The Health-able Communities Program

Evidence-level

Promising (About evidence-level criteria)

Description

In a region some consider one of the Pacific Northwest's most geographically isolated areas, around 30,000 people reside in frontier Idaho's Clearwater, Idaho, and Lewis counties. Here, healthcare access is limited not just by distance and transportation barriers, but by the number of medical providers in the area.

In the early 2010s, local healthcare leaders were concerned these factors were linked to concerning county-level statistics around suicide, cancer deaths, and chronic diseases such as diabetes, hypertension, and obesity. With Federal Office of Rural Health Policy grant funding in 2015-2018 — the Rural Health Care Services Outreach Program" — St. Mary's Hospital, a Critical Access Hospital (CAH) in Cottonwood, Idaho, and its associated facilities led a consortium of 9 partners to implement a Community Health Workers (CHWs) model for a project focusing on disease screening and health education for residents in these counties.

The project, originally referred to as the Health-Able Communities Program, combined three CHW models to create a singular hybrid CHW that addressed medical needs and the social determinants of health: Best Practice Guidelines for Implementing and Evaluating Community Health Worker Programs in Health Care Settings; the Centers for Disease Control and Prevention's (CDC) Addressing Chronic Disease through Community Health Workers; and information from a federally funded rural Community Health Workers Toolkit.

With the original federal support, 11 CHWs performed disease screenings, provided general health and wellness education, and led chronic disease self-management programs. Overseen by physicians and nurses, the CHWs were also part of some medical home teams. Referrals made by medical providers and community members resulted in assistance to residents located in even the most remote locations. An additional five-year philanthropic grant further tailored the CHW work.

Based on the value discovered with the grant-funded model, the central healthcare organizations have continued a modified CHW program. As of 2024, five CHWs are still employed by St. Mary's Health, Cottonwood, and Clearwater Valley Health, Orofino. Under the umbrella of their Department of Population Health, the CHWs are strategically located within the service area's geographic footprint. Standardized training is completed through Idaho State University, with additional health system community-focused training.

Services offered

As part of the Department of Population Health, the current CHW activities include:

• Organize community screening events and offer:
  • Hemoglobin A1C testing for diabetes screening
  • Body mass index (BMI) and blood pressure assessments
  • Patient Health Questionnaire-2 (PHQ-2) screening
  • Organize community education events, for example:
  • Fall prevention: Physical therapists
  • Anxiety management: Behavior health professionals
  • End of Life themes: lawyers, hospice and palliative care specialists, funeral home representatives
  • Insurance products: Insurance company representatives
  • Chronic Disease Self-Management Program (CDSMP) education
• Social determinants of health (SDOH) screening

Current CHW work includes assistance with housing, transportation, and healthcare access, along with connecting with local healthcare providers. CHW collaboration with hospital staff occurs as needed.

Results

Original grant-funded results:

• Nearly 3,000 people were evaluated at over 100 events to reach approximately 10% of the population in the tri-county area
• Over 750 FIT tests performed, an activity which screened approximately 7% of the population eligible for colorectal cancer screening
• 49 participants with positive FIT tests were offered assistance with follow-up arrangements

Results as part of population health management current services:

A few of many positive outcomes from the current screening services and community outreach include:

• Increased trust between the community and the healthcare providers
• High impact on social isolation with attendance at education events

For more on this program, see these academic publications:

• McGrath, Kelly. Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream? Journal of General internal Medicine. Vol. 38, Suppl 1 (2023): 16-17.
• Tanumihardjo, Jacob P et al. New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 56-64.
• Sherman, Anne et al. Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 78-80.
• Sommers, Isaiah J et al. Trust Dynamics of Community Health Workers in Frontier Food Banks and Pantries: a Qualitative Study. Journal of General Internal Medicine. Vol. 38, Suppl 1 (2023): 18-24.

Challenges

Original challenges during early model implementation included CHW recruitment and retention challenges. However, as of 2024, this is no longer a challenge. Current challenges are reimbursement for services and funding for community outreach and engagement activities.

Contact Information

Cody Wilkinson MHA, Director of Population Health
St. Mary's Health and Clearwater Valley Health
cody.wilkinson@kh.org