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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.

Promising Examples

funded by the Federal Office of Rural Health Policy 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.
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.

Other Project Examples

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration ASPIN's Certified Recovery Specialist Program
Updated/reviewed September 2022
  • 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 230 CHWs, cross-trained 70 behavioral health case managers as CHWs, and 35 individuals in the Indiana Navigator Pre-certification Education.
Rural Libraries and Health Cooperative Agreement
Added May 2022
  • 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's social worker program currently has 62 active clients, and another library screens an average of 215 residents a month.
Disabled Adults Oral Health Initiative
Updated/reviewed April 2022
  • 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.
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.
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.
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 results 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: 11/14/2022