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

Hidalgo Medical Services – Family Support Program
Updated/reviewed April 2023

• Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
• Intervention: Community health workers worked 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.

Salud es Vida Cervical Cancer Education
Updated/reviewed January 2023

• 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 provided 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.

Kentucky Homeplace
Updated/reviewed September 2022

• 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 2022, over 182,783 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Regional Oral Health Pathway
Updated/reviewed August 2022

• 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 increased oral health visits in the area and provided residents with valuable information on oral health resources and services.

Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed August 2022

• 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.

Community Health Worker-based Chronic Care Management Program
Added May 2020

• Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
• Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
• Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.

Health Coaches for Hypertension Control
Updated/reviewed December 2019

• 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.

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.

Promising Examples

Health without Borders
Updated/reviewed December 2022

• Need: To improve the health of communities in the south central region of New Mexico.
• Intervention: A program was developed to specifically 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.

Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed November 2022

• 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.

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