approach to substance use disorder treatment within the primary care practice.

Violence Intervention Advocacy Program (VIAP)

In our Violence Intervention Advocacy Program (VIAP), an advocate helps guide victims of community violence through recovery from physical and emotional trauma, empowering them to make positive changes in their lives.