The Community Health Worker (CHW) serves as an integral member of an individual's support and care team. Using an evidence-based, person-centered approach, the CHW provides goal setting, education, advocacy, care coordination, and practical support to individuals experiencing care transitions, chronic health conditions, disabilities, or barriers related to Social Determinants of Health (SDOH). The CHW works directly with individuals, their circles of support, healthcare providers, and community partners to improve health outcomes, independence, and self-sufficiency. Services are provided in homes, community settings, by telephone, or at designated program locations and are documented in required data systems.