Field-Based Outreach Workers Facilitate Access to Health Care and Social Services for Underserved Individuals in Rural Areas

Service Delivery Innovation Profile

Field-Based Outreach Workers Facilitate Access to Health Care and Social Services for Underserved Individuals in Rural Areas



Rural and Urban Access to Health is an integrated network of field-based workers that connects vulnerable populations, including Hispanic migrant workers and immigrants, to health, human, and social services in eight largely rural counties in central Indiana. The program facilitates health care access and provides care coordination, outreach and education, medical interpreting, and translations of vital documents. The program has enhanced access to medical services and free or reduced-cost prescription drugs for a population that would otherwise be unable to access these services.

Evidence Rating

Suggestive: The evidence consists of post-implementation data on the volume of services provided to clients.

Developing Organizations

St. Vincent Health

Indianapolis, IN

Rural and Urban Access to Health is a collaboration of eight of St. Vincent Health's hospitals, four of which were involved in the development stage. St. Vincent Health instigated the initial meetings and is currently responsible for spearheading program strategy and organization.

Information provided in January 2014 indicates that Rural and Urban Access to Health is now under St. Vincent Medical Group.

Date First Implemented


Problem Addressed

Compared with urban and suburban dwellers, individuals living in rural areas have fewer health care resources and less access to preventive services and are more likely to be poor, have chronic health conditions, and be in fair or poor health. Individuals of low socioeconomic status living in urban areas have similar barriers to access. Disparities are even greater for certain racial and ethnic groups, such as Hispanic populations.

  • Barriers to access among rural and urban poor: Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.
  • Leading to higher risks: Individuals living in rural areas are more likely to be poot ; poor or near-poor individuals are more likely to have chronic health conditions and to experience periods of time during which they are uninsured. Individuals studied as part of the HOPE IV project, a government-funded study of the problems faced by urban populations, were found to be roughly twice as likely as their nonurban peers to suffer serious conditions, including arthritis, asthma, depression, diabetes, hypertension, and stroke. Poverty, lack of health insurance, inadequate access to preventive care, and language/cultural barriers are associated with poor health outcomes among Hispanics.

Patient Population

The patient population also includes Medicaid and dually eligible (Medicare and Medicaid) populations.

Description of the Innovative Activity

Rural and Urban Access to Health is a collaborative program that provides safety net services for the growing at-risk population, including Hispanic migrant workers and immigrants, in nine counties in central Indiana. Sponsored by eight hospitals (six in rural areas and two in rural/urban areas) and St. Vincent Medical Group, the program employs field-based workers to coordinate and integrate care, provide outreach and education, and facilitate access to health care and prescription drugs. The program also trains individuals to serve as interpreters and translates educational materials to facilitate clients' health care knowledge and access. Key elements of the program include the following:

  • Field-based workers: Field-based health access workers, medication access coordinators, and volunteers, all of whom are residents of the communities they serve, assess the needs of vulnerable individuals (focusing on those with incomes below 200 percent of the Federal poverty level) in the nine-county service area.
  • Client identification: Health access workers identify individuals in need by visiting community locations that are frequented by potential clients, such as community centers, retirement centers, clinics, and even laundromats. Health access workers may hold scheduled meetings or information sessions or may simply spend time in these locations to connect with potential clients. Often, clients proactively approach the health access workers to ask for assistance; providers, agencies, and existing clients also refer new clients to the program.
  • Arrangement of services: Health access workers complete a Pathways Navigational Tool on each referred client. Based on client needs identified, they then educate clients, using Education Checklists, about available health care resources and help them enroll in public or private sector assistance programs for which they are eligible. Health Access Workers use the Pathway's Model to work with each client. Information provided in January 2014 indicates that pathways currently include Enrollment, Medical Home, Medical Referral, Pregnancy, Social Services, and Diabetes.
  • Access to free or low-cost prescription drugs: The primary role of the medication access coordinator is to arrange for clients to access needed medications. Physicians, nurses, health access workers, social workers, and other community members refer clients to the medication access coordinators. The coordinators identify programs that can help clients by using the RxAssist Plus electronic system, an Internet-based prescription assistance program that summarizes all available prescription access programs provided by pharmaceutical companies, and then applying for those programs on behalf of their clients. Medication access coordinators may also contact community agencies and the local Veterans Administration office to inquire about potential support.
  • Ongoing client support: Health access workers meet with their clients on an ongoing basis to ensure that they are receiving needed services, taking their medications, keeping their medical appointments, and asking if they need additional wrap-around services.
  • Coordination of care: Using a Web-based data collection system (called “eCAP”) accessible through their laptop computers, health access workers coordinate and track clients' ongoing use of medical care and services from local health clinics and other safety net providers. The system also allows health access workers to input their clients' demographic and medical information. eCAP has also been adapted to support the Pathways Model, a community care coordination outcome-based measurement system.
  • 24-hour interpreter services: “Bridging the Gap” (licensed through the Cross Cultural Health Care Program; ) is the training mechanism for medical interpreters. Interpreters can help health access workers, medication access coordinators, health care providers, and others communicate clearly with their non–English-speaking clients. As of January 2014, 1,602 medical interpreters have been trained; interpreter agencies provide additional capacity. Interpreters are available 24 hours a day, 7 days a week, to provide services in person at participating hospitals or by telephone.
  • Health equity: In an effort to facilitate communication with non–English-speaking clients, the program has formed an interdisciplinary health equity team in each participating hospital. Nurses, social workers, environmental service workers, chief executive officers, other hospital leaders, and representatives of the departments of quality and finance serve on these teams. These teams take the lead on a number of access-related activities, including ensuring that core hospital documents and signs are translated so clients can understand them.
  • Community roundtables: Community roundtables serve the local area and help health access workers solve both general problems and issues related to specific cases. Roundtables include representatives from the school board, police department, fire department, church federation, Salvation Army, local hospital, free clinics, or social service agencies.

Context of the Innovation

St. Vincent Health is a member of Ascension Health, the nation's largest not-for-profit Catholic health care system, and is Indiana's largest health care employer, with 20 hospitals serving more than 47 counties. Representatives of St. Vincent Health recognized that access and outreach were major concerns in its service areas' many rural communities. Approximately one-third of the population comprised individuals and families living at or below 200 percent of the Federal poverty level, and an estimated 75 percent of this population did not have access to health care services. A secondary concern was the large Hispanic population, many of whom did not have health insurance, given that they work in small businesses or serve as migrant field workers in Indiana for only 6 months of the year.


Rural and Urban Access to Health has enhanced access to care for thousands of at-risk, low-income individuals, including Hispanic migrant workers and immigrants. As reported in January 2014, between November 2002 and December 2013, the program achieved the following results:

  • Improved access to needed services:
    • High number of client encounters and connections: Between November 2002 and September 2011, the program had more than 43,000 client encounters with 78,000 connections to care. Those referrals include public program enrollment; making appointments with primary care physicians; and making referrals to physicians and local health, human services, and social services agencies.
    • Recent fiscal year data on Pathways ® completion: Information provided in January 2014 indicates that, as of September 2011, the program is using Pathways to track the number of Pathways opened, pending, and completed quarterly for each of its six Pathways (Diabetes, Enrollment, Medical Home, Medical Referral, Pregnancy, and Social Services). Half-way through the fiscal year ending June 30, 2014, the number of Pathways completed for clients totaled 3, 560, 156, 101, 8, and 1,331 respectively. (Note: Clients may have multiple Pathways. Additionally, for a Pathway to be “completed,” measurable goals must be achieved; for example, for Pregnancy Pathway completion, the baby must be viable and weigh at least 2,500 grams at birth.)
  • Enhanced access to free or low-cost drugs: The program has facilitated the distribution of $51.5 million worth of free or reduced-cost prescription drugs as of December 2013.
  • Development of bilingual hospital documents and signs: As of December 2013, more than 1,151 core hospital documents have been translated from English into Spanish, as have key hospital signs.
  • Many interpreters trained: As of December 2013, more than 1,602 interpreters have been trained since program inception.

Evidence Rating

Suggestive: The evidence consists of post-implementation data on the volume of services provided to clients.

Planning and Development Process

The planning and development process included the following:

