Community Health Worker Referral
Are you or someone you know struggling to understand, advocate for or improve your health? Community Health Workers (CHWs) are your partners in care, trained in evidence-based practices to help you reach your personal and health goals. CICOA CHWs are individuals that come from your community to help you learn about and manage your health, navigate your healthcare (including appointments and medications), work towards personal goals, and access programs and resources to assist with needs (such as food, housing and transportation).
Complete this form to refer yourself or someone else to receive personalized support from a CICOA Community Health Worker.
Participants will receive up to 90 days of personalized support, with help available in your home or out in the community. The program is free to all participants, regardless of age, income, insurance or ability. Eligibility for the program includes meeting at least one of the below criteria:
- Recent hospitalization/ER visit in the last 30 days
- Fall in the past 3 months
- Lost primary caregiver in the past 6 months
- Have not seen a primary care provider in the last 12 months
- Have a chronic health condition
- Have an identified social determinants of health need (housing, food, transportation, etc.)
- Caring for someone who meets one of the above criteria
Once a referral is submitted, the individual will be assigned to a CHW within 2 business days, and the CHW will contact the individual within an additional 2 business days.
Service area: Marion, Hamilton, Hancock, Johnson, Morgan and Shelby counties in Indiana. Please note that we are not currently able to serve Boone and Hendricks counties yet.
This form is specifically for individuals interested in Community Health Worker services. If you are specifically looking for other CICOA programs (such as case management and/or Medicaid Waivers) please call CICOA's Aging & Disability Resource Center at (317) 803-6131.
The referral form requests information that is privileged and confidential, including patient information protected by federal and state privacy laws. We use security measures on our website to protect against the loss, misuse and alteration of data used by our system. CICOA Aging & In-Home Solutions will not share, sell, rent or distribute personal information with anyone without your permission or unless ordered by a court of law. Information submitted to us is available only to employees managing this information for purposes of contacting you and assessing eligibility for services.