Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
Intervention: Consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a diverse set of healthcare offerings to frontier area residents.
Results: Increased healthcare access, especially for cancer and chronic disease screening, along with providing education on a diverse array of health topics.
In a region some consider one of the Pacific Northwest's
most geographically isolated areas, 28,000 people reside
in frontier Idaho's Clearwater, Idaho, and Lewis
counties. Here, healthcare access is limited not just by
distance and transportation barriers, but by the limited
number of medical providers practicing in the area. These
factors likely contribute to startling county-level
statistics associated with suicide, cancer, and chronic
diseases such as diabetes, hypertension, and obesity. St.
Mary's Hospital, a Critical Access Hospital (CAH) in
Cottonwood, Idaho, and its associated facilities led a
consortium of 9 partners in a project offering health
education and disease screening for residents in these
The project, the Health-Able Communities Program,
leveraged a specially-trained professional force of
Community Health Workers (CHWs). The consortium
leaders pooled different components of several well-known
evidence-based CHW models to create a hybrid CHW role for
addressing the area's specific medical needs and related
needs linked to the social determinants of health.
Eleven CHWs performed disease screenings, provided
general health and wellness education, and led chronic
disease self-management programs. Their modified roles
allowed them to receive referrals from medical providers
and community members in order to offer assistance to
residents in even the most remote locations. CHWs were
overseen by physicians and nurses. They were also part of
some medical home teams.
In addition to the St. Mary's team, the project's
consortium members included:
2 additional CAHs – Clearwater Valley
Hospital and Clinics, Syringa Hospital
2 health services agencies – Grangeville's
and Clearwater's Human Needs Councils
Public health department – Idaho North
Central Health District
Indian Health Service clinic – Nimiipuu
Free urban clinic – Snake River Community
Tertiary care center –
St. Alphonsus Regional Medical Center
St. Alphonsus Regional Medical Center provided education
on mental health topics. The councils provided other
resources and the public health department assisted with
The project's data tracking was accomplished with
system that allowed surveys as well as some data
analysis. All partners worked together to develop a
5-year strategic plan for program sustainability.
Federal Office of Rural Health
Policy's Community Health Workers Evidence-based Models
Toolbox, current version available online as the Community Health Workers Toolkit.
Consortium members have been invited as presenters to
multiple state and national gatherings and conferences.
CHW recruitment/retention and need for continual
Unanticipated costs for:
Mobile hemoglobin A1C monitors that required more
expensive reagents/testing kits than hospital
High number of individuals qualifying for
Hemoglobin A1C test performance time interval
This test performance time necessitated
additional CHW personnel at screening events in order
to keep waiting participants engaged
Unanticipated travel expenses required to cover
geographic footprint of service area
Tracking extensive data categories associated with
Inclusive recruitment of an area's healthcare
organizations and related community agencies will provide
the broadest outreach and services to meet a specific
Identify the correct data-tracking system for CHW
work, for example, REDCap.
Develop team leadership skills for CHWs.
Shari Kuther, RN, Director of Population Health
St. Mary's Clearwater Valley Hospital and Clinics
Chronic disease management
Community health workers
Frontier and remote areas
Wellness, health promotion, and disease prevention
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.