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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

funded by the Federal Office of Rural Health Policy Health Coaches for Hypertension Control
Updated/reviewed September 2018
  • 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.
funded by the Federal Office of Rural Health Policy Regional Oral Health Pathway
Updated/reviewed August 2018
  • Need: To address the oral health needs of low-income uninsured and underinsured residents in rural Appalachia.
  • Intervention: An oral health education program was implemented in Appalachian Maryland, Pennsylvania, and West Virginia.
  • Results: This program has increased oral health visits in the area and has provided residents with valuable information on oral health resources and services.
Hidalgo Medical Services – Family Support Program
Updated/reviewed June 2018
  • Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
  • Intervention: Community health workers work with clients to help them better manage their health and promote awareness of healthy lifestyle options in the community.
  • Results: Better health outcomes for patients.
Kentucky Homeplace
Updated/reviewed May 2018
  • 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 address the lifestyle choices, inadequate health insurance, and environmental factors that are believed to contribute to these diseases.
  • Results: From July 2001 to June 2016, over 152,262 rural residents have been served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
Salud es Vida Cervical Cancer Education
Updated/reviewed January 2018
  • Need: Hispanic women have the highest incidence rates of cervical cancer among any ethnicity in the United States.
  • Intervention: The development of a lay health worker (promotora) curriculum that provides information on cervical cancer, HPV, and the HPV vaccine to Hispanic farmworker women living in rural southern Georgia and South Carolina.
  • Results: Significant increases in post-test scores relating to cervical cancer knowledge and increases in positive self-efficacy among promotoras.
funded by the Federal Office of Rural Health Policy Madison Outreach and Services through Telehealth (MOST) Network
Updated/reviewed November 2017
  • Need: More mental health and substance abuse prevention and treatment services in rural Texas.
  • Intervention: A network was formed to bring counseling services through telehealth systems and community health workers to Brazos Valley, Texas.
  • Results: The program improved health outcomes, increased general knowledge of the impact of substance abuse, and raised awareness of services among Hispanic residents.
funded by the Federal Office of Rural Health Policy One Community Health's Wellness Programs
Updated/reviewed October 2017
  • Need: Difficulties obtaining healthcare access to treat diabetes and obesity for low-income and Spanish-speaking residents of Oregon and Washington's Columbia River Gorge area.
  • Intervention: A local healthcare facility developed wellness programs using bilingual community health workers to provide education and support that improves diets, physical activity, and teaches stress management.
  • Results: Many participants in the wellness programs have maintained or lost weight and have seen reductions in their cholesterol levels, blood pressure, and blood sugar levels. Vegetable vouchers, cooking classes, and budgeting education has also helped patients afford healthy food.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed June 2017
  • Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
  • Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
  • Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.

Promising Examples

funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed September 2018
  • 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 MI-Connect Community Health Worker Program
Updated/reviewed March 2018
  • Need: To improve healthcare access for rural Michigan residents managing chronic diseases.
  • Intervention: Community health workers (CHWs) were used to link chronically ill patients with the healthcare services in the Michigan counties of Alcona, Iosco, Arenac, Ogemaw, and Oscoda.
  • Results: This program has provided assistance to more than 400 individuals in the 5-county service area.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Updated/reviewed January 2018
  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers were utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: Over 1700 people were screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol levels and blood pressure after engaging with a Community Health Worker.
funded by the Federal Office of Rural Health Policy Heartland Rural Health Network
Updated/reviewed November 2017
  • Need: To assist diabetic patients in rural Florida with chronic disease management.
  • Intervention: Heartland Rural Health Network set out to expand the Diabetes Master Clinician Program and implement healthy eating in 4 Florida counties.
  • Results: Initial participating clinics exceeded national averages of successful management of diabetes. The program remains active and successful.
funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed October 2017
  • Need: To properly address and treat patients who have concurrent substance abuse and chronic healthcare issues.
  • Intervention: A referral system was created that utilizes Community Health Workers (CHWs) in a drug and alcohol treatment setting.
  • 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 September 2017
  • Need: To reduce barriers to accessing healthcare for migrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce the barriers to accessing healthcare and provides services and education.
  • Results: Some barriers to accessing healthcare have been reduced or removed for migrant farmworkers in certain counties in Vermont.

