Patient Navigation and Service Delivery Strategies to Improve Healthcare Access

Other approaches and strategies for improving healthcare access to address rural social determinants of health (SDOH) focus on patient navigation and service delivery. Community health workers, patient navigators, and health extension agents can be used to improve healthcare access by helping individuals navigate the healthcare system and address barriers to care. Services integration, multigenerational approaches, and interdisciplinary care teams not only provide healthcare, but also provide services to address other SDOH.

Community Health Workers and Patient Navigators

Community health workers (CHWs) are non-clinical public health workers who are from and knowledgeable about the communities they serve. CHWs are often known by other names, such as community health advisors, lay health educators, or promotores de salud. CHWs can also serve as patient navigators, helping to connect individuals with healthcare services and decrease barriers to care. For more information about how CHWs can improve health and well-being in rural communities to address SDOH, see the Rural Community Health Workers Toolkit.

Health Extension Agents

Health extension is based on the approach used by the Cooperative Extension System to connect communities with healthcare services. It aims to improve health by leveraging the resources and knowledge of universities and other local organizations. Health extension agents, who are residents of the communities in which they work, can connect residents with services such as healthcare, education, and career opportunities. In rural New Mexico, Health Extension Rural Offices (HEROs) were developed to help residents navigate health services and connect them with care. HEROs are a promising approach to address SDOH and improve health for residents. HERO agents work to build community capacity and connect with different sectors to provide local communities with extension resources and services focused on improving health.

Services Integration and Multigenerational Approaches

Services integration programs deliver comprehensive health and human services. These programs can help address SDOH by increasing access to healthcare, connecting people with social services, and improving health outcomes. A multigenerational, or two-generation approach, is a type of services integration approach that focuses on addressing the needs of the entire family, often with the ultimate goal of reducing rates of poverty and improving the financial and employment outlooks of families. Programs using a two-generation approach typically focus on 5 key elements aligned with SDOH:

Postsecondary education and employment pathways
Early childhood education and development
Economic assets
Health and well-being
Social capital

For additional information about rural programs and models that use a services integration or multigenerational approach to address SDOH, see program models in the Rural Services Integration Toolkit.

Interdisciplinary Care Teams

Interdisciplinary care teams, also known as multidisciplinary care teams or community care teams (CCTs), are teams of healthcare providers that work to address multiple patient needs. The services offered to patients through interdisciplinary care teams might include:

Financial services
Transportation
Food and nutrition services
Housing
Care management
Social services

Additional information about patient navigation, care coordination, and community care team approaches to improve health and well-being to address SDOH can be found in the Rural Services Integration Toolkit.

Remote Access to Healthcare

In rural areas, people may need to travel long distances to access healthcare services. In addition, many rural communities lack public transportation systems, and some rural residents may not have access to their own vehicle. Telehealth applications and mobile health clinics are two promising approaches to overcoming the challenges of geography and transportation by delivering healthcare services to rural patients outside of a clinical setting. For more information about telehealth, mobile health approaches, and implementation of rural programs to address SDOH, see the Rural Telehealth Toolkit.

Examples of Rural Programs That Improve Access to Healthcare

The Community Caring Collaborative (CCC) collaborates with partner agencies and organizations in rural Maine to address SDOH by providing support to families to address health and social challenges to reduce health disparities. One CCC-incubated program using a two-generational approach is Family Futures Downeast (FFD). This program provides one year of post-secondary education to parents of young children, services to support workforce development, and transportation services and technology resources to remove employment barriers. FFD also links families with high-quality educational programming for their children.
The Community Outreach and Patient Empowerment (COPE) Training and Outreach program trains CHWs to serve residents in the Navajo Nation. Doctors, local trainers, and COPE staff develop and deliver trainings on topics including childhood obesity prevention, diabetes in pregnancy, and congestive heart failure. Navajo CHWs employed through COPE are known as Community Health Representatives (CHRs). CHRs are members of the community where they work, thus sharing many characteristics with community members, and have special certifications to practice in their community. Navajo CHRs partner with tribal leaders to provide tailored healthcare information to the community.
Generational Opportunities to Achieve Long-Term Success (GOALS) is a program using a two-generation approach to improve access to stable, quality housing in Arapahoe County, Colorado. GOALS is a short-term housing program for families with children that provides housing and wrap-around social services to improve economic stability. These services address the needs of the adult family members and the early development and educational needs of their children.
Kentucky Homeplace is a CHW program founded in 1994 to address health disparities in the Appalachian region of Eastern Kentucky. The program trains CHWs from the community to connect residents with services such as chronic disease self-management, reduced cost medications, help with enrolling in insurance programs, eye and dental exams, and care coordination, among others.
Perry County Transition 2 Hope is a nonprofit organization established to help those with housing insecurity in Perry County, Ohio. The organization has established a resource center, which provides support and services to those in need, distributes warm meals, and offers resources and referrals to other partner agencies. The organization plans to offer a warming center and transitional housing in the future.
The Chatham County Public Health Department in North Carolina worked with Chatham County Planning, the Chatham County Board of Health, and the Chatham Health Alliance to implement a Health in All Policies (HiAP) approach to updating the county's comprehensive plan. The final plan includes considerations for improving health through multiple sectors, including housing, neighborhood development, and transportation. Using this approach has enabled the county to address health priority needs through SDOH.
The Health-able Communities Program used CHWs to address healthcare needs and SDOH in remote and frontier areas of rural Idaho. This program, led by several organizations who partnered to address issues related to poor health outcomes and limited healthcare access in the region, used CHWs to provide direct healthcare services to residents and connect them with social services. The CHWs also worked on community improvement efforts, such as creating trails to increase walkability and physical activity.

Program Clearinghouse Examples

Resources to Learn More

Community-Clinical Linkages for the Prevention and Control of Chronic Diseases: A Practitioner's Guide
Document
Provides key considerations and action steps for public health practitioners looking to build relationships between communities and clinical sectors with the goal of preventing and controlling chronic diseases and improving population health.
Organization(s): Centers for Disease Control and Prevention
Date: 12/2016

Rural Spotlight: Creating Family Economic Security in Western Maryland
Document
Shares an example of a two-generation approach to address economic insecurity in rural Maryland.
Author(s): Dolkart, P.M.
Organization(s): Federal Reserve Bank of Richmond
Date: 9/2021