  • Creating a collaborative: In 2000, representatives of St. Vincent Health met with the St. Vincent hospitals, community-based organizations, and the public at large in four central Indiana counties to discuss the most effective ways to help the community. Based on general interest in access issues, St. Vincent Health initiated the development of Rural and Urban Access to Health in four hospitals; four additional St. Vincent Health hospitals joined the program in 2006.
  • Securing initial grant funding: The program applied for funding from the Healthy Communities Access Program and received a 4-year grant in 2001.
  • Conducting an (informal) needs assessment: The four founding hospitals researched access issues in their service areas, all of which had a significant growing population of Hispanic residents and a high number of residents living at or below 200 percent of the Federal poverty level. As part of this needs assessment, the program began hosting community meetings to determine what services were provided, where gaps in care existed, and which community organizations might be interested in partnering.
  • Forming a partnership: St. Vincent Health formed a partnership with Indiana Health Centers; ADVANTAGE Health Solutions, Inc.; Health and Hospital Corporation of Marion County; and the Butler University College of Pharmacy and Health Sciences. These organizations helped fund or provide services as part of the Healthy Communities Access Program grant; they also contributed in-kind assistance in the form of staffing, services, and supplies. (The program still works loosely with these organizations even though the grant has ended.)
  • Creating a staffing design: The program created a staffing design centered on community-based health access workers who would develop relationships with relevant agencies to address access problems. Health access workers do not require a specified educational degree and come from a variety of professional and nonprofessional backgrounds.
  • Training health access workers: New health access workers receive 2 weeks of training regarding access issues and solutions and then continue their training by shadowing experienced health access workers. Information provided in November 2011 indicates that a training manual has also been developed.
  • Contracting with software vendor: The program assessed different prescription assistance software programs and ultimately contracted with a vendor.
  • Forming community roundtables: In each area, a community roundtable was developed to address local needs and assist health access workers as needed.
  • Developing a management information system: The St. Vincent informatics department developed a data tracking application that captures the program's clients' demographic and referral data, public and private program enrollment data, and chronic disease assessment tracking data.
  • Developing resource lists: These lists were initially developed based on local resource books and directories and were expanded over time based on the experiences of health access workers.
  • Building payer relationships: Program representatives worked with insurance companies to determine coverage options for their clients. The program is currently working with the Healthy Indiana Plan to facilitate enrollment of clients.
  • Adopting the Pathways model: The program has adopted the community care coordination outcome measure model Pathways, which uses community health workers to connect at-risk individuals to care via the use of a “pathway” of action steps designed to produce healthy outcomes. The program held a kickoff stakeholder meeting in June 2009. Information provided in January 2014 indicates that there are currently six pathways being tracked: Diabetes, Enrollment, Medical Home, Medical Referral, Pregnancy, and Social Services.
  • Participation in a study: The program participated in a National Institutes of Health study regarding community-based care coordination.

Resources Used and Skills Needed

  • Staffing: Information provided in January 2014 indicates that staffing includes a system director, a manager for all access workers and medication coordinators, an operations manager, language access workers (who organize all of the training, assessment, and process improvement initiatives), 10 health access workers, 4.5 medication access coordinators, and an unspecified but large number of volunteers.
  • Costs: The cost of running the program is estimated at $1.1 million annually; costs include salaries and an annual fee of $13,800 for the prescription assistance software.

Funding Sources

Rural and Urban Access to Health was initially funded through a 4-year grant from the Healthy Communities Access Program, which ran from 2001 to 2005. Ascension Health provided matching funds, bringing total funding during this period to approximately $2 million. Since grant funding ended, St. Vincent Medical Group has taken over financial responsibility for the program through its local health care ministries. Each participating hospital and physician office is responsible for paying access workers.

Tools and Resources

More information on the Culturally and Linguistically Appropriate Services standards is available at the following Web site:

Information on how to access the new Joint Commission standards is available at (Added November 2011.)

The following manual related to implementation and evaluation of community care coordination programs and the Pathways model is available through the following link: Pathways: Building a Community Outcome Production Model

Watch related video from the Frontline Innovators series.

Getting Started with This Innovation

  • Carefully consider the commitment before embarking on this initiative: If organizational commitment to the initiative is questionable, organizational relationships may be harmed and trust with community residents will be lost.
  • Collaborate with hospital leaders to gain their support: Hospital leaders may not fully understand the work of the project, because it does not fit into an acute care paradigm. Educating them on the program's merits is critical because their support is vital to long-term success.
  • Develop an accountability and sustainability plan: Having a long-term plan from the outset helps overcome skepticism about the program's sustainability once outside funding is no longer available.
  • Meet with local payers to understand their views on reimbursement: If a site wants to pursue a waiver or receive third-party payment for services offered, it is important that the parent organization understand the process for obtaining these funds, including who needs to be involved and the required timeframe. This process can be time consuming, so start early, make all intentions clear, and find ways to prove that there will be a return on investment. Understanding this process becomes especially important in the absence of grant funding or once initial grant funding ends.

