CHW LEADS integrates CHWs into care teams in patient care and community settings to screen for and address the adverse social determinants of health affecting Medicaid recipients. The University of New Mexico Health Sciences Center, Office for Community Health(UNM OCH) will collaborate with the Southwest Center for Health Innovation(SWCHI) and the Human Services Department (HSD)/Medical Assistance Division(MAD)to further develop, evaluate, and disseminate the model for integration of Community Health Workers(CHW)into patient care sites and communities to improve population health out comes and reduce healthcare costs for Medicaid recipients.