In order to reach everyone in our community, we created a network of Community Health Workers whose job was to visit every household in our community. We divided the North End into ten zones, each with approximately 1,000 people. For each zone there is 1 community health worker assigned. This worker is not assigned to any particular program or to any service provider, but to her geographic zone and the people in it. The Community Health Workers each come from the community and share life experience with their neighbors. Each worker is employed full time, with benefits, and has been extensively trained in a program developed by the Spanish American Union.

At the start of the project and each year thereafter each worker walked and mapped her zone, labeling every building, noting the numbers of households in each building, mapping every parcel of land, noting every business and vacant lot, and recording the findings in a graphic form (map). Each of the workers has primary responsibility for reaching and engaging all the households in her zone; giving information, making referrals, providing education, helping families access services and collecting information from the families. The workers help families access services in health, housing, food, daycare, jobs, transportation, headstart, school choice, health insurance and other areas. They teach the families how to access the services themselves. They are recruited by the providers when families or children are falling behind in school or not receiving regular primary and preventive care. They visit families of inmates at our county jail, where the health center cares for the inmates who come from the North End, helping the families keep things together while a parent is incarcerated. And they work with community residents and providers to address systemic, political and economic issues on behalf of the North End families.

Each household in the North End is asked to complete an Individual Family Assessment Form (attached). Demographic, financial, educational, and medical information is gathered and documented. We hope soon to combine our data collected with a GIS software program, to clearly present the issues on which we need to work. We are holding that technological melding until we better understand how to protect the information and how to give it to the people of our community to foster real change and development.