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Rural Health Information Hub

ARcare Aging Well Outreach Network

  • Need: To reduce falls and improve chronic care management for adults 50 or older in rural Cross County, Arkansas.
  • Intervention: The ARcare Aging Well Outreach Network, run by an FQHC, provided services like falls prevention assessments, transportation to appointments, medication management, and senior-specific exercise opportunities.
  • Results: From May 2015 to April 2018, the network served 639 patients through 1,580 medical encounters.


Promising (About evidence-level criteria)


Community needs assessments in rural Cross County, Arkansas, show that county residents 50 years old or older would benefit from falls prevention programs, medication management, chronic disease self-management education, and exercise opportunities designed for older adults.

The Federally Qualified Health Center (FQHC) ARcare ran the ARcare Aging Well Outreach Network, which worked to ensure that this population, especially those with chronic diseases, are able to improve their health and to age in place. The outreach network worked with ARcare's Longevity Center, a medical home that focuses on older patients' primary care needs. This center provides:

  • Case managers
  • Falls prevention assessment and planning
  • Geriatric specialist
  • Home health coordination
  • Medication reconciliation
  • Transportation to appointments and exercise opportunities
  • Wellness and fitness center

ARcare also works with the University of Arkansas for Medical Sciences to implement the Institute for Healthcare Improvement's 4Ms Framework: What Matters (to the patient), Medication, Mentation, and Mobility. Two educational webinars are held each month for providers and staff to attend.

Aging Well Network banner

The outreach network received funding from a 2015-2018 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant as well as private foundation money. There is no longer an official network, but former members continue to collaborate on projects and refer patients to one another's services.

Services offered

ARcare identified patients who would benefit from the Aging Well Outreach Network. This network provided:

  • Cooking classes
  • Chronic disease support groups
  • Exercise opportunities designed for older adults
  • Falls prevention assessment and education
  • Medication management
  • Nutrition education
  • Transportation
ARcare patient and treadmill
An ARcare staff member helps a patient with the treadmill at the fitness center.


From May 2015 to April 2018, the network served 639 patients through 1,580 medical encounters. Of these patients:

  • 335 improved their blood pressure rates
  • 256 were diagnosed with diabetes, 174 of whom improved their A1C levels
  • 280 received clinical pharmacy services, with 255 receiving changes to their medications as a result
  • 308 used the fitness center
  • 100% of these patients had a falls risk assessment each year

From May 2018 through December 2019, 514 patients were served. Of the 230 patients with a diabetes diagnosis, 43% improved their A1C levels. Of the 444 with a hypertension diagnosis, 189 had improved their blood pressure at the end of the tracking period.

ARcare has provided three community training events that focus on age-appropriate screenings, driver education safety for older adults, and the differences between Alzheimer's and dementia.

ARcare has expanded this model of care for the aging population to two other ARcare clinic sites in Arkansas and is in the process of expanding this model to ARcare clinics in western Kentucky. With this expansion, services have been added such as Medical Nutrition Therapy, mental health and substance use disorder services, diabetes prevention program, Transitional Care Management, and chronic care management services.

At the expansion sites, 686 patients were served. Of the 260 patients with a diabetes diagnosis, 97 patients improved their A1C levels. Of the 553 with a hypertension diagnosis, 257 patients had improved their blood pressure at the end of the tracking period.

In three longevity clinics, about 10 staff and 7 providers have completed Dementia-Friendly training, leading to these clinics being recognized by the Institute for Health Improvement as Dementia-Friendly clinics. In addition, implementing the 4Ms Framework has led to two clinics experiencing a 100% increase in the number of Medicare Annual Wellness Visits conducted, a 12% increase in Screenings for Future Falls assessments, and an 11% increase in Depression Screening.

The outreach network is also featured as a program model in RHIhub's Aging in Place Toolkit.


One challenge was securing patient buy-in. Patients were a little skeptical of the services at first, but once they learned about the different services and the opportunity for a longer appointment with their provider, they were on board.

Transportation is a barrier in this service area, as ARcare has only one van to reach patients. In 2019, ARcare started offering diabetes education and primary care services via telehealth to help alleviate these barriers.

Patient and ARcare staff
A patient poses with ARcare staff.


Gain community buy-in through community outreach (public relations) and collaborate with other local organizations to better provide resources to older adults.

Partner with specialty providers to host education sessions on specific aging health issues, and contract or collaborate with them to work in your clinic once a week or every other week to meet with patients who have these specific illnesses.

Since appointments are longer and more in-depth, providers might not see as many patients during the day. Remind them that a longer appointment allows them to treat the whole patient, not just one specific illness.

Contact Information

Carrie Fortune, Director of Grants Management

Aging and aging-related services
Chronic disease management
Elderly population
Federally Qualified Health Centers
Wellness, health promotion, and disease prevention

States served

Date added
February 23, 2018

Date updated or reviewed
March 31, 2021

Suggested citation: Rural Health Information Hub, 2021. ARcare Aging Well Outreach Network [online]. Rural Health Information Hub. Available at: [Accessed 7 February 2023]

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.