Maine Medical Center
Flowers by Maine Medical Center

Community Engagement

The MaineHealth Preventive Medicine Enhancement for Maine (PrevME) program was established to improve health outcomes and prevent chronic disease by integrating public health best practices into clinical care across our health system. PrevME initiatives train physicians to help bridge the gap between public health programs and traditional, one-on-one, clinical care. PrevME has developed several programs to support and coordinate preventive medicine education and program development within the communities we serve.

Participants in the Leadership in Preventive Medicine Fellowship Program collaborate with PrevME as:

  • Public health educators
  • Clinical advisors
  • Learning session facilitators
  • Flexible emergency response
  • Participants in community engagement projects

For example, the pandemic had a disproportionate impact on Maine immigrant health conditions, health access, health equity and social determinants of health (SDoH). Our fellows quickly developed a translation of the scientific information about COVID-19 and mRNA vaccines and created both physician education and patient education materials to support greater equity in the dissemination of public health information during the pandemic.

The work is co-produced: Community representation in planning, implementation and review. Community health workers are leaders and stakeholders are advisors.

  • Co-production is the collaboration between service providers and service utilizers. Co-production increases the understanding of context, cultural competency, and health literacy. Per an Institute of Medicine (IOM) report: health equity means “providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”
  • Co-production creates partnerships that generate informed, meaningful exchange, which is necessary for behavior change and health improvement. This depends on trust and relationship and mutually respectful dialogue around health and lifestyles which enhances connection, credibility and self-management.

Be community based: Intervention occurs in the community where people eat, work, live and play

Be sustainable/generative/meaningful: Funding moves away from grants. Staff are salaried with benefits. Programs can respond to needs as identified by the community. Program momentum is self-generated

Use evidenced-based decision making in planning, implementation, management and revision: Implement data-informed practices and decision making.

Community Informed Care Initiative (CICI)

The PrevME CICI addresses gaps in health care delivery, access and care plan implementation experienced by non-English speaking and other disenfranchised communities in the greater Portland area. The approach of this initiative is innovative and unique.

The platform responds to community-identified needs related to health care access, connects disenfranchised communities to providers, and provides a network that connects care across disciplines. It also supports the transition of care from medical institutions to the community, allowing for appropriate care in the appropriate location.

This work supports the role of community health workers as members of community health teams while improving patient and provider satisfaction. We are partnering with community-based organizations that serve the immigrant community, community health care leaders, immigrant community leaders and members, as well as MMP/MMC/MaineHealth leadership, and health care providers involved in delivering care to these communities.

About our Community Health Workers (CHWs)

  • Our CHWs speak: English, Portuguese, Lingala, French, Swahili and Kikongo
  • General CHW role with individuals:
    • Culturally-appropriate health education and information
    • Care coordination, case management and health system navigation
    • Coaching and social support
    • Relate to community members as peers
    • Expertise in shared culture or life experience of the patient
    • Do not provide clinical care
  • CHWs support for the work of health care teams:
    • Outreach in community settings
    • Educate patients on lifestyle changes, medication adherence and treatment
    • Help patients navigate health care systems
    • Provide social support
    • Create community-clinical linkages
    • Track and support patient progress on care plan
    • Increase cultural competence of the care team
    • Support individual goal setting
  • CHWs support in screening for social determinants of health:
    • Administer screening tools
    • Connect patients to available resources
    • Document screening results/referrals
    • Follow-up with patients
  • CHWs are suited to deliver screening and clinical connections with their abilities to:
    • Relate to patients, understand their needs and build trust
    • Share awareness of community resources
  • How providers can refer patients:
    • EPIC - Send an in-basket message to pool number 10364, which is named MMP FMC Portland CICI CHW

Current CHWs 

  • Grace Lapika
    • Speaks English, Lingala, French, Swahili, and Kikongo
  • Maria Nianga
    • Speaks English, Portuguese, and Lingala

Community Stakeholder Group

The CICI has formed a community stakeholder group to foster trust and collaboration between communities and institutions. This advisory panel will help inform the development, implementation and revision of this CHW program. The workgroup will be comprised of MaineHealth leaders, community leaders, clinical leaders and CHWs.