Sustaining This Innovation

  • Build and sustain strong community coalitions: Coalitions comprising various organizations are essential to both the launch and ongoing sustainability of this type of community outreach program.
  • Do not rely on formal (published) lists of resources: Published lists are likely to be incomplete and need to be supplemented through informal discussions and ongoing interactions with community organizations.
  • Be patient and flexible: Building community collaboratives takes a long time. Understand that building relationships can be tough, but maintain a long-term commitment to working through problems as they arise. Expect and acknowledge changes in leadership and the overall vision of the program. Be prepared to renegotiate roles on an ongoing basis.
  • Ensure that health access workers are committed to the clients they serve: Health access workers should “have a heart” for this population and truly like and want to help these clients. Clients will not feel comfortable receiving services from workers with negative or disdainful attitudes. A clinical background is not required; rather, health access worker success is contingent on communication and relationship-building skills and style.
  • Ensure support for health access workers in the field: Local community groups should be asked to participate in roundtables so that health access workers have access to individuals who can offer advice when needed.
  • Keep an eye to results: Tie program efforts to outcomes, making sure that financial and operational outcomes are included in evaluations. See the Tools and Other Resources section for links to manuals that can provide further information on how to evaluate community care coordination models.

Spreading This Innovation

Information provided in November 2011 indicates that Rural and Urban Access to Health worked with the St. Mary's Health System in Evansville, IN to initiate many of the key components of this work. This startup funding came as a result of receiving the state's only Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA or Public Law 111-3) grant.

In addition, information provided in January 2014 indicates that Rural and Urban Access to Health has placed a health access worker in a physician office in Hamilton County, IN; this office is part of St. Vincent Medical Group.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Sherry E. Gray, MA
Project Director
Raphael Health Center
401 East 34th Street
Indianapolis, IN 46205
Phone: (317) 860-3962

Nicole D. Kowalski
Health Access Manager
Rural and Urban Access to Health (RUAH)
St. Vincent
8424 Naab Road, Building 1, Ste. 1A
Indianapolis, IN 46260
Phone: (317) 338-8675

Innovator Disclosures

Ms. Gray and Ms. Kowalski have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Health Insurance for Indiana Families Committee. Safety Net Assessment 2004. Available at:


  1. Agency for Healthcare Research and Quality. 2008 National Healthcare Disparities Report. AHRQ Publication, no. 09-0002. Rockville, MD: U.S. Dept. of Health and Human Service, Agency for Healthcare Research and Quality; 2009. Available at:

  2. Probst JC, Samuels ME, Jespersen KP, et al. Minorities in Rural America: An Overview of Population Characteristics . Columbia, SC: South Carolina Rural Health Research Center, Dept. of Health Administration, Norman J. Arnold School of Public Health, University of South Carolina; 2002. Available at:

  3. van Dis J. MSJAMA. Where we live: health care in rural vs urban America. JAMA. 2002 Jan 2;287(1):108. [PubMed]

  4. National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the Health of Americans . DHHS publication, no. 2007-1232. Hyattsville, MD: Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2007. Available at:

  5. Kiefe CI, Hyman DJ. Do public clinic systems provide health care access for the urban poor? A cross-sectional survey. J Community Health. 1996;21(1):61-70. [PubMed]

  6. Manjarrez C, Popkin SJ, Guernsey E, et al. Poor health: adding insult to injury for HOPE VI families. The Urban Institute; 2007. Available at:

  7. Wallace SP, Gutiérrez VF, Casta & ntilde;eda X. Health policy fact sheet. Health service disparities among Mexican immigrants. UCLA Center for Health Policy Research and California-Mexico Health Initiative; 2005. Available at:

Funding Sources

St. Vincent Health


St. Vincent Health

Indianapolis, IN

Rural and Urban Access to Health is a collaboration of eight of St. Vincent Health's hospitals, four of which were involved in the development stage. St. Vincent Health instigated the initial meetings and is currently responsible for spearheading program strategy and organization.

Information provided in January 2014 indicates that Rural and Urban Access to Health is now under St. Vincent Medical Group.


By Carl H. Rush, MRP on
Congratulations on a wonderful innovation that should be replicated. My comment is that these workers appear to meet the federal definition of "community health workers" (SOC 21-1094). It would be helpful to acknowledge this so we can progress further in recognition of this occupation with standardized qualifications, and creation of a viable job market for the benefit of other employers as well as the workers themselves. Indiana already has an occupation called CHW for its prenatal care coordination program; standards for these CHWs could be generalized to include other workers.
Original Publication: 01/13/09

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 04/23/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 01/27/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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