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.
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:
- 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:
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:
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 DirectorTri-County Health Network
970.708.7096
lynn@telluridefoundation.org
Topics
Cardiovascular disease
Care coordination
Community health workers
Diabetes
Wellness, health promotion, and disease prevention
States served
Colorado
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: https://www.ruralhealthinfo.org/project-examples/835 [Accessed 4 December 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.