CHAI
Partner Sites
CCHA oversees the implementation of CHAI, ensuring that CHWs are properly trained and that funded organizations maintain strong community ties. CCHA provides guidance to subrecipients on maintaining CHW program fidelity and develops processes for funding clinical and community-based organizations to hire and support qualified CHWs. Each participating site focuses on specific health conditions and social drivers of health relevant to their service populations, often focusing on barriers to care common in rural areas.
CHAI Support Services Provided
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Darlington County First Steps (DCFS)
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Organization type: Community-based organization
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Pee Dee (Darlington County)
Participants served: Uninsured and underinsured individuals in Darlington County, with a focus on 29550 and 29532.
Services provided:
Connect residents to federally qualified health centers, local health departments, and family support services.
Provide education on healthcare access, chronic disease prevention, and social resources.
Conduct community outreach through events, faith-based programs, grassroots outreach, and annual health/resource events with local partners.
Impact:
Projected to serve 120 individuals annually.
Through CHAI, Darlington County First Steps (DCFS) is expanding its impact by establishing strategic partnerships to assist uninsured individuals in Darlington County. These efforts aim to establish accessible community hubs where the Community Health Worker (CHW) can host standing meeting times and provide support services.
Recently, DCFS met with the Director of the Darlington County Library System to introduce their newly hired CHAI CHW and share information about the services offered to uninsured residents. As a result, discussions are underway to set a recurring schedule at the library to serve community members. Similar efforts are in progress with the Darlington County Housing Authority to establish another hub for outreach and support.DCFS is also actively recruiting eligible participants through local outreach events. One example is their planned participation in the 2025 Gospel in the Park Series, held on Sundays in Hartsville, SC.
CHAI enables DCFS to reach beyond its traditional scope, offering vital resources to uninsured individuals and fostering healthier communities across Darlington County.
Medical University of South Carolina (MUSC)
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Organization type: Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 4
SC region(s) served: Statewide
Participants served: Uninsured adults identified through hospital and community screenings, with a focus in 29817, 29810, 29406, 29405, 29436, 29201, 29204, 29203, 29576, 29590, 29554, 29556, 29056, 29440, 29403, 29414, and 29407
Services provided:
Conduct screening for social determinants of health using EHR-integrated worklists and CHW referrals.
Provide outreach, care coordination, and system navigation services through in-person, phone, and virtual visits.
Partner with community-based organizations to address social and medical needs.
Prioritize uninsured patients identified through payer data for targeted outreach.
Impact:
Projected to serve 700 participants annually. Additional impact data is forthcoming.
Prisma Health Access Health
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Organization type: Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 2
SC region(s) served: Midlands and Upstate (Richland County and Greenville County)
Participants served: Uninsured adults in Columbia and Greenville, with a focus on individuals utilizing emergency departments for non-emergent care and those experiencing barriers to primary care (29605, 29611, 29201, 29203, 29204)
Services provided:
Provide care coordination, system navigation, and social service referrals for uninsured participants.
Identify participants through emergency department reports and referrals from healthcare partners.
Assist participants with financial assistance, medication access, transportation, language interpretation, and social drivers of health needs.
Conduct community outreach, build partnerships, and collaborate with safety net clinics and social service providers.
Impact:
Projected to serve 400 participants annually. To date, Prisma has successfully hired, trained, and oriented two new CHWs who were then able to serve 274 unique clients.
Roper St. Francis Healthcare (RSFH)
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Organization type: AccessHealth Network, Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 2
SC region(s) served: Lowcountry (Charleston County, Berkeley County, and Dorchester County)
Participants served: Uninsured and underinsured adults, with a focus on 29436, 29406, and 29405
Services provided:
Support patients with navigating medical care
Access community resources like financial assistance and behavioral health services
Attend outreach events such as health fairs in collaboration with the RSFH Diversity, Inclusion & Health Equity Specialist.
will integrate CHW-trained navigators into Greer's multidisciplinary primary care clinical teams to improve patient health outcomes and reduce socioeconomic barriers.
Impact:
Projected to serve 300 participants annually. To date, RSFH has served 552 unique clients.
Safe Space Dinners (Reformation Lutheran Church)
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Organization type: Community-based organization
Project health topic(s): Behavioral health, high-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Midlands (Richland County)
Participants served: Uninsured and underinsured youth and young adults.
Services provided:
Enroll participants in CHAI and connect to healthcare and social resources.
Provide family planning services, trauma support, behavioral health referrals, and insurance enrollment.
Host safe, welcoming community dinners as outreach and connection opportunities.
Collaborate with community partners to identify uninsured participants and address unmet social needs.
Impact:
Projected to serve 100 participants annually. Since November 2024, SSD has served 52 unique clients.
Participants were assisted with Medicaid, ACA, and emergency Medicaid enrollments.
