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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 Delta, Montrose, Ouray, and San Miguel counties.
  • Results: Over 1700 people were screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol levels and blood pressure 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 to 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 5 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.

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

Services offered

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

CHW activities use the 5 evidence-based programs:

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
  • 1,729 individuals were screened for diabetes and/or cardiovascular disease risks, with 906 individuals identified as “at-risk”
  • Primary care referrals for 906 new clients
  • CHW referrals for 870 at-risk individuals back to primary care for further evaluation by physicians
  • Continued CHW engagement with 505 clients after first screening
  • 72.8% of patients with diabetes have an A1c less than 8 and a 6.4% increase in number of patients whose blood pressure was less than 140/90
  • Chronic disease registries by consortium partners to accurately track clinical outcomes for more than 1,131 diabetic patients and 4,144 CVD patients
  • CHWs 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
January 23, 2018

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.