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The Care Model Hospitals Can’t Ignore: Sinai Chicago’s Community Health Worker Playbook

The Care Model Hospitals Can’t Ignore: Sinai Chicago’s Community Health Worker Playbook

Kelly McCabe

Director, Community Health Interventions & Research
Sinai Urban Health Institute

Kelly McCabe joined SUHI in June 2020 and currently serves as Director of Community Health Interventions & Research, providing leadership for SUHI’s community health worker (CHW) interventions and research development, along with efforts to integrate and evaluate CHW interventions within Sinai Chicago (Sinai). She develops, designs, implements, and evaluates intervention research, focusing on integration into Sinai. As director, she leads grant writing and management, developing research and funding plans, data analysis, and dissemination activities. She serves on the DePaul University/SUHI Advisory Committee and leads Sinai’s inaugural CHW Steering Committee. Kelly has over 20 years of experience in health equity work, public health grant management, and community-based research. Her experience includes designing, implementing, and evaluating research programs aimed at addressing health inequities in underserved communities. She brings considerable epidemiological skills to her work in analyzing health data to develop impactful and practical strategies.

Kelly has advanced public health strategies in a variety of settings including field locations in developing countries, state and local governmental entities, academia, and currently at SUHI. Prior to joining SUHI, Kelly worked at the Department of Medicine at the University of Illinois at Chicago where she directed federally funded clinical research studies testing and implementing an HIV intervention for African American women and their teenage daughters. She served as Co-Investigator on a pilot research study to expand the intervention to a younger cohort and was a Sub-Investigator on a randomized control trial in South Africa.

Kelly also has experience working at the Cook County Department of Public Health and the Louisiana Office of Public Health Infectious Disease Epidemiology Section. She has conducted outbreak investigations, led emergency preparedness exercises, and analyzed large amounts of surveillance data to develop and evaluate programmatic initiatives and disseminate information to a broad audience.

Most notably, her Peace Corps experience in Paraguay was formative and motivated her to pursue a career rooted in community health.

The Care Model Hospitals Can’t Ignore: Sinai Chicago’s Community Health Worker Playbook

What if the most effective care model isn’t built inside the hospital at all?

This episode features the opening presentation from the recent Home Care Innovation Summit, a half-day virtual summit produced by Bright Spots Ventures in partnership with TytoCare, focused on how leading organizations are redesigning care to reach patients where they are.

Kelly McCabe, Director of Community Health Innovations, Sinai Chicago and the Sinai Urban Health Institute (SUHI) shares a practical, equity-driven model: clinically integrating community health workers (CHWs) into care delivery to bridge the gap between hospital, home, and community.

She’s joined briefly by Jeanette Avila, Manager of Community Health Innovations at SUHI offering a frontline perspective on what this model looks like in practice and how it builds trust with patients day-to-day.

Serving one of the most complex patient populations in the country, with roughly 90% uninsured or covered by Medicare/Medicaid, Sinai Chicago has built a model that doesn’t just acknowledge social needs, but operationalizes them. 

You’ll hear how Sinai Chicago:

  • Integrates community health workers directly into clinical teams, not as an add-on, but as core infrastructure
  • Extends care beyond hospital walls through home visits and community-based engagement
  • Tracks social determinants and community interactions to shape real-time interventions
  • Builds trust with patients in underserved neighborhoods through culturally aligned care
  • Uses a hybrid model of in-person outreach and centralized coordination to improve outcomes while reducing burnout 

Key topics covered:

  • Why community health workers are essential, not optional, for high-need populations
  • Turning social determinants from “insight” into actionable care interventions
  • How to operationalize a community-based care model inside a hospital system
  • The role of trust, proximity, and lived experience in improving engagement
  • Blending home-based care with clinical oversight to scale impact

If you’re a health system leader, population health executive, or payer/provider partner working to close equity gaps and deliver care beyond traditional settings, this is a real-world blueprint for making it work.

Kelly McCabe

Director, Community Health Interventions & Research
Sinai Urban Health Institute

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