Community Health Workers in Rural Settings – Models and Innovations

Effective Examples

Salud es Vida Cervical Cancer Education

Updated/reviewed January 2024

• Need: To deliver information about cervical cancer to rural Hispanic women 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 October 2023

• 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 2023, over 189,338 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Health Coaches for Hypertension Control

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.

Regional Oral Health Pathway

Updated/reviewed August 2023

• 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.

Promising Examples

Health without Borders

Updated/reviewed January 2024

• 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.

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

The Possibility Shop

Updated/reviewed January 2024

• Need: To connect vulnerable populations 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 2023, 8,684 service encounters occurred and 501 intakes to services were performed.

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