Target population: 30–69 years.

Sociodemographic characteristics: high illiteracy rates; low per capita income.

Healthcare challenges: poor access to laboratory testing despite high coverage of primary healthcare; low rates of self-management of conditions; inefficient communication among care team members.

Screening and follow-up: hosted health fairs in collaboration with primary care providers in each municipality; targeted home visits by CHWs for screening and follow-up;

Technologies for care coordination: equipped basic health units (BHUs) with computers, notebooks, tablets and Wi-Fi for patient consultations with Central Telehealth Units; implementation of a Clinical Decision Support System; increased availability of specialised tests, including A1c point-of-care strategy;

Workforce development: developed online courses focused on providing routine HTN and DM care, including strategies for disease management and healthy nutrition;

Clinical and non-clinical patient support: created association for people with HTN and DM; coordinated patient support and educational activities, like cooking workshops and physical education sessions.

Target population: ≥30 years.

Sociodemographic characteristics: 40% of population living under the poverty line;

Healthcare challenges: inadequate chronic disease management at the primary care level, including limited staffing (eg, 1 physician per 8000 people); lack of electronic medical records (EMRs);

Screening and follow-up: hosted 23 health fairs in collaboration with primary care providers in urban areas; industry worker screening; targeted follow-up home visits by CHWs;

Technologies for care coordination: implemented EMRs in 16 BHUs; developed digital screening and job aid tools on promoting healthy lifestyles for CHWs; increased availability of specialised tests, including A1c point-of-care strategy;

Workforce development: trained healthcare professionals on digital tools and care management;

Clinical and non-clinical patient support: CHWs surveyed patients at each BHU for adherence to follow-up care; educated patients on self-care, adherence to treatment and healthy behaviours; produced educational cartoons for CHWs to show patients on tablets and at waiting rooms; three outdoor gyms built at strategic primary healthcare units.

Target population: 15–70 years.

Sociodemographic characteristics: 80% of population is rural and considered tribal; among India's most underdeveloped districts for sociodemographic indicators.

Healthcare challenges: challenges in physical access to facilities; low health literacy for NCDs; public health facilities are overburdened, with inadequate resources and staff for chronic care.

Screening and follow-up: conducted multipronged campaigns to increase awareness about screening camps; involved outreach workers, accredited social health activists (ASHAs) and auxiliary nurse midwives (ANMs) in screening and postscreening activities, follow-up visits and follow-up calls;

Technologies for care coordination: developed electronic management information system (MIS); tracked NCD diagnoses and treatment data through NCD registries; developed referral system for government health centres.

Workforce development: implemented trainer of the trainers curriculum of NCD skills and HealthRise approaches to ASHAs, ANMs and medical officers to facilitate sustained NCD care practices;

Clinical and non-clinical patient support: set up support groups for patients and families; implemented the SALT approach (Stimulate, Appreciate, Learn, and Transfer) in five pilot villages to empower communities to understand and improve their health.

Target population: 15–70 years.

Sociodemographic characteristics: 75% of population in rural areas; 84% literacy rate in 2011; 22% unemployment rate in 2016.

Healthcare challenges: challenges in physical access to facilities; insufficient human resources for health, equipment and infrastructure for chronic disease management; competing priorities among patients, hindering NCD diagnosis and treatment adherence.

Screening and follow-up: conducted multipronged campaigns to increase awareness about screening camps; involved outreach workers, ASHAs, and ANMs in screening and post-screening activities, follow-up visits and follow-up calls;

Technologies for care coordination: established e-clinics for rural patients to access advanced care; strengthened data collection capacity at sub-centres and primary health centres (PHCs); developed electronic MIS for sub-centres; developed and implemented electronic Health Card, a tablet application for ASHAs to catalogue individual risk factors and facilitate referral follow-up at PHCs;

Workforce development: delivered trainer of the trainers curriculum on NCD skills and HealthRise approaches to ASHAs, ANMs, and medical officers to facilitate sustained NCD care practices;

Clinical and non-clinical patient support: set up support groups for patients and families that met quarterly; implemented SALT approach in 14 villages to empower communities to understand and improve their health;

Target population: Emthanjeni municipality; populations living in this area identify as 57.7% coloured, 32.2% black African and 8% white.

Sociodemographic characteristics: primarily rural population; 43.5% poverty rate; 28% employment rate in 2016.

Healthcare challenges: long distances to health facilities; limited transportation options; compounding health issues and socioeconomic vulnerabilities pose additional challenges to an overburdened local health system.

Screening and follow-up: promoted awareness of and screening for DM and HTN in partnership with the extensive CHW network of Nightingale Hospice; conducted screenings and NCD education at community health events, targeted door-to-door campaigns, HIV and Tuberculosis (TB) support groups, retirement homes and shelters, and farms and solar plants; conducted follow-up via phone or in-person as needed, and facilitated patient visits (eg, arrange for transportation);

Technologies for care coordination: supported the creation of a database of DM and HTN patients; enabled tablet-based data collection at community screening events and door-to-door visits;

Workforce development: trained CHWs in DM and HTN screening processes; provided screening equipment to CHWs; provided 4 day trainings on DM and HTN management for clinic-based providers;

Clinical and non-clinical patient support: clinic nurses ensured confirmatory diagnoses and follow-up with patients who failed to attend appointments, pick up medications, or meet control targets; organised patient support groups for patient empowerment and self-care; set up gardening, via the Department of Agriculture and Forestry, and village savings and loans programmes.

