Health and health systems are part of larger ecologies that dynamically shape and impact the elements that are part of that system – people, families, organizations, communities, cultures, economies, and environments. An effective health system is aware of its place in larger community systems, its relationship to other system elements, and how those elements come together to support health (or not). