Arizona CEAL: Linking Social Care With Healthcare Systems to Address SDOH

The goal of the Arizona Community Engagement Alliance (AZ-CEAL) will be to combine social care with healthcare programs. The study will be connecting selected patients from clinics with trained community health workers (CHW) who will assist participants in getting the help that is needed for their health such as transportation needs, accessing healthy food, health information, accessing good health care, job opportunities, and housing. The study will collect information from both the patients and the health care systems to test how effectively the care plan works over time.

Inclusion Criteria: * 18 years of age or older * Must meet at least one of the three criteria: * Medicaid or dual-insured beneficiary or * Racial/ethnic minority or rural resident and * Household income in the bottom national quartile of household median income (low SES definition). Exclusion Criteria: * Unable to provide informed consent due to cognitive impairment * Other specified reason that, in the opinion of the investigator makes the participant unsuitable for enrollment