Table 2.

Linking Individual Needs to Community and Clinical Services (LINKS) Assessment Schedule

Assessment	Measures	Timing
Emotional Well-being Questionnaire	• Behavioral Risk Factor Surveillance System [42] • Short Form 8 Health Survey [43] • Social Support Inventory [44] • State Hope Scale [45] • Center for Epidemiologic Studies Depression Scale [46]	0, 3, 6 months
Social Determinant of Health Needs (CHW follow-up visits)	• Resources needed • Participant-driven utilization • Issues addressed and reflections on participant well being	0–6 months
Clinical Data Collection (Electronic Health Records)	• Glycosylated hemoglobin (HbA1c) • Body mass index (BMI) • Blood pressure • Blood lipid profile	-2 years; 3, 6 months; 1 year