CHAI partner highlights
AccessHealth Horry (AHH)
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Organization type: AccessHealth Network
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 3
SC region(s) serviced: Pee Dee (Horry County)
Participants served: Uninsured adults residing in high-need communities in Horry County, with a focus on 29576 ZCTA
Services provided:
Connect uninsured residents with safety net healthcare services through a network of volunteer physicians, hospitals, and social service agencies.
Provide care coordination, system navigation, advocacy, health education, and case management services.
Conduct outreach in collaboration with community partners including faith-based groups, schools, and food assistance programs.
Use culturally and linguistically appropriate outreach materials and events to increase awareness of available services.
Impact
Expanded capacity by hiring 2 CHWs, increasing the team to 12 staff members.
Projected to serve an additional 500 participants annually in underserved areas. To date, AHH has served 95 unique clients.
Access Kershaw (AK)/Community Medical Clinic (CMC) of Kershaw Co.
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Organization type: Community-based organization
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1 full time and 1 part time
SC region(s) served: Midlands (Lancaster County, Northern Kershaw County)
Participants served: Uninsured and underinsured adults in Lancaster and northern Kershaw counties with a focus on 29720.
Services provided:
Conduct CMC intake, application, and Arizona Self-Sufficiency Matrix assessments to identify needs and gaps.
Provide resource navigation, referrals, and care coordination to safety net providers.
Conduct community outreach at local businesses, doctor’s offices, and events.
Adjust CHW schedules to meet community demand and conduct targeted outreach.
Impact:
Addressed a critical care gap in Lancaster County, previously without AccessHealth or free medical services.
Projected to serve 100 annually. To date, AK has served 126 unique clients.
Browns Ferry Community Outreach (BFCO)
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Organization type: Community-based organization
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 3
SC region(s) served: Pee Dee (Georgetown County)
Participants served: Uninsured and underserved adults in Georgetown with a focus on 29440 and 29510.
Services provided:
Connect uninsured residents with safety net services, including healthcare, financial assistance, and emergency resources.
Host collaborative community resource events and conduct outreach in partnership with over 15 local organizations.
Provide culturally and linguistically appropriate outreach materials and services.
Offer emergency support, such as rent, utilities, prescriptions, food assistance, and on-site health services through partner collaborations
Impact:
Projected to
Hope Health
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): Chronic disease prevention and management (diabetes, hypertension, HIV)
Number of CHWs supported: 5
SC region(s) served: Pee Dee (Clarendon, Florence, Orangeburg, and Williamsburg Counties)
Participants served: Uninsured individuals in multiple underserved communities with a focus on 29148, 29102, 29501, 29505, 29506, 29048.
Services provided:
Lead door-to-door outreach, workshops, and health education events in partnership with local hospitals, faith-based groups, and social service agencies.
Promote HopeHealth’s sliding fee programs and preventive healthcare services.
Provide health system navigation, application assistance for financial and social service programs, and chronic disease management support.
Use social media and digital platforms for outreach and community education.
Impact:
Projected to serve
Prisma Health PASOs
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Organization type: Community-based organization
Project health topic(s): Perinatal health, high-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Midlands (Richland County)
Participants served: Latino individuals and families, including pregnant women, children from birth to five, and uninsured adults, with a focus in 29201, 29203 and 29204
Services provided:
Provide culturally tailored education, health system navigation, and resource connections to uninsured Latino families.
Conduct outreach, facilitate workshops, and organize community health events.
Collaborate with schools, clinics, and healthcare partners to expand access to perinatal and primary care services.
Assist participants with insurance enrollment, financial assistance applications, and access to safety net healthcare programs.
Impact:
Projected to serve 400 individuals annually. Their CHW began in November 2024, successfully completing training and orientation. Since then they completed 111 encounters with 44 unique patients, and all 111 encounters were successfully closed.
The PASOs CHW plays an important role in supporting social workers and nurses with patients who were recently discharged and managing various chronic conditions like diabetes, hypertension, and end-stage renal disease.
Many of these participants needed help with financial assistance (such as applications for medication assistance or Medicaid), but also accessing specialty care and food. The CHW pointed out that helping with financial assistance also helps relieve the participants’ anxiety and stress.
ReGenesis Health Care (RHC)
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 3
SC region(s) served: Upstate (Spartanburg County, Cherokee County, and Union County)
Participants served: Uninsured adults, with a focus in 29301, 29302, 29306, 29340,
29341, and 29342.
Services provided:
Provide health education, medication assistance, rental assistance, and financial counseling.
Enroll participants in Medicaid, SNAP, Welvista, and other social service programs.
Partner with community organizations to coordinate referrals and access to additional services.
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Conduct outreach events and provide culturally relevant services to uninsured populations.
