seniors in exercise class

The PWTF Grantee Program supports nine partnerships, representing both urban and rural communities and covering 15% of the state’s population, with a focus on populations with higher burdens of disease. The partnerships have a combined disease burden that is 23% higher than the state and have a 28% higher hospitalization rate for Blacks and Hispanics for the health conditions that the program addresses. The Grantee Program has five key elements:

  • extending care into the community,
  • promoting sustainable change,
  • focusing on priority conditions and evidence-based interventions,
  • targeting sufficient resources to sufficient population levels, and
  • using data-driven quality improvement.

The partnerships focus on improving clinical care to keep people well, referring to prevention and wellness services in the community and providing services that are accessible and evidence-based. Community organizations play a vital role by providing culturally appropriate evidence-based interventions and promoting community-wide policies. Community health workers (CHWs) play a central role in the partnerships – they deliver interventions, help patients navigate clinical and community systems, create supportive environments for patients, and eliminate barriers to care. This program is allocated 75% of the Trust funding and focuses on four priority conditions that have a high burden of disease in Massachusetts and can be improved in three to five years. These conditions are: pediatric asthma, high blood pressure, falls in older adults and tobacco use.

To date, clinical interventions supported better treatment of 300,000 patients across the state. It also created 317 condition-specific clinic and community connections resulting in 15,404 referrals to community prevention programs and 6,992 individuals who have completed their programs. PWTF built significant capacity in 48 communities – over 13% of cities and towns in Massachusetts. More than 340 people were supported by PWTF with 148 new jobs created and 194 additional jobs expanded.

Massachusetts Department of Public

The Massachusetts Department of Public Health (DPH) has been responsible for the design of the PWTF model, managing and monitoring the resources, and facilitating successful implementation of the programs. Changing healthcare delivery to include public health takes planning. The Department spent over one year developing the PWTF model and procuring the partnerships and vendors to implement the programs. The Department received guidance from the Prevention and Wellness Advisory Board to support alignment of PWTF with healthcare reform efforts as well as to select the partnerships and develop the evaluation strategies.


This information is provided by the Bureau of Community Health and Prevention within the Department of Public Health.