The Health-able Communities Program
- Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
- Intervention: With early federal grant-funding, a 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 health-related interventions to frontier area residents.
- Results: With additional private grant funding, success continued to build into the current model of an established and separate CHW division within the health system's population health department.
Evidence-level
Effective (About evidence-level criteria)Description
In a region some consider one of the Pacific Northwest's most geographically isolated areas, around 30,000 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 number of medical providers in the area.
In the early 2010s, local healthcare leaders were concerned these factors were linked to concerning county-level statistics around suicide, cancer deaths, and chronic diseases such as diabetes, hypertension, and obesity. With Federal Office of Rural Health Policy grant funding in 2015-2018 — the Rural Health Care Services Outreach Program — St. Mary's Hospital, a Critical Access Hospital (CAH) in Cottonwood, Idaho, and its associated facilities led a consortium of 9 partners to implement a Community Health Workers (CHWs) model for a project focusing on disease screening and health education for residents in these counties.
The project, originally referred to as the Health-Able Communities Program, combined three CHW models to create a singular hybrid CHW that addressed medical needs and the social determinants of health: Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings; the Centers for Disease Control and Prevention's (CDC) Addressing Chronic Disease through Community Health Workers; and information from a federally funded rural Community Health Workers Toolkit.
With the original federal support, 11 CHWs performed disease screenings, provided general health and wellness education, and led chronic disease self-management programs. Overseen by physicians and nurses, the CHWs were also part of some medical home teams. Referrals made by medical providers and community members resulted in assistance to residents located in even the most remote locations. An additional five-year philanthropic grant further tailored the CHW work.
Based on the value discovered with the grant-funded model, the central healthcare organizations have continued a modified CHW program. As of 2024, five CHWs are still employed by St. Mary's Health, Cottonwood, and Clearwater Valley Health, Orofino. Under the umbrella of their Department of Population Health, the CHWs are strategically located within the service area's geographic footprint. Standardized training is completed through Idaho State University, with additional health system community-focused training.
Services offered
As part of the Department of Population Health, the current CHW activities include:
- Organize community screening events and offer:
- Hemoglobin A1C testing for diabetes screening
- Body mass index (BMI) and blood pressure assessments
- Patient Health Questionnaire-2 (PHQ-2) screening
- Organize community education events, for example:
- Fall prevention: Physical therapists
- Anxiety management: Behavior health professionals
- End of Life themes: lawyers, hospice and palliative care specialists, funeral home representatives
- Insurance products: Insurance company representatives
- Chronic Disease Self-Management Program (CDSMP) education
- Social determinants of health (SDOH) screening
Current CHW work includes assistance with housing, transportation, and healthcare access, along with connecting with local healthcare providers. CHW collaboration with hospital staff occurs as needed.
Results
Original grant-funded results:
- Nearly 3,000 people were evaluated at over 100 events to reach approximately 10% of the population in the tri-county area
- Over 750 FIT tests performed, an activity which screened approximately 7% of the population eligible for colorectal cancer screening
- 49 participants with positive FIT tests were offered assistance with follow-up arrangements
Results as part of population health management current services:
A few of many positive outcomes from the current screening services and community outreach include:
- Increased trust between the community and the healthcare providers
- High impact on social isolation with attendance at education events
For more on this program, see these academic publications:
- McGrath, Kelly. Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream? Journal of General internal Medicine. Vol. 38, Suppl 1 (2023): 16-17.
- Tanumihardjo, Jacob P et al. New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 56-64.
- Sherman, Anne et al. Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 78-80.
- Sommers, Isaiah J et al. Trust Dynamics of Community Health Workers in Frontier Food Banks and Pantries: a Qualitative Study. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 18-24.
See also: Rural Community Health Worker Programs: Proving Value and Finding Sustainability. Rural Monitor, 24 Jul. 2024.
Challenges
Original challenges during early model implementation included CHW recruitment and retention challenges. However, as of 2024, this is no longer a challenge. Current challenges are reimbursement for services and funding for community outreach and engagement activities.
Contact Information
Cody Wilkinson MHA, Director of Population HealthSt. Mary's Health and Clearwater Valley Health
cody.wilkinson@kh.org
Topics
Access
Cancer
Cardiovascular disease
Chronic disease management
Community health workers
Diabetes
Frontier and remote areas
Health disparities
Health screening
Wellness, health promotion, and disease prevention
States served
Idaho
Date added
March 28, 2019
Date updated or reviewed
August 15, 2024
Suggested citation: Rural Health Information Hub, 2024. The Health-able Communities Program [online]. Rural Health Information Hub. Available at: https://www.ruralhealthinfo.org/project-examples/1054 [Accessed 11 October 2024]
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.