Population Health




Population Health/Community Health Worker (CHW) Wellness Coach

           The Population Health program offers home visiting services to adults 18 years of age and older that have been diagnosed with a chronic illness. This community health worker (CHW) program provides peer support through home visits to improve health literacy, patient care, and chronic disease self-management. Community health workers motivate and assist individuals with health care, social services, and community resources to improve access to community services and coordinate care through primary care providers. The community health worker works in collaboration with the client to ultimately improve quality of health independently while reducing Emergency Room visits, admissions and re-admissions to the local area hospitals. 



How do you get involved in the program?

  • First, you must be 18 years old or older and have a chronic condition.
  • Reside in Jefferson, Lewis, and/or St. Lawrence Counties
  • There is a referral form that is easily filled out and you can access it directly through our website.


Who can make a referral?

  • Doctors, nurses, case managers, social workers, etc., and you can fill one out for yourself!

How it works:

  • A Community Health Worker (CHW) meets with a client at a mutually agreed location or in the home. They work as a wellness coach and offer support and motivation to obtain healthier goals. They work with their client to achieve more independence within their health management.



Contact us if you have any questions or would like to become enrolled in the program today! 



Meet our team:


Barbara Bastardo - Jefferson County CHW

Brianna Wilt- CHW

Danielle Huestis- CHW

Patrick O'Connell-CHW







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