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Rural Health Information Hub

Community Health Worker Model

In this model, community health workers (CHWs) support diabetes prevention and management programs by helping address individual- and community-level factors affecting diabetes care and outcomes. CHWs are also known as lay health advocates or promotores(as) de salud. CHWs help people in the community to adopt healthy behaviors, among other activities. They possess characteristics similar to the populations they serve. These characteristics include, for example, common language, ethnicity, socio-economic status, values, and experiences. Because of their similarities with the community, CHWs can develop trusting, one-on-one relationships with patients.

CHWs can support diabetes care in a variety of ways. Commonly, CHWs help patients with diabetes to improve their self-management skills and behaviors. CHWs can also help patients by:

  • Providing patient care
  • Supporting patient care delivered by other healthcare providers
  • Identifying and accessing community resources to meet clinical and lifestyle goals
  • Interpreting and translating clinical information
  • Providing care coordination
  • Providing culturally appropriate health education
  • Providing social support
  • Supporting diabetes self-management programs
  • Providing outreach and enrollment services
  • Providing home visiting services

The Community Preventive Services Task Force (CPSTF) recommends employing CHWs in programs for diabetes management and diabetes prevention. Interventions that engage CHWs have helped patients improve control of blood sugar (glucose) and lipids. Evidence also indicates these interventions are cost-effective.

For more information on how rural communities can use CHWs to improve health outcomes, see the Community Health Workers in Rural Settings topic guide.

To learn about opportunities and strategies for developing a rural CHW program, see the Community Health Worker Toolkit. The toolkit includes information on CHW program models, implementation considerations, sustainability strategies, and evaluation.

Examples of Rural Diabetes CHW Programs

  • The Brazos Valley Care Coordination Program was established to help patients in rural Texas access primary and follow-up care, with the goal of reducing preventable emergency department visits. CHWs worked closely with providers and patients with diabetes to coordinate care. CHWs provided assistance with scheduling, reminders, and coordinating transportation for appointments. They also connected patients to needed community resources and conducted home visits to provide diabetes education and other supports.
  • In eastern Kentucky, a CHW initiative called Kentucky Homeplace was established to help address the environmental factors that contribute to chronic diseases such as diabetes. The program trains CHWs to provide and coordinate health and social services, such as health information, referrals to agencies or providers, scheduling appointments, and coordinating transportation. The program also provides the Diabetes Self-Management Program and diabetes education.

Implementation Considerations

Rural communities seeking to implement a CHW model for diabetes care should ensure that CHWs work as part of a team. Successful programs integrate CHWs into an existing team and clarify their specific role within the team. Depending on the scope of the diabetes program and the role of the CHW, they may be paid or volunteer. For more information on implementing CHW programs, see Program Implementation in the Community Health Workers Toolkit.

Program Clearinghouse Examples

Resources to Learn More

Resources for Community Health Workers (CHWs)
Provides links to free resources to help CHWs support people with diabetes.
Organization(s): American Diabetes Association

Diabetes Initiative: Build a Program - Community Health Workers
An overview of how community health workers (CHWs) can support patients and assist providers in diabetes self-management programs. Includes links to program examples, presentations, and journal articles focused on CHWs and diabetes care and self-management.
Organization(s): Robert Wood Johnson Foundation