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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

Salud es Vida Cervical Cancer Education
Updated/reviewed January 2021
  • 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.
funded by the Federal Office of Rural Health Policy Regional Oral Health Pathway
Updated/reviewed November 2020
  • 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.
Kentucky Homeplace
Updated/reviewed June 2020
  • 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 2019, over 166,464 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
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.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed May 2020
  • 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.
funded by the Federal Office of Rural Health Policy 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.
Hidalgo Medical Services – Family Support Program
Updated/reviewed June 2019
  • 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.
funded by the Federal Office of Rural Health Policy Madison Outreach and Services through Telehealth (MOST) Network
Updated/reviewed December 2018
  • 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.

Promising Examples

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration Health without Borders
Updated/reviewed December 2020
  • 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.
funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed November 2020
  • 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.
funded by the Federal Office of Rural Health Policy Bridges to Health
Updated/reviewed October 2020
  • Need: To reduce barriers to accessing healthcare for immigrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce barriers to accessing healthcare on an individual level. The program offers targeted technical assistance to address systemic barriers at health access points in areas with high numbers of immigrant farmworkers.
  • Results: Some barriers to accessing healthcare have been reduced or removed for immigrant farmworkers in certain counties.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
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.
funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed December 2019
  • 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.

Other Project Examples

funded by the Federal Office of Rural Health Policy La Red Health Center
Updated/reviewed December 2020
  • Need: Meeting the health care needs of 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
Updated/reviewed November 2020
  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker used technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.
funded by the Federal Office of Rural Health Policy NEON Pathways Community Hub
Updated/reviewed July 2020
  • 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.
Disabled Adults Oral Health Initiative
Updated/reviewed May 2020
  • Need: To help rural Maryland adults with disabilities learn more about oral health and access care.
  • Intervention: Health Right community health workers gave educational presentations at agencies serving those with disabilities.
  • Results: From March 2014 to February 2016, educational presentations reached 1,084 adults with disabilities and 344 staff and caregivers, and 256 people received dental treatment.
AmeriCorps Community Health Workers Program
Updated/reviewed December 2019
  • Need: Chronic diseases, diabetes, and opioid misuse has caused significant health disparities in Ohio and West Virginia.
  • Intervention: A program recruiting AmeriCorps members to serve as community health workers helps bring health services and education to local residents.
  • Results: As a result of the program, community members have reported weight loss, increased physical activity, reduction in medication, and improvements in self-management of chronic diseases.
funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration ASPIN's Certified Recovery Specialist Program
Updated/reviewed November 2019
  • Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's underserved rural counties.
  • Intervention: A network was established that trained community health workers (CHW) to be certified health insurance enrollment navigators and provide mental health services.
  • Results: This year, ASPIN trained 61 CHWs, cross-trained 37 behavioral health case managers as CHWs, and 26 individuals in the Indiana Navigator Pre-certification Education.
Taos First Steps Program
Updated/reviewed May 2019
  • 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 The Bridge Program
Updated/reviewed November 2018
  • 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.

Last Updated: 1/19/2021