The goal is to help patients address real-life obstacles (e.g., social driver of health) that keep them from staying healthy, by supporting them with health care navigation, specialty appointments/referrals, PCP appointments/establishing routine care and preventative health screenings, cultural broker, financial services, and provide culturally appropriate health information on topics related to chronic disease management and prevention. CHWs receive training in Epic & Essette, DHCS requirements, trauma-informed care, motivational interviewing, health care navigation, harm reduction, mental health first aid, domestic/intimate partner violence, advocacy, insurance enrollment, social service/resource applications and referrals, and basic case management.