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Rural Health Information Hub
Rural Health Information Hub

Community Health Workers in Rural Settings – Models and Innovations

These stories feature model programs and successful rural projects that can serve as a source of ideas and provide lessons others have learned. Some of the projects or programs may no longer be active. Read about the criteria and evidence-base for programs included.

Effective Examples

Updated/reviewed October 2024

  • Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
  • Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
  • Results: From July 2001 to June 2024, over 196,801 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Updated/reviewed August 2024

  • Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
  • Intervention: A unique community health worker-based chronic care management program, created with philanthropy support.
  • Results: After a decade of use in attending to population health needs, health outcomes, healthcare costs, in 2024, the medical condition-agnostic model has a 4-year track record of financial sustainability with recent scaling to include 31 rural counties in a 3-state area of Appalachia and recent implementation in urban areas.
funded by the Federal Office of Rural Health Policy

Updated/reviewed September 2023

  • Need: A cost-effective approach to help rural patients with hypertension learn to manage their condition.
  • Intervention: Community volunteers trained as health coaches provided an 8-session hypertension management training program to hypertension patients older than 60, with an optional supplemental 8 sessions focused on nutrition and physical activity.
  • Results: Just 16 weeks after the program, participants had improved systolic blood pressure, weight, and fasting glucose, greater knowledge of hypertension, and improved self-reported behaviors.

Promising Examples

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration

Updated/reviewed January 2025

  • Need: To improve the health of communities in the south central region of New Mexico.
  • Intervention: A program was developed to address diabetes prevention and control, behavioral healthcare, and immunization in Luna County.
  • Results: During the program, 1,500 immunizations were distributed, baseline measurements of participants improved, and 935 new patients were seen for behavioral health issues.
funded by the Federal Office of Rural Health Policy

Updated/reviewed December 2024

  • Need: To properly address and treat patients who have concurrent substance use disorders 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

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.

Other Project Examples

Updated/reviewed March 2025

  • Need: To connect people in need in Allegany County, Maryland, to health and human services and to items like hygiene products, food, and clothing.
  • Intervention: The Possibility Shop partners with health organizations, insurance navigators, food banks, and other agencies.
  • Results: In 2024, 15,246 service encounters occurred and 940 intakes to services were performed.

Added December 2024

  • Need: To provide basic pregnancy-related and preventive health services to women in the Texas Rio Grande Valley.
  • Intervention: A mobile clinic travels to different communities and provides basic preventive care, contraception, and pregnancy testing and ultrasounds.
  • Results: Since the program began, clinical staff have provided services to nearly 6,000 women.
funded by the Federal Office of Rural Health Policy

Updated/reviewed October 2024

  • Need: To bring preventive care and other services to rural Missouri patients with chronic illnesses and difficulties accessing primary care.
  • Intervention: Community paramedics and community health workers make home visits and provide basic care, home assessments, and medication reconciliation and facilitate telehealth visits.
  • Results: Patients experienced improved access to care, health status, and compliance with medication regimens along with increased patient engagement, satisfaction, and access to community resources.

Updated/reviewed July 2024

  • Need: To increase access to healthcare and social services in rural South Carolina via library systems.
  • Intervention: Pilot sites are hiring social workers and community health workers to provide consultations, case management, and referrals.
  • Results: One library screens an average of 215 residents a month, and another library's programming reached over 800 female patrons.
Last Reviewed: 3/21/2025