Rural Health Care Services Outreach Grant Program - Tillamook County Community Health Centers (TCCHC) and its partners are applying for the regular track of this grant and focusing primarily on lowering incidence rates and improving the management of prediabetes and type 2 diabetes (T2D). The ConnectWell Program (CWP) will serve the Tillamook County area of Oregon, a rural coastal region. This consortium’s application qualifies for a funding preference under Qualification 1: Health Professional Shortage area, Qualification 2: Medically Underserved Community/Populations, and Qualification 3: Focus on Primary Care, and Wellness Prevention Strategies. This project will serve patients with A1cs above 5.7%; this includes prediabetic and diabetic patients. There is significant overlap between the patient population suffering from diabetes and those who are historically underserved. Multi-generational poverty and lower levels of education impact health literacy and attainment of self-agency needed to make positive and sustainable lifestyle changes. As a result, low-income and minority populations experience higher rates of chronic disease and obesity. This effect is compounded for Spanish-speaking individuals, who often postpone care due to concerns of language barriers and the cost of services. In 2022, the Tillamook County rate for individuals ever diagnosed with T2D was 10.78%. This project intends to lower this rate using Traditional Health Workers (THWs) to ensure that individuals with lower health literacy and limited English proficiency will experience increased access to healthcare and the social supports they need. Oregon Administrative Rule (OAR) 410-180 defines community health workers, peer wellness specialists, peer support specialists, doulas, and personal health navigators, therefore for ease of translation, we have opted to follow Oregon Health Authority’s (OHA) approach and use "traditional health workers" or “THWs” to encompass all worker types defined in OAR 410-180 (OHA, 2025) and use “community health workers” or “CHWs” when specifically referring to this worker and as identified in evidence-based models. To address the needs of these populations, our Network will use the evidence-based practices of a Community Health Worker Model, Transtheoretical Model and Motivational Interviewing to inform a hub for CHWs to respond to the needs of our target population. These models will support the creation and implementation of the ConnectWell Program, a hub of Community Health Workers that will work alongside patients with prediabetes and T2D. ConnectWell, with the support of this grant, will develop workflows among healthcare partners for shared screening, referral, data, and patient monitoring. Once established, the program will be promoted to patients meeting the criteria of being prediabetic or type 2 diabetic, who will then be enrolled in the program and partnered with a CHW to support navigation for health-related social needs. Participants will work with their assigned CHW to identify the programs that best support their health goals. Additionally, CHWs and Peer Support Specialists can connect program participants with recovery services, partner violence advocacy, law enforcement, and other organizations that are working together strategically to address prevention and treatment for opioid and substance use disorders. This project recognizes the role CHWs will play in optimizing that network of care delivery and the level of data it can provide in understanding resource utilization, service gaps and program efficacy. The ConnectWell Program aims to have a pool of appropriately trained and funded CHWs in Tillamook County to support meeting individual needs of patients. This will require increased collaboration between Network partners, which is reflected in the goals of this project. The CWP will focus on development of foundational systems including screening processes, workflows, and a system for closed-loop referrals between partner agencies.
