Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements

Service Delivery Innovation Profile

Outreach Workers Connect Low-Income Individuals Living in Rural Areas to Home- and Community-Based Services, Reducing Costs and Nursing Home Placements



The Tri-County Rural Health Network, a nonprofit community development organization that works with the low-income individuals in the Mississippi Delta, uses outreach workers with ties to the local community to identify Medicaid-eligible residents who have unmet, long-term health care needs that put them at high risk of nursing home placement. Known as “community connectors,” these individuals then arrange for residents to receive appropriate home and community-based care, such as medical equipment delivery, home health aide visits, and meal provision. During a 3-year period, no program participants required nursing home placement, and, based on comparisons between participants and a similar group of nonparticipants, the program meaningfully reduced health care costs and generated a positive return on investment.

Evidence Rating

Moderate: The evidence consists of an assessment of the number of nursing home admissions among program participants and a comparison of health care expenditures in program participants to those in a matched comparison group of similar Medicaid recipients in five nearby counties.

Date First Implemented


Problem Addressed

Low-income individuals, especially the elderly, those in rural areas, and/or those who are racial or ethnic minorities, often have unmet health needs that can lead to nursing home placement if left unaddressed. Identifying these individuals and matching them with home- and community-based services can help them remain at home and potentially reduce costs. However, multiple barriers exist in doing so.

  • Many unmet health needs: Over half (58 percent) of elderly people who have functional limitations and are dually eligible for Medicare and Medicaid have unmet long-term care needs,1 with Blacks being significantly more likely than Whites to report these needs.2 A high proportion of low-income residents of the Mississippi Delta have unmet needs, due primarily to being in a rural location with limited access to care and services, high rates of poverty, and a disproportionately large number of minorities, elderly, and disabled individuals (caused in part by a decade-long trend of younger and able-bodied residents' moving elsewhere).3
  • Unrealized potential of home and community-based support: In-home medical care and social support can help at risk-seniors remain at home longer, preserving their quality of life and avoiding the high costs of nursing home care. Yet, despite a preference for remaining at home, many low-income seniors in these areas end up living in nursing homes.
  • Driven by multiple barriers: The failure to provide home- and community-based support stems from barriers to identifying those in need of support and to helping those identified access needed care and services.4 Standard methods for identifying and reaching out to these individuals tend to be ineffective, as physicians are often unaware or unwilling to make referrals for noninstitutional services,5 and older, minority, and low-income individuals may have limited ability to use electronic information.6 Other common obstacles include lack of information and related counseling, mistrust of existing information sources, and difficulties navigating the fragmented system.

Description of the Innovative Activity

Outreach workers with strong ties to community residents identify Medicaid-eligible individuals who have unmet long-term health care needs that put them at risk of nursing home placement. Known as “community connectors,” these individuals arrange for residents to receive appropriate home- and community-based care, such as medical equipment delivery, home health aide visits, and meal provision. Key program elements include the following:

  • A dedicated workforce with strong community ties: Community connectors live in their communities, and, as a result, often have existing relationships as peers, friends, neighbors, or relatives of those they serve. They also share similar socioeconomic status and race or ethnicity, making it easy for them to gain clients' trust when sharing information about available services and helping them understand family dynamics and relevant caregiving expectations.
  • Identifying potential clients: Community connectors use a number of techniques to identify those who might benefit from the program, including “foot patrols” (walking though the community and talking with individuals about their needs or those of someone they may know), knocking on doors, and passing out program flyers and brochures at community events. They also follow up on informal referrals from family, friends, and church leaders, and on formal referrals from physicians, staff at county public health units, and hospital discharge planners. To facilitate referrals, Tri-County has partnerships with service providers in the targeted counties, including local physicians, public and private health agencies, churches, and the regional hospital.
  • Determining eligibility: During initial conversations, the community connector preliminarily assesses whether the individual is interested in participating and likely eligible for program services. State Medicaid officials ultimately make the final eligibility determination. Most participants tend to be older adults and younger adults with physical disabilities. Many are female and African American, with most being age 60 or older.
  • Connecting to needed care and services: Community connectors generally work with the individual and his or her family over a period of several weeks. As experts in home- and community-based services and their eligibility criteria, they work to understand the individual's specific long-term needs and arrange for care and services to meet those needs. The individual's physician approves all medical-related services. Examples of services include the following:
    • Medical equipment: Connectors can arrange for the delivery and installation of medical equipment and supplies, such as bed rails, stair lifts, and walkers.
    • Home health care: Connectors work with agencies that schedule nurses or health aides to stop by the home once or more each week to check on the person and treat his or her medical needs.
    • Medicaid issues: The connector can assist in completing Medicaid-related paperwork and in sorting out eligibility issues.
    • Homemaker services and meal delivery: The connector arranges for homemaker services as needed, which may include assistance with essential shopping, laundry, light housekeeping, and light meal preparation. The connector can also schedule delivery of hot, prepared meals if needed.
    • Caregiver respite services: As necessary, the connector identifies and contacts nearby relatives who may be able to help with the resident's needs, and/or arranges for services that can ease family stress. For example, the connector might arrange for a program participant to attend an adult day care program that offers social activities for several hours a day, thus providing a respite to family members and/or other caregivers.
  • Monitoring and followup with participants: After arranging for needed services, the connector may occasionally contact the person to verify that they are working out. Participants can also call the community connector if any problems arise.
  • Monitoring and support of community connectors: Tri-County's executive director closely monitors the activities of the community connectors to ensure their effectiveness and help resolve problems as they arise. All community connectors are required to call in to organization's headquarters at least once a day to detail their activities. In addition, community connectors attend weekly in-person meetings to discuss new developments and share lessons and strategies, and they go to periodic training sessions (see the Planning and Development Process section for more details on training).

Context of the Innovation

In 2003, the Arkansas Delta Rural Development Network, an organization that works to improve health care in 38 rural Arkansas counties, issued a call for proposals for local strategies to increase access to health care. In response, Naomi Cottoms, a community leader with experience addressing health care disparities and fostering community empowerment, formed the Tri-County Rural Health Network, a nonprofit community development organization that initially served Lee, Phillips, and Monroe Counties in the Mississippi Delta. After partnering with staff from the University of Arkansas for Medical Sciences' College of Public Health and winning grant funding from the Foundation for the Mid-South, Tri-County conducted an assessment of area assets. This analysis identified a wide variety of available health and social services in the community, but found that many eligible residents did not access them. Aware of programs in which lay workers help hard-to-reach populations access services in a variety of settings, Tri-County leaders decided to create a program using community outreach workers to match residents to needed services.


During a 3-year period, no program participants required nursing home placement, and, based on comparisons between participants and a similar group of nonparticipants, the program meaningfully reduced health care costs and generated a positive return on investment (ROI).

  • Continued home living: Between mid-2005 and mid-2008, none of the participants entered a nursing a home. Anecdotal examples of success stories include the following:
    • When one of two elderly sisters sharing a house had health problems that forced her to move to a nursing home, the other sister began planning to move to the home as well so they could be together. A community connector arranged for a niece to move into the house and for the sisters to receive a range of community services, enabling the first sister to return home.
    • A grandmother in her 60s became ill, who had been caring for 90-year-old mother. This placed a tremendous burden on her grandson, leading him to have excessive school absences and low grades, and forcing him to consider dropping out of high school. (The young man's mother had a substance use problem and did not help with the two women's care.) A community connector arranged for a range of services, including regular visits from a home care nurse, allowing the grandson to stay in school and subsequently attend college.
  • Significant cost savings: Average annual per-person Medicaid spending rose by 19.3 percent for participants over the 3-year period (from $16,074 to $19,174), well below the 30-percent increase in a matched comparison group of 944 similar ($15,559 to $20,224). This difference yielded an estimated $3.5 million in savings to the State Medicaid program.
  • Positive ROI: During the 3-year study period, the program incurred $896,000 in operational expenses, yielding a net savings of roughly $2.6 million for the Medicaid program, or roughly $2.92 in savings for each dollar invested in the program.

Evidence Rating

Moderate: The evidence consists of an assessment of the number of nursing home admissions among program participants and a comparison of health care expenditures in program participants to those in a matched comparison group of similar Medicaid recipients in five nearby counties.

Planning and Development Process

Key steps included the following:

  • Pilot testing: In 2004, the Arkansas Delta Rural Development Network funded Tri-County's initial proposal, which called for a pilot program in one county. Tri-County's executive director recruited six community connectors. During the 18-month pilot, the community connectors' work enabled 11 residents who had moved or were about to move to nursing homes to return to or stay in their homes. The pilot's success suggested a larger program could produce significant cost savings for the Arkansas Medicaid program.
  • Full-scale demonstration: In 2005, the Arkansas Department of Human Services received funding from the Robert Wood Johnson Foundation to contract with Tri-County to implement a full-scale demonstration of the program in three counties, and a grant from the Enterprise Corporation of the Delta funded a formal economic evaluation of the initiative. The original contract called for a 3-year demonstration, from July 2005 to June 2008.
  • Hiring and training additional staff: To staff the demonstration project, Tri-County created positions for six additional community connectors. Those hired received extensive training covering various topics, including how to identify and contact people in need, how to refer individuals to programs in accordance with eligibility criteria, and how to keep program records and maintain the confidentiality of those records.
  • Creating and updating resource guide: As part of their training, community connectors developed a resource guide that includes the names of health and social services agencies providing services in the target counties, the scope of services offered, basic eligibility requirements, agency location and hours of operation, and a point of contact. Subsequent hires updated the guide by calling each agency to confirm its continued existence and the accuracy of details.
  • Ongoing training: Community connectors attend regular (typically biweekly) inservice trainings sessions led by the program director, senior community connectors, and, on occasion, outside presenters on the following areas:
    • Programs operations and processes: Topics include defining the target population, processes for making connections, paperwork and program reporting requirements, understanding the definition of a home- and community-based service, and using the program database.
    • Social service delivery system: Topics include adult protective services, public health performance and assessment, Medicare Part D, the Arkansas Medicaid program (including training on the computerized application process), the Arkansas Minority Health Commission's 50-Million Pound Challenge Program, home health and hospice programs, Medicaid and Medicare fraud, and the Arkansas Department of Health's Stamp Out Smoking Program .
    • Professional skills development: Topics include computer training, leadership, grant writing, effective interpersonal communication, community trust-building, workplace relaxation and stress reduction, and nutrition and physical activity.
  • Program continuation and expansion: Through Medicaid funds, the original contract serving three counties was extended for 1 year (through June 2009). In July 2010, additional Medicaid funding enabled the program to begin serving 12 more counties.

Resources Used and Skills Needed

  • Staffing: The current program staff includes the executive director, three outreach coordinators, a data input specialist, and 25 full-time community connectors who work with about 2,000 residents in 15 counties.
  • Costs: The program's chief expenses are staff salaries and benefits for office staff and the community connectors and mileage reimbursements for the connectors, who average 500 to 1,000 miles of driving each month.

Funding Sources

The Arkansas Medicaid Program currently funds the program. Funding sources during its initial years included the Arkansas Department of Human Services' Division of Medical Services, the Robert Wood Johnson Foundation, the Enterprise Corporation for the Delta, and the University of Arkansas for Medical Sciences.

Getting Started with This Innovation

  • Hire self-starters: When hiring community connectors, look for dedication to the program's goals, a drive to succeed, and familiarity with the community and culture. These factors are much more important than health care experience, because staff can be trained on the job details. Community connectors spend most of their time unsupervised, so those hired must exhibit good judgment and dedication.
  • Define roles clearly: To maximize the program's reach, make sure that the community connectors and their clients understand that the connector's role is to help residents access service, not to provide those services themselves. While workers should strive to be as supportive as possible and check in occasionally with their client base after arrangements have been made, the bulk of the work should occur during the initial encounters.
  • Target those at risk of nursing home placement: To remain cost-effective, the program should target those at high risk of near-term nursing home placement. Although the cost of nursing home care is generally much higher than remaining at home (even with home and community-based services), the cost savings generated by the program may be diminished if many of those served could have remained at home without home and community-based services.
  • Do not overpromise: When recruiting participants, community connectors should avoid creating expectations that are unlikely to be fulfilled. For example, although home care can be an important service, in most cases, individuals will qualify for one or two visits a week, not daily or round-the-clock care.

