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Rural Project Examples: Community health workers

Promising Examples

funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed November 2020
  • Need: To properly address and treat patients who have concurrent substance use and chronic healthcare issues.
  • Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.
funded by the Federal Office of Rural Health Policy Bridges to Health
Updated/reviewed October 2020
  • Need: To reduce barriers to accessing healthcare for immigrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce barriers to accessing healthcare on an individual level. The program offers targeted technical assistance to address systemic barriers at health access points in areas with high numbers of immigrant farmworkers.
  • Results: Some barriers to accessing healthcare have been reduced or removed for immigrant farmworkers in certain counties.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Updated/reviewed May 2020
  • 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.
SASH® (Support and Services at Home)
Updated/reviewed January 2020
  • Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, poses significant challenges for those who want to remain living independently at home.
  • Intervention: SASH® (Support and Services at Home), based in affordable housing communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
  • Results: Compared to their non-SASH peers, SASH participants have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, and fewer emergency room visits.
funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed December 2019
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.
funded by the Federal Office of Rural Health Policy The Health-able Communities Program
Added March 2019
  • Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
  • Intervention: Consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a diverse set of healthcare offerings to frontier area residents.
  • Results: Increased healthcare access, especially for cancer and chronic disease screening, along with providing education on a diverse array of health topics.

Other Project Examples

funded by the Federal Office of Rural Health Policy La Red Health Center
Updated/reviewed December 2020
  • Need: Meeting the health care needs of the uninsured and underinsured population of Sussex County, Delaware.
  • Intervention: La Red Health Center was created to offer culturally competent primary and preventative care to children and adults, regardless of ability to pay.
  • Results: La Red Health Center (LRHC) serves thousands of residents at four clinical sites, a school-based wellness center and through a collaborative effort with a local senior center.
Super-Utilizer Pilot Project
Updated/reviewed November 2020
  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker used technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.
funded by the Federal Office of Rural Health Policy NEON Pathways Community Hub
Updated/reviewed July 2020
  • Need: Connect individuals to services that address health barriers.
  • Intervention: A pay-for-outcomes model utilizing Community Health Workers who help provide community members with tools to address needs associated with improving health.
  • Results: Trained Community Health Workers help patients navigate the healthcare and social service systems and provide education about community healthcare resources.
Disabled Adults Oral Health Initiative
Updated/reviewed May 2020
  • Need: To help rural Maryland adults with disabilities learn more about oral health and access care.
  • Intervention: Health Right community health workers gave educational presentations at agencies serving those with disabilities.
  • Results: From March 2014 to February 2016, educational presentations reached 1,084 adults with disabilities and 344 staff and caregivers, and 256 people received dental treatment.