The workgroup will advise on how to create a collaboration between clinical and community stakeholders to address SDoH using CHWs. This team includes individuals from community-based organizations, state leaders, health system employees and community health workers. The group generates alignment for health care goals and public health priorities and provides an opportunity to improve health through addressing SDoH.


Ask the Doc is a collaboration between the Maine Alliance Immigrant Network (MAIN), the Preventive Medicine Enhancement for Maine and the Preventive Medicine Fellowship Program that provides health information to an underserved population with limited access.

The Ask the Doc series is intended to fill the gap in available services by bringing the physician to the people. This unique direct access format where a physician answers questions the community has about a specific health topic is currently conducted via zoom, where members of different communities can log in via video or phone.

Each session is co-hosted by a member of MAIN, a community health worker, a translator and a physician. Members of the community who might otherwise not interact with medical providers are able to do so in a relaxed, open format setting with representatives from their community as facilitators. It allows people to engage with the medical community on issues that affect them daily, personally and materially.

Related Videos

With the goal of promoting health equity, effective communication and improved patient care for immigrant communities in Maine, Maine Medical Center’s Preventive Medicine Enhancement for Maine Program hosted a two-year Project ECHO series that was led by community health workers and others involved in immigrant health care in our state.

This series tapped into the wealth of knowledge that exists in the community to better understand the cultural barriers that impact patient care and experience. Presenters included community leaders from various community-based organizations, such as Main Access Immigrant Network (MAIN), Catholic Charities of Maine, Minority Health Program at City of Portland, Maine Immigration Rights Coalition, The New Mainer Public Health Initiative, Maine Community Integration, as well as statewide organizations such as Maine CDC and DHHS, Gateway Community Services, MaineHealth and Maine Medical Center. Participants learned from experts in the field, collaborated with community health workers, and developed long-term solutions to barriers to health.

Project Echo presentation schedule:




Case Presenters

September 2021

How Immigration as a social determinant of health and associated stress impacts health care

Inza Ouattara


November 2021

Access to Information: How gaps in information and other forms of access influence care and care plans

Heritier Nosso

Fowsia Musse, Maine Community Integration

December 2021

Social support and resources

Charles Mugabe


January 2022

System Literacy: How lack of familiarity with system affects care

Melissa Hue, Director of DEI, City of Lewiston

Mohammed Hassan, MAIN

February 2022

Cultural Competence and context

Nelida Berke, Minority Health Program Coordinator

Hibo Omer, NMPHI

March 2022

Food insecurity’s role in immigrant health

Mary Zwolinski, Wayside

Micky Bondo, In Her Presence

April 2022

Transportation barriers to health in immigrant populations

Zoe Miller

Gabriela Fuentes, PresenteMaine

May 2022

Barriers to mental health in immigrant populations

Krista Hall, LCSW, Gateway

Sanaa, MAIN

June 2022

The role of the CHW

Ben Hummel, ME CDC

Henoc Ngoy

October 2022

Immigrant status and associated stress: How immigration as a social determinant of health and associated stress impacts health care

Inza Ouattara, Ed.D, MPPM


November 2022

Language barriers: CHWs and medical interpreters

Malvina Gregory

Sara Jodi

December 2022

Collaboration and Community Oriented Primary Care

Katherine Gilbert

Marge Powers

January 2023

An Introduction to Pregnancy-Related Health Concerns affecting New Mainers

Nadi Nina Kaonga

Grace Lapika

February 2023

Early intervention

Cate Donatelli


Cate Donatelli

March 2023


Preventive health episode 1: vaccination

Peggy Akers

Sarah Lewis

Peggy Akers

Sarah Lewis

April 2023

Aging out of place

Sarah Elhassan

Grace Lapika

May 2023

Mental Health

Hibo Omar

Hibo Omar

June 2023

Preventive Care

Emily Follo

Christina Holt

Grace Lapika