Clinical Community Health Workers Initiative Services

The Mississippi government authority is seeking clinical community health workers initiative services to support patient engagement, follow-up, and care coordination activities. The agency needs to address social determinants of health and improve cardiovascular disease prevention and management outcomes. The selected provider will help strengthen systems-level approaches to improve health equity and reduce disparities by examining existing organizational policies, workflows, and barriers impacting patient outcomes. The scope of work covers home visits, telehealth encounters, team huddles, patient education, blood pressure monitoring, referral coordination, lifestyle change program referrals, and linkage to social services. The agency requires the utilization of standardized screening and referral activities to identify and address social determinants of health, including transportation, food insecurity, housing instability, insurance access, and behavioral health. Participating healthcare systems must utilize and support standardized bidirectional referral processes to document, track, monitor, and report referrals and referral outcomes. The agency requires the collection, monitoring, and submission of programmatic, clinical, and social determinants of health data, including monthly and quarterly reports. Bidders must perform all work onsite and must be located onshore within the United States. The agency is requesting proposals to determine the budget, and the resulting contract will have a performance period of one year. Bidders must submit all questions regarding this opportunity no later than June 12, 2026. The agency allows digital submission of responses via email or online portal. The evaluation will focus on the bidder's ability to fulfill the clinical community health worker activities and data reporting requirements.