Impact:
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Projected to serve 150 participants annually. To date, RHC has 179 unique clients which include financial assistance, connection to medical homes (20 clients), and completion of
applications for assistance programs.
Roper St. Francis Healthcare (RSFH)
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): Chronic disease management (diabetes, hypertension), women’s health, high-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Midlands (Aiken County)
Participants served: Uninsured and underinsured adults in Aiken County (29801), with outreach to agricultural workers and seasonal laborers.
Services provided:
Connect participants with healthcare services, health education, vaccinations, and financial support.
Address social drivers of health through resource navigation for food, housing, employment, and transportation.
Support chronic disease management and remote patient monitoring.
Engage the agricultural community through outreach events and partnerships with local food banks and service agencies.
Impact:
Projected to serve 400 participants annually. To date, RHS has served 552 unique clients.
The Courage Center (TCC)
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Organization type: Community-based organization
Project health topic(s): Behavioral health, substance use recovery support
Number of CHWs supported: 2
SC region(s) served: Midlands (Orangeburg County)
Participants served: Uninsured and underinsured adults, with a focus in 29115, 29118, 29163, and 29048
Services provided:
Provide care coordination, social service navigation, and behavioral health referrals.
Host mobile outreach pop-up events offering health education, harm reduction resources, and medical screenings.
Convene advisory committees to inform outreach strategies and community engagement.
Partner with public health departments, schools, and churches to deliver health services and health education.
Impact:
Projected to serve 250 participants annually. To date, TCC has served 98 unique clients. Additional impact data will be forthcoming.
The Courage Center (TCC)
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Organization type: Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 4
SC region(s) served: Statewide
Participants served: Uninsured adults identified through hospital and community screenings, with a focus in 29817, 29810, 29406, 29405, 29436, 29201, 29204, 29203, 29576, 29590, 29554, 29556, 29056, 29440, 29403, 29414, and 29407
Services provided:
Conduct screening for social determinants of health using EHR-integrated worklists and CHW referrals.
Provide outreach, care coordination, and system navigation services through in-person, phone, and virtual visits.
Partner with community-based organizations to address social and medical needs.
Prioritize uninsured patients identified through payer data for targeted outreach.
Impact:
Projected to serve 700 participants annually. Additional impact data is forthcoming.
Medical University of South Carolina (MUSC)
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Organization type: Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 4
SC region(s) served: Statewide
Participants served: Uninsured adults identified through hospital and community screenings, with a focus in 29817, 29810, 29406, 29405, 29436, 29201, 29204, 29203, 29576, 29590, 29554, 29556, 29056, 29440, 29403, 29414, and 29407
Services provided:
Conduct screening for social determinants of health using EHR-integrated worklists and CHW referrals.
Provide outreach, care coordination, and system navigation services through in-person, phone, and virtual visits.
Partner with community-based organizations to address social and medical needs.
Prioritize uninsured patients identified through payer data for targeted outreach.
Impact:
Projected to serve 700 participants annually. Additional impact data is forthcoming.
AccessHealth Spartanburg (AHS)
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Organization type: AccessHealth Network
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 5
SC region(s) served: Upstate (Spartanburg County)
Participants served: Uninsured adults at or below 200% federal poverty level, regardless of age or immigration status, with a focus on 29301, 29302 and 29306
Services provided:
Connect uninsured residents to medical homes, specialty providers, and social services.
Provide care coordination, health education, system navigation, advocacy, and home visits.
Collaborate with healthcare providers, social service agencies, faith-based organizations, and other community resources.
Conduct outreach events with libraries, churches, and recreation centers.
Impact
Projected to serve 500 additional participants annually.
To date, AHS has served 1,211 unique clients.
CHAI funding will help AHS serve 500 individuals in the ZCTA. In Year 1, CHWs facilitated 3441 encounters, with 2,111 unique patients focusing on the corresponding zip codes 29301, 29302 and 29306. • 31% of the patients were coached in ER visit protocols, mentored, and supported by CHW meeting with patients at their office, visits in the community, patient’s home and accompanying them to their doctor appointments.
1031 patients were referred and connected to specialty providers (General Surgery, Physical Therapy, Ortho, and Obstetrics being the top Specialties). o 1211 Specialty referrals created
1031 specialty referrals were successfully closed/authorized. ▪ 85% of referrals were successfully closed
AnMed/AccessHealth Anderson
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Organization type: AccessHealth Network
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Upstate (29624, 29625)
Participants served: Uninsured adults residing in high-need Anderson County areas.
Services provided:
Provide care coordination, patient navigation, and education to uninsured residents.
Collaborate with Foothills Community Health Care, Anderson Free Clinic, and the Anderson Community Safety Net Council.
Address social drivers of health through referrals to food security programs, transportation services, financial assistance, and more.