Target population: those in Msunduzi, uMshwathi, and Mkhambathini subdistricts. Msunduzi has the provincial capital.

Sociodemographic characteristics: uMshwathi and Mkambathini have unemployment rates of 25% and over 15% of the population has no formal schooling;

Healthcare challenges: long distances to health facilities; low adherence to prescribed medications; high comorbidities with chronic infectious diseases make clinical management complex.

Screening and follow-up: conducted screenings through household visits, workplace screenings, and health education campaigns by community caregivers (CCGs) and in collaboration with the provincial Department of Health; established health teams of a professional nurse or doctor and CCG to provide clinical support at public health clinics and community follow-up by CCGs;

Workforce development: provided trainings on DM and HTN to CCGs; equipped CCGs with digital blood pressures and glucometers, as well as bicycles for reaching patients; trained clinicians and health professionals on diagnostics, clinical support, and ongoing follow-up at public health clinics;

Clinical and non-clinical patient support: established Central Chronic Medicine Dispensing Distribution system to enable patients to be able to pick up their medications closer to their community; hosted support/adherence groups to provide education on the importance of medication adherence, healthy nutrition and exercise, and discussing problems such as medication side effects with providers.

Target population: North Minneapolis, where the population is 50% African American, 20% Asian, 15% Caucasian, and 15% Hispanic/Other;

Sociodemographic characteristics: 40% of households are at or below the 200% poverty level; unemployment is 21.6% among working age adults;

Healthcare challenges: low trust in local health systems by patients; poor access to high-quality education, healthcare and nutritious foods; inadequate data integration of EMR records across community healthcare sites.

Follow-up: community paramedics (CPs) and/or CHWs visited patients to provide wrap-around care, including medication management, health education, food/cooking demonstrations, home safety checks, and broader support for social needs (eg, insurance, care coordination, transportation, housing);

Workforce development: hired and trained CHWs and CPs to work in providing home-based care for high-risk patients, leveraging the medical expertise and ambulatory primary care capacity of CPs alongside the cultural context and language skills of CHW;

Clinical and non-clinical patient support: coordinated home-based care with clinic-based service team of doctors, nurses, pharmacists, clinical care coordinator, and diabetes educators; established a full-service grocery store with linkages to an interdisciplinary wellness team (eg, CHWs, nutritionist, pharmacy liaison, coordinator) and a Wellness Resource Centre

Community-based activities: community or CHW-led activities offered by Oak Park community centre or other community spaces, including healthy eating education sessions, food demonstrations, grocery store tours, walking/exercise programmes, nutritious family meals.

Target population: patients receiving care at Minnesota Community Care (MCC) clinics in Saint Paul, Minnesota;

Sociodemographic characteristics: 97% of MCC patients live below the 200% federal poverty line; 30%–65% are non-English speaking;

Healthcare challenges: Data systems between hospitals and MCC clinics not well integrated.

Follow-up: CPs and/or CHWs visited patients at home 1–4 times per month, monitoring health status, reinforcing clinic education, and addressing social determinants of health (eg, CHW-led patient empowerment and connecting to community resources); tailored frequency of in-home visits to patient care plans and based on trends in clinical targets for blood pressure and A1c;

Technologies for care coordination: used Pathways tool from Care Coordination Systems to ensure coordinated care and updates from CHWs and CPs and clinic-based care teams for patients;

Workforce development: hired and trained CHWs and CPs to provide in-home care and linkages to clinic-based providers in MCC;

Community-based activities: developed and implemented a nutrition-focused programme, in both English and Spanish, wherein sessions focused on nutrition education, effects of non-nutrition factors on blood sugar, and grocery store tours highlighting ways to shop for healthy and affordable foods.

Target population: patients receiving care or associated with HealthFinders Collaborative, Inc (HFC).

Sociodemographic characteristics: Past HFC patients were comprised of 60% Latino immigrants and 25% Somali refugees.

Healthcare challenges: HFC primarily serves uninsured patients or those with public insurance plans;

Technologies for care coordination: designed EMR system to document home visits within patient medical records; employed electronic tools for improving contact with patients, including short message service (SMS)/text-based appointment reminders and education programmes (ie, Care Message);

Workforce development: leveraged pre-existing community networks to develop clinic-community care coordination through the use of frontline health workers (including CHW and CP care teams), community wellness programmes, and added services (eg, mental health services, wellness programmes, and on-site lab for easier access to diagnostic tests);

Community-based activities: offered community-based programming tailored to linguistic and cultural needs of participants, including monthly and quarterly diabetes management classes; Somali Health series; patient advocacy; and Pura Vida programmes (ie, wellness and education programmes including exercise classes, local walks and runs, cooking and nutrition classes, etc); partnered with Northfield Hospital and Clinics to expand CP programme; collaborating with the Mayo Clinic and Allina Health System to extend model beyond NCDs (eg, ob/gyn care for Somali populations).