See pages S9-S10:

Identification or development of community resources to support healthy lifestyles is a core element of the CCM. Health care community linkages are receiving increasing attention from the American Medical Association, the Agency for Healthcare Research and Quality, and others as a means of promoting translation of clinical recommendations for lifestyle modification in real-world settings. Community health workers (CHWs), peer supporters, and lay leaders may assist in the delivery of DSMES services, particularly in underserved communities.