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Rural Health Information Hub

Prevention through Care Navigation Outreach Program

  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.


Promising (About evidence-level criteria)


Tri-County Health Network logo Tri-County Health Network (TCHNetwork), along with 7 consortium members, created the Prevention through Care Navigation Outreach Program to reduce the prevalence of diabetes and cardiovascular disease (CVD) in a 4-county service region in rural southwestern Colorado.

Consortium members include Federally Qualified Health Centers, a mental health center, a nonprofit hospital, a rural health clinic, a community clinic, and a community foundation.

In this geographic area, rugged terrain, limited state highway systems, and a lack of public transportation challenge residents' access to healthcare. On the healthcare provider side, limited health literacy, rural social/cultural challenges, and an aging population also present challenges when serving residents.

The program overcomes these issues using a community-based support system provided by Community Health Workers (CHWs). CHWs conduct field-based, no-cost biometric screenings; assess and refer clients to needed services; provide peer support; and hold clients accountable for their daily health-related decisions. CHWs also provide evidence-based guidance to make healthy lifestyle changes. To further mitigate barriers related to travel and transportation, CHWs meet community members where they are: banks, churches, libraries, human services offices, clients' home.

The CHW program's core is the Colorado Heart Healthy Solutions (CHHS) model and includes multiple evidenced-based programs (below). CHHS is a statewide program that aims to prevent, detect, and control cardiovascular disease and diabetes, with CHWs helping clients to create individual action plans that foster a healthy lifestyle.

Relationships built with community businesses, local practitioners, community resource providers, and even restaurants help facilitate program goals. Partner clinic collaboration identifies noncompliant patients that may need CHW outreach for biometric testing.

Still operational, this program received original support from a 2012-2015 Federal Office of Rural Health Policy Rural Health Care Services Outreach grant. This program is also receiving support from a 2018 – 2021 Rural Health Care Services Outreach Program grant.

Services offered

All CHW services and classes are offered at no-cost to participants on a continual basis.

CHW activities use the following evidence-based programs:

  • Colorado Health Healthy Solutions
  • Cooking Matters: 6 week classes (bilingual offerings) providing education on healthy cooking with limited budgets
  • Diabetic Retinopathy Telescreening (DRT): CHWs with photography certification use special cameras to first photograph, then "store and forward" images for electronic consult technology. TCHNetwork offers this free service on a bi-annual basis at each partner clinic.
  • Rural Restaurant Healthy Options: Participating restaurants can create new, healthy menu items and offer healthier food prep options like grilled instead of fried chicken and half-sized portions. In return, partner restaurants receive free advertising and marketing through TCHNetwork.

New services as of 2018/2019 are:

Program activities also include:

  • Biometric health screening targeting underserved populations at-risk for developing diabetes, hypertension, and/or cardiovascular disease conducted throughout the community
  • Data collection and program evaluation tracking outcomes and impact

As of 2018/2019 the Chronic Disease Self-Management Program is no longer offered.


Results from current grant cycle 2018-2021 are pending and will be shared at grant's completion.

Accumulative data 2012 through 2018:

  • CHWs have now conducted a total of 4275 screenings
  • 2,709 individuals were screened for diabetes and/or cardiovascular disease (CVD) risks, with 51% identified as "at-risk"
  • 76.5% of diabetic patients maintained an A1C of less than 5.7
  • CHW engagement with 823 clients continued after first screening
  • Chronic disease registries by consortium partners are now tracking clinical outcomes for more than 1,422 diabetic patients and 5,120 CVD patients
  • CHWs continue to make referrals to community resources within four rural counties


Some challenges this program has faced include:

  • Limited CHW applicant pool, who must be from the rural community
  • Longer-than-anticipated CHW training time
  • Prolonged time to achieving community clinic provider and staff buy-in
  • Provider reluctance for referring to nonclinical staff and acceptance of biometric testing tool validity
  • Identification of rural medical and healthy living resources


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

  • Understand that clinical buy-in came after continued education and one and a half years of successful program activity
  • Focus on developing a trusting relationship between CHWs, medical professionals, and community resources
  • Hire culturally appropriate CHWs with established community trust
  • Explore external funding opportunities
  • Develop a strong referral system between local clinics and CHWs
  • Consider consortium member dues to help 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

Date updated or reviewed
May 2, 2020

Suggested citation: Rural Health Information Hub, 2020. Prevention through Care Navigation Outreach Program [online]. Rural Health Information Hub. Available at: [Accessed 19 April 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.