Office of Rural Health and Primary Care - aging services models

Successful Model for Rural and Underserved Communities

Community Health Workers and Heart Disease Quality Improvement

Target Population: This project targeted populations experiencing greater health disparities: urban American Indian population in Minneapolis and medically uninsured, underinsured and underserved residents of St. Paul.

Description:The Minnesota Department of Health Heart Disease and Stroke Prevention Unit and two federally qualified health centers—Native American Community Clinic and United Family Medicine—designed and implemented a pilot in which community health workers (CHW) helped patients manage their heart disease risk factors.

Background: During a three-year pilot, community health workers worked with patients to develop and/or adhere to their case management plan by addressing socio-economic or health systems barriers that inhibit successful chronic disease management. CHWs referred patients to and assisted with securing community resources.  In addition, they placed reminder phone calls about patients’ medical appointments.

Patient contact primarily occurred over the telephone; however, patients were also seen at the clinic and in their homes.  Enrollment in the initiative ranged from 0.3 to 35.5 months with a median length of enrollment of 15 months.  The CHW also referred patients to support agencies.  Patients received anywhere from 1-19 referrals.  Furthermore, 74 percent of the patients set self-management goals at some point during the duration of the program. 

The cardiovascular disease risk outcomes examined included: body mass index, blood pressure, LDL cholesterol, A1c and smoking status.  The overall changes from baseline were:

  • 10 percent moved to a more optimal BMI category
  • 32 percent improved their systolic or diastolic blood pressure level
  • 27 percent moved to a more optimal LDL cholesterol category
  • 19 percent improved their A1c level
  • The majority of patients remained in either the non-smoking or smoking category.

The community health workers at both clinics were integrated into the care management/clinical teams and they reinforced health messages from the providers.  They had more time than the provider to get to know the patients and their families; thus, gaining trust. They also met patients outside of the clinic, which led to an increase in calls to the CHW and a decrease in calls to the provider.

Challenges: Some patients were unsure of what to expect from the CHW and some clinic staff were unclear of the role of the CHW. Other challenges included setting boundaries with patients, working with limited resources to assist patients and getting referrals from clinic staff. In addition, the CHW position was physically and emotionally draining. Both clinics experienced turnover during the three-year period.

Plans for the Future:  One of the pilot clinics, United Family Medicine, had two of their existing staff go through the Community Health Worker certification program. The Minnesota Department of Health has been sharing the results of this pilot at various meetings and conferences (PDF: 406KB/2pgs).

Contact:Sueling Schardin, M.P.H., R.D., Community Health Planner, Minnesota Department of Health-Health Promotion & Chronic Disease/Heart Disease and Stroke Prevention Unit at or 651-201-4051.

A printable version of this model (PDF: 25KB/2pgs)

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Updated Tuesday, July 25, 2017 at 11:24AM