Community Health Workers Improve Heart Health Care

Community-University Health Care Center (CUHCC) is a Federally Qualified Health Center (FQHC) in the Phillips community of Minneapolis. CUHCC serves more than 12,000 patients a year through approximately 54,000 visits in 54 languages.

The clinic serves many immigrants, refugees, and people from low-income communities who face social, economic and structural disadvantages that make it more challenging to achieve their health goals. CUHCC strives to hire staff that reflect the diversity of the patients they serve. 

Evolution of a CHW model 

Community Health Workers play a crucial role in the public health system as a trusted bridge between health systems and underserved populations. CHWs are trusted frontline health workers who typically come from the communities they serve and share similar life, cultural, and linguistic experiences. Learn more about Community Health Workers.

CUHCC has been working on its Community Health Worker model for years. CUHCC first hired a CHW in 2017, piloting disease-specific models. more recent years, the clinic’s CHWs: 

• Focused on community outreach as the clinic responded to the COVID pandemic (2020-2022).
• Provided navigation support for Afghan refugees, as CUHCC was one of the participating clinics for refugee resettlement (2022-2023).
• Integrated into the care team to provide one-one-one patient health education, connect community members to care, and improve health outcomes (2023-present).

CUHCC CHWs have become an essential part of the integrated care team. They continue to define their service delivery model, provide ongoing training and support, integrate into the clinical care team, and standardize workflows and documentation. As the community’s needs change, the CHW team responds accordingly.

Self-measured blood pressure program

CHWs are vital to the clinic’s self-measured blood pressure program. Patients receive a blood pressure cuff from the clinic. The CHWs teach patients how to use the cuff to check their blood pressure.

Using a three-visit hypertension workflow, the CHWs schedule follow-up visits that occur in the clinic, in patients’ homes, over the phone, or virtually.

• The first visit is within three days to assess proper use, ask about use of medication, provide health education, review patient’s goals, and schedule any follow-up appointments with their care team.
• Two to three additional follow-up visits are scheduled to review blood pressure logs, further discuss the patient’s goals, orient the patient within MyChart, perform additional social needs screening, and respond to other gaps in care.
• CHWs continue to connect with patients until 50% or more of their daily readings are at their blood pressure goal in the last two weeks. 

The CHWs at CUHCC worked with a patient who had recently arrived in Minnesota, did not have medical insurance, and had high blood pressure readings. After a warm hand-off from one of the healthcare providers, the CHW gave a cuff to the patient and taught them how to use it (a warm hand-off is when one provider, who has already established a relationship and trust, introduces the patient to another provider, reviewing the most relevant information, so that the patient does not have to repeat themselves).

The CHW followed their hypertension protocol, including:

• Checking to see if the patient was using the cuff correctly, reviewing their blood pressure log, providing hypertension health education, and discussing the patient’s goals. 
• Conducting a home visit to learn more about the patient’s daily habits towards food, physical activity, and medication adherence.
• Adjusting medications in collaboration with the care team and connecting with the patient to clarify goals and next steps. 

With the support of the CHW and care team at CUHCC, the patient achieved blood pressure control within three months. The patient attributes their success to support from the provider and CHW, eating more fruits and vegetables, building in more minutes of physical activity each day, and taking their medication as prescribed.

More minutes of personalized heart health care

In 2025, the CHWs had 1,570 patient interactions that included health education visits of more than 16 minutes. About one third (509/1570 interactions) of these visits focused on self-measured blood pressure and hypertension management and control. The majority of these hypertension interactions (406/509 or 80%) were visits in patients’ home, the clinic, or community.

At times, CUHCC’s quality measures around hypertension have gotten up to 58%, meaning that more than half of their patients who have a hypertension diagnosis have achieved hypertension control. However, incremental wins can easily be lost when variables change. For example, CUHCC saw their quality numbers started to trend downward when they had a vacancy in their CHW team in late 2025. In early 2026, CUHCC saw a drastic decline in clinic visits due to Operation Metro Surge.

Hypertension management and control is a process of ongoing quality improvement, with intention and effort to routinely review progress, and adapt accordingly to changing conditions.

Lessons learned

While this is a replicable example, each clinic needs to adapt a system to their capacity and local conditions, stay nimble and responsive to patient needs, and work with patients towards their blood pressure goals. Recommendations from CUHCC’s experience are: 

• Find a distinct function for the CHW with standardized workflows that dictate how CHWs are integrated into the care team. The workflow can include a description of their role, workflow, and documentation practices (i.e., how CHWs document their patient interactions in the electronic health records).
• Tailer health education and patient support to the patient’s needs and interests. For example, when they provide resources, they may simply provide a list and the patient will call or connect on their own, they may sit alongside and call together, or they may even go in person to another physical location, if the patient needs additional assistance to use the resource. 

CUHCC cardiovascular health clinical quality metrics

Chart 1. Percent of Adult Hypertension Patients with Controlled Blood Pressure (<140/90 mmHg)

The Federally Qualified Health Centers (FQHC) use the National and Minnesota averages as benchmarks. In 2024, 53% of CUHCC patients with a hypertension diagnosis achieved blood pressure control. In 2025, CUHCC’s blood pressure control numbers increased to 55%.

Chart 2. Number of Hypertension Patients at CUHCC with Controlled Blood Pressure

CUHCC invested staff time, resources, and sought opportunities to improve cardiovascular health outcomes. When CUHCC incorporated CHWs into their care delivery model for heart health, it contributed to the clinic’s overall improvement in blood pressure control. Inclusion of CHWs on the integrated care team made the self-measure blood pressure with clinical support program possible, from engaging patients into the clinic, serving them in culturally appropriate ways, meeting them where it is convenient for patients (in clinic, virtually or at their home), and continuing to serve them until they reached their blood pressure goal.

To learn more about managing your blood pressure, visit About Blood Pressure.