Community Health Workers Can Boost Care for Rural Seniors

TOPLINE:

Community health workers were integrated into primary care to deliver age-friendly care services to rural older adults. Initial results indicated a reduction in hospitalizations, with positive feedback received from patients, caregivers, and primary care providers (PCPs).

METHODOLOGY:

Researchers conducted a pilot study of a program in rural Oregon that embedded community health workers into primary care teams to implement age-friendly care protocols aimed at improving the quality of care and engagement of rural older adults.
The study enrolled 388 medically frail patients (average age, 77 years; 63% women; 82% White) referred by 79 PCPs across seven clinics.
Community health workers conducted home or clinic visits and made patient phone calls.
Protocols comprised a conversation tool for patient priorities, support for completing the advance directive, in-home reviews of medications, information on brain health and cognitive concerns, and fall risk reduction assessments with safety checklists and exercise resources.
Community health workers documented outcomes and social conditions in electronic health records for review by PCPs.

TAKEAWAY:

The Connected Care for Older Adults pilot expanded from a single federally qualified health center in 2022 to seven sites serving 250 patients annually by June 2025. Surveys were completed by 120 patients, 17 caregivers, and 19 referring PCPs.
Overall, 95% of responding patients reported a positive impact on their lives, with community health workers providing support and engagement.
All PCPs who completed the survey reported satisfaction with the program and appreciated community health workers for facilitating resource connections, addressing social isolation, and engaging patients and families in care.
Emergency department visits decreased from 32.26% to 7.74% and hospitalizations decreased from 15.05% to 2.08% from 3 months prior to the intervention to 12 months postintervention.

IN PRACTICE:

“Our results indicated that CHWs [community health workers], when trained in well-developed 4Ms [what matters, mentation, medication, and mobility] protocols and given appropriate clinical supervision, feel confident in assisting the implementation of all 4Ms, even in rural, under-resourced settings where it may be most challenging but critical to foster age-friendly care,” the authors wrote.

SOURCE:

The study was led by Bryanna De Lima of the Division of General Internal Medicine and Geriatrics at Oregon Health & Science University in Portland, Oregon. It was published online on January 10, 2026, in the Journal of the American Geriatrics Society.

LIMITATIONS:

The survey response rates were low, and there were limited data on usage. The use of different frailty definitions by PCPs may have led to inconsistencies in patient selection.

DISCLOSURES:

The study was supported by grants from the PacificSource Foundation for Health Improvement, Oregon Health Authority, and the Oregon Community Foundation, among others. The authors declared no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.