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Prevention through Care Navigation Outreach Program

  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers were utilized to create a system of coordinated care in the counties of Montrose, Ouray, and San Miguel.
  • Results: 1,192 people were screened for diabetes and cardiovascular disease. As a result, many at-risk patients lowered their cholesterol levels and blood pressure through this program.
Promising (About evidence-level criteria)

Tri-County Health Network logo Tri-County Health Network, along with consortium members, created the Prevention through Care Navigation Outreach Program to reduce the prevalence of diabetes and cardiovascular disease (CVD) in rural southwestern Colorado. Consortium members consisted of two Federally Qualified Health Centers (FQHCs), a mental health center, a nonprofit hospital, a rural health clinic, a community clinic, and a community foundation. In this area, rugged terrain, limited state highway systems, and lack of public transportation make it a challenge for residents to access care. Limited health literacy, rural social/cultural challenges, and an aging population are also difficulties to serving residents in this rural region. This program was formed to create a system of support for clients trying to make healthy lifestyle changes. Community Health Workers (CHWs) were hired within the community to refer patients to the services they need, as well as to provide peer support and hold patients accountable for their daily healthcare decisions.

This program utilized 5 evidence-based models, including the Colorado Heart Healthy Solutions (CHHS) model. CHHS involves forming a network of CHWs who conduct outreach to underserved community members and provide health assessments, biometric testing, health education, coaching, referrals to local medical and health living resources, and ongoing support to at-risk individuals. Tri-County Health Network adapted this model to include the addition of a diabetic care management component. This program also featured Chronic Disease Self-Management Program (CDSMP) classes which provide individuals with peer support and assistance in navigating barriers to care. Attendees leave these classes with the necessary tools, peer support, and coping skills to continue with their own action plans to lead a healthier life. Tri-County Health Network offers these classes in English and Spanish, and they are facilitated by CHWs.

This program received support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant.

Services offered

Program activities included:

  • Providing biometric testing to screen underserved people at risk for developing diabetes and/or CVD
  • Offering individual peer support to manage lifestyle changes and improve overall health
  • Conducting the 6-week Stanford CDSMP classes throughout all three counties
  • Developing relationships with community businesses and local practitioners to establish an understanding of the program
  • Working collaboratively with partner clinics to engage noncompliant patients who have barriers to getting biometric testing within prescribed timeframes
  • Implementing a program evaluation to track outcomes and impact
  • 1,360 individuals were screened for risk of diabetes and/or cardiovascular disease (CVD)
  • Of those screened, 675 individuals were identified as at-risk
  • Of those identified as at-risk, 906 individuals had no knowledge of their risk prior to screening
  • CHWs referred 685 at-risk individuals back into primary care for further evaluation by physicians
  • 721 clients who did not have a primary care provider were referred to local clinics
  • 505 clients chose to remain engaged with a CHW after their first screening
  • CHWs established 124 community referral resources within three rural counties and referred 582 clients to these resources
  • A local health information exchange was created to transfer biometric test results
  • Consortium clinics developed chronic disease registries to accurately track clinical outcomes for more than 800 diabetic patients and 1,800 CVD patients
  • 12.3% increase in number of patients with a LDL less than 100 and a 6.1% increase in number of patients whose blood pressure was less than 140/90

Some challenges this program has faced include:

  • Limited applicant pool when hiring CHWs who must be from the rural community
  • CHWs required more training time than anticipated
  • Achieving clinician and staff buy-in with community clinics was a timely process
  • Doctors and clinical staff were reluctant to refer to nonclinical people
  • Doctors questioned the validity of the testing tool used by CHWs
  • Identifying medical and healthy living resources was a challenge in rural areas

In order to create a similar program, it is important to:

  • Know that clinical buy-in was achieved after continued education and one and a half years of successful program activity
  • Develop trusting relationships between CHWs, medical professionals, and community resources
  • Hire CHWs that are culturally appropriate and trusted in their community
  • Look into external funding opportunities
  • Develop a strong referral system between local clinics and CHWs
  • Consider consortium member dues, as they have the potential to off-set program costs
Contact Information
Lynn Borup, Executive Director
Tri-County Health Network
Cardiovascular disease
Care coordination
Community health workers
Wellness, health promotion, and disease prevention
States served
Date added
October 6, 2015

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.