Other Project Examples

funded by the Federal Office of Rural Health Policy ASPIN Network's Community Health Worker Program
Updated/reviewed June 2018
  • Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana’s underserved rural counties by increasing access through health insurance enrollment and providing health literacy education.
  • Intervention: A network was established that dually trained community health workers (CHW) and certified health insurance enrollment navigators to aid in behavioral health and primary care services.
  • Results: This year, ASPIN trained 49 CHWs, cross-trained 191 behavioral health case managers as CHWs, and 175 individuals in the Indiana Navigator Precertification Education.
funded by the Federal Office of Rural Health Policy NEON Pathways Community Hub
Updated/reviewed June 2018
  • 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.
Taos First Steps Program
Updated/reviewed March 2018
  • Need: Support for families that promotes early childhood development and the parent-child relationship.
  • Intervention: Home visits which provide information, support, and access to early childhood resources and tools for building relationships.
  • Results: Easily replicable program, even for rural areas, that result in growth in knowledge and self-sufficiency for families as they provide for and understand their child's earliest years.
funded by the Federal Office of Rural Health Policy La Red Health Center
Updated/reviewed December 2017
  • Need: Meeting 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
Added November 2017
  • Need: To address patients' complex physical, behavioral, and social health needs in order to reduce unnecessary visits to the emergency department or inpatient admissions.
  • Intervention: A pilot project in rural Montana provides intensive outpatient care management to high-need and high-cost patients.
  • Results: With the program's first 27 patients, the healthcare team in Kalispell has saved more than $1.6 million in hospital costs.
funded by the Federal Office of Rural Health Policy The Bridge Program
Updated/reviewed November 2017
  • Need: Access to primary medical, dental, and mental health services for rural Appalachia Kentuckians.
  • Intervention: Community Health Workers provide outreach, education, navigation, and care coordination services to 5 counties in the Western Appalachian area of Kentucky through The Bridge Program.
  • Results: Emergency room visits have decreased throughout the course of the program and referrals to healthcare services have increased. Increases in self-efficacy and decreases in A1c levels have reached statistical significance.
NEON Community Health Worker Training Program
Updated/reviewed September 2017
  • Need: To train, equip and prepare Community Health Workers for certification to practice in Oregon’s rural settings
  • Intervention: Development of a 90-hour training program that requires an additional 80 hours of seat time, written summaries, and a final skills evaluation.
  • Results: With its original program, NEON trained 83 CHWs, with 38 currently registered with the state. Of those initially certified and registered, 8 are hospital or clinic-based, 8 are embedded in mental health organizations, 10 are in community-based organizations and 7 are in health departments or with the Department of Human Services.
AmeriCorps Community Health Workers Program
Updated/reviewed August 2017
  • Need: A significant number of people struggle with obesity, diabetes, and high blood pressure in the Mid-Ohio Valley of West Virginia, yet there was a limited number of health department staff available to address these issues.
  • Intervention: The Mid-Ohio Valley Health Department utilized AmeriCorps members to serve as community health workers, educating people on health topics in the areas in which they live.
  • Results: AmeriCorps members have motivated people to exercise, lose weight, and self-manage their chronic diseases, leading to healthier residents of the Mid-Ohio Valley.
funded by the Federal Office of Rural Health Policy Reach Out Program
Updated/reviewed January 2017
  • Need: Diabetes is the most common health problem in the African American, Latino, and Native American populations of rural Lake County, California.
  • Intervention: A Promotores/Community Health Workers model is used to teach positive lifestyle habits to people of all ages in order to live healthier lives, specifically to manage or prevent Type 2 diabetes.
  • Results: Participants in the Reach Out Program have improved their habits relating to nutrition and physical activity, leading to healthier lives.

Last Updated: 9/7/2018