Sustaining This Innovation

  • Scrutinize service providers: Identifying reliable service providers can be an ongoing challenge. Ideal providers treat clients with compassion and deliver services promptly. Program leaders should constantly search for new, qualified service providers and reevaluate existing providers to verify their continued reliability.
  • Expand gradually: Setting up this type of program requires considerable work, because it often covers a large geographical area, and identifying reliable service providers and training new staff takes significant time and effort. As a result, program leaders should make sure that sufficient services and qualified staff are available before expanding to additional counties.
  • Expect turnover: Turnover can be an issue, because some find the job of a community connector to be quite demanding over the long term, and others may be inspired to pursue degrees in nursing and social work. Consequently, program leaders should always be on the lookout for potential new hires.

Contact the Innovator

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

Naomi Cottoms
Executive Director
Tri-County Health Network
107 Professional Plaza
Helena, AR 72342
(870) 338-8900
E-mail: ncottoms@aol.com

Innovator Disclosures

Ms. Cottoms has not indicated whether she has financial interests or business/profession affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Felix HC, Mays GP, Stewart MK, et al. The care span: Medicaid savings resulted when community health workers matched those with needs to home and community care. Health Affairs. 2011;30(7):1366-74. [PubMed]

“Crossroads: Rural Health Care in America,” a documentary by the Vision Project featuring an interview with a Community Connector, is available here http://www.visionproject.org/documentary_film/crossroads.htm.


  1. Komisar H, Feder J, Kasper J. Unmet long-term care needs: an analysis of Medicare-Medicaid dual eligibles. Inquiry. 2005;42:171-82. [PubMed]

  2. Casado B, van Vulpen K, Davis S. Unmet needs for home and community-based services among frail older Americans and their caregivers. J Aging Health. 2011;23(3):529-53. [PubMed]

  3. Neaves T, Feierabend N, Butts C, et al. A portrait of the Delta: enduring hope and enduring despair. J Health Hum Serv Adm. 2008;31(1):10–29. [PubMed]

  4. The John A. Hartford Foundation. PACE: Independent Living, Better Health for Frail Older Americans.

  5. Felix H, Dockter N, Sanderson H, et al. Physicians play an important role in families' long-term care decisions: choice of home care vs. nursing home. J Ark Med Soc. 2006;103(3):67-9. [PubMed]

  6. Lorence D, Park H. Group disparities and health information: a study of online access for the underserved. Health Informatics J. 2008;14(1):29-38. [PubMed]

"Community Connector" Goes the Extra Mile for Delta Residents

Ask Jackie White about some of her most memorable clients and she lets out a loud laugh. “There's just so many, I could go on all day,” she says.

White, 50, has worked as a “community connector” for the Tri-County Rural Health Network for five years, linking residents of St. Francis County, Ark., to services that help them keep living at home instead of having to move to nursing homes. In a typical month, she drives 600 to 700 miles, often on dusty and rocky roads, checking on existing clients and searching for new ones.

One unforgettable case was a very religious 89-year-old woman who was so hard of hearing White had to literally holler to communicate. After going over the woman's Medicare paperwork, White noticed she qualified for extra help paying her premiums.

“That comes up a lot,” White says. “A lot of folks can't read and are ashamed to ask for help, so they just let the mail stack up.”

White helped her straighten out the problem, which ultimately led to a higher monthly Social Security check. The woman was so grateful that she now regularly mails White her favorite gospel tracts, as well as any mail she does not understand.