Support health system efficiency by guiding appropriate healthcare utilization.
Impact:
Projected to serve 130 participants annually.
In Year 1, CHWs facilitated 1,753 encounters with 119 unique clients.
Made 284 referrals, with 117 (41%) successfully closed; 100% of participants connected to a medical home.
Greenville Free Medical Clinic (GFMC)
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Organization type: Free Medical Clinic
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Upstate (Greenville County)
Participants served: Uninsured adults and families, with a focus in xxx
Services provided:
Provide free primary, specialty, and dental care to uninsured adults.
Connect patients to financial, housing, and social support services through CHW carecoordination.
Conduct health education and outreach events in partnership with local churches, foodpantries, and community groups.
Provide medication assistance, screening, and preventive services.
Impact:
Projected
McLeod Health
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Organization type: AccessHealth Network, Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 5
SC region(s) served: Pee Dee
Participants served: Uninsured adults in McLeod Health’s hospital service area, especially rural hospitals.
Services provided:
Provide system navigation, care coordination, and health education services for uninsured individuals.
Address social determinants of health including food insecurity, housing, and transportation.
Collaborate with local health systems and community agencies to connect patients to primary care and specialty services.
Impact:
McLeod Access Health serves uninsured and underinsured patients with chronic conditions at rates significantly higher in rural hospitals (up to 10.2% in Dillon County). • Projected to serve 425 participants annually. Additional data and impact forthcoming due to having challenges collecting and reporting through electronic health records and are
Prisma Health Healthy Start
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Organization type: Hospital
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Upstate (Greenville County)
Participants served: Pregnant, postpartum women and their infants.
Services provided:
Provide care coordination, and health education to pregnant and postpartum women and their infants, as well as other community members.
Through referrals and/or community outreach, the CHW engages people of reproductive age and others identified as needing support, connecting them to appropriate resources and services.
Following a referral or outreach encounter, the CHWs conduct an assessment to determine the individual’s needs.
They plan educational sessions around health and other social drivers of health-related factors that could increase the risk of adverse perinatal health outcomes. • The CHW facilitates access to community resources and maintains communication to support follow through and service completion
Impact:
Projected to serve 250 participants annually. Prisma Healthy Start hired their CHAI-funded CHW in November 2024. Following the completion of training and job shadowing, the CHW began delivering direct services in December 2024, reaching five participants between December 2024 and January 2025.
In addition, the CHW actively engaged in over seventeen events through partnerships and collaborations within Prisma Health and community organizations.
The CHW provided over ten encounters to the five participants, providing them with resources and referrals for WIC, breastfeeding support, financial assistance, and maternal supplies.
Rural Health Services (RHS)
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 3
SC region(s) served: Upstate (Spartanburg County, Cherokee County, and Union County)
Participants served: Uninsured adults, with a focus in 29301, 29302, 29306, 29340,
29341, and 29342.
Services provided:
Provide health education, medication assistance, rental assistance, and financial counseling.
Enroll participants in Medicaid, SNAP, Welvista, and other social service programs.
Partner with community organizations to coordinate referrals and access to additional services.
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Conduct outreach events and provide culturally relevant services to uninsured populations.
Impact:
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Projected to serve 150 participants annually. To date, RHC has 179 unique clients which include financial assistance, connection to medical homes (20 clients), and completion of
applications for assistance programs.
Tandem Health
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 2
SC region(s) served: Midlands (Sumter County)
Participants served: Uninsured and underinsured adults, with a focus in 29150.
Services provided:
Restructured their Enabling Services Team to proactively identify social needs and address barriers.
Provide care coordination, resource navigation, insurance enrollment, and transportation support.
Collaborate with local social services, churches, and community organizations.
Offer health education and connect patients to chronic disease prevention and management resources.
Impact:
Projected to serve 300 participants annually. Additional impact data will be forthcoming. However, to date, Tandem has served 303 unique clients.
Affinity Health
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Organization type: Federally Qualified Health Center (FQHC)
Project health topic(s): High-need/high-cost service utilization
Number of CHWs supported: 1
SC region(s) served: Midlands (York County)
Participants served: Uninsured and underinsured adults residing in York County, with a focus on 29730.
Services provided:
Connect uninsured and underserved residents to affordable healthcare services, including medical, dental, behavioral health, and pharmacy services.
Provide culturally appropriate outreach, health education, navigation assistance, and care coordination to uninsured patients.
Engage vulnerable individuals through targeted outreach events, collaborations with local organizations, and connections to social services.
Assist patients with insurance applications, financial assistance, and navigation of sliding fee programs.
Impact:
CHAI funding enabled AHC to hire 1 CHW to support outreach, engagement, and resource navigation for 250 participants annually,
Projected to serve 150 participants annually. To date, AHC has served 140 unique clients.