Prevention through Care Navigation Outreach Program

Evidence-level

Promising (About evidence-level criteria)

Description

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

Grant funding supported the evolution of the current programs with 2024 services including:

Behavioral Health

Care Coordination

• A care coordination team connects with those community members facing challenges to remain in their homes and provide assistance with accessing resources and multiple home-based programs.

School-based programs:

• Communities That Care
• Dental programs

Diversity, Equity & Inclusion (DEI) programs:

• Through work of a special multicultural advocacy team, the network provides offerings ranging from Immigrant Legal Services and Language Assistance programs to multicultural policy and advocacy community activities, along with multiple DEI-themed workshops

Prescription eyewear assistance

Eligibility and enrollment assistance:

• Health insurance
• Food security programs

Regional shuttle transportation assistance

Emergency Monetary Assistance

Results

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

Challenges

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

Replication

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
970.708.7096
lynn@telluridefoundation.org