Another time, White worked with a woman who was struggling to cope with the aftereffects of breast cancer treatment while also caring for her 91-year-old mother. Feeling overwhelmed, the woman was considering putting her mother in a nursing home. White arranged for a range of services, including visits by home personal care and health aides and delivery of medical equipment and hot meals, enabling the duo to continue living together.

Once, on Christmas Eve, White encountered a family who had no food. White started making phone calls, and after finding most service providers closed for the holiday, she got in touch with a church whose members immediately brought over several bags of groceries. White later arranged for regular meal delivery.

But White's favorite tale involves a 92-year-old woman and an 89-year-old man who had recently moved from California. Despite health problems, they wanted to get married. White arranged for a home health aide through Medicaid's long-term care program, paving the way for their subsequent wedding.

“That was my love story,” she says. “It was something else, seeing them both come down the aisle with their walkers. About a year later, he passed away, but I believe he died a happy man.”

Community Connectors Help Seniors Maintain Their Independence

By Brenda Leath, PhD, Westat; and Christine Lehmann, MA

Training laypeople to connect low-income, Medicaid-eligible seniors with community services is a win-win situation. It helps seniors stay longer in their homes and avoid expensive nursing home care. Being able to stay in their homes longer fosters continued independence, enhances their quality of life, and results in cost savings to Medicaid.

Like community health workers, community connectors are trusted individuals who live in the same community as the people they serve. They often have existing relationships and share the same socioeconomic status and race or ethnicity, which facilitates gaining the client's trust to share information about available services and helps them understand family dynamics and caregiving expectations.

Low-income seniors, especially those living in rural areas, tend to have unmet health needs that, if left unaddressed, put them at risk of nursing home placement. Many elderly residents of the Mississippi Delta faced that situation with limited access to care and services, high rates of poverty, and a disproportionately high number of minorities, elderly, and disabled individuals.

The Tri-County Rural Health Network trained outreach workers to identify Medicaid-eligible residents and arrange for them to receive home and community-based care such as medical equipment delivery, home health aide visits, and meals. The program required the residents' physicians to approve all medical-related services. In some cases, they completed Medicaid-related paperwork and sorted out eligibility issues.

The community connectors usually worked with the individual and his/her family for several weeks. For example, when two elderly sisters who lived together were separated when one of them had health problems and entered a nursing home, a community connector arranged for a niece to move into the house and for the sisters to receive a range of community services, which enabled them to reunite and live together again.

As a result of the program, no participants required nursing home placement, which reduced health care costs. The average annual per-person Medicaid spending rose by only 19.3 percent for participants during the 3-year program period compared with 30 percent for a matched comparison group. This saved the State Medicaid program an estimated $3.5 million.

The factors that made the program effective include understanding the needs of the residents and training workers who are representative of the community to follow-through on connections to health and social services. This ensures that recipients benefit and are satisfied with the quality of care. If the “community connectors” are properly trained and are passionate about the work, they will ultimately help a lot of people who are undeserved.

The program could be generalized to rural and urban areas where there are elderly populations with low incomes and unmet health care needs. Knowing the community and providing training and oversight are important considerations.

About the Authors:

Brenda Leath, PhD is a Senior Study Director at Westat. She is also the Co-Executive Director of the Center for Pathways Community Care Coordination. Ms. Leath's career spans 25 years in health services administration and research, including a focus on vulnerable populations, health disparities, and k nowledge transfer and dissemination.

Christine Lehmann, MA is a health care writer and journalist whose career spans 15 years with a focus on public health, health disparities, policy, and mental health.

Disclosure Statement : Ms. Leath and Ms. Lehmann reported having no financial interests or business/professional affiliations relevant to the work described in this commentary.

Funding Sources

Arkansas Medicaid Program


Tri-County Rural Health Network


By Robin Carmichael RN on
Clearly this program saves our nation money and gives quality care. The concept should be implemented throughout the nation. This is the missing link between public health and home health. Wonderful work. Robin Carmichael RN
Original Publication: 05/23/12

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

Last Updated: 05/21/14

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

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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