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
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
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
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