Bridges to Health Community Health Worker Program - Vermont is a predominantly rural, mountainous state in which 13 of 14 counties are federally designated as rural. Despite a network of 11 Federally Qualified Health Centers and several free and referral clinics, significant gaps remain in access to primary care, dental services, and behavioral health providers. Residents face persistent challenges including long travel distances, limited transportation options, workforce shortages, and rising healthcare costs. Fragmented systems and workforce shortages contribute to a lack of coordinated, person-centered care, negatively impacting health outcomes. The University of Vermont will serve as the lead applicant and fiscal agent and will partner with Bridges to Health at Vermont’s Free & Referral Clinics, which will implement core program activities through a subaward. Together, the partners will strengthen and expand the Community Health Worker (CHW) workforce to improve access, care coordination, and health outcomes for Vermonters. CHWs are trusted frontline public health workers who bridge gaps between communities and health and social service systems. This project will: (1) strengthen CHW capacity through enhanced training and professional development; (2) improve system coordination and partnerships across health and social service organizations; and (3) expand access to whole-person, coordinated care. Using an evidence-based model, CHWs will deliver home- and community-based services to individuals and families who are uninsured, medically vulnerable, or socially isolated. Services will include outreach and enrollment, system navigation, health education, chronic disease support, and referrals to health and social services. Through cross-training and coordinated communication strategies, partner organizations will improve knowledge-sharing, reduce duplication of efforts, and better serve communities that face challenges receiving needed services. This collaborative model will enhance continuity of care across systems, reduce unnecessary emergency department utilization, and improve patient satisfaction. The project is expected to increase access to care, strengthen the health workforce, and improve health outcomes for Vermonters who have limited access to care by advancing a more integrated, person-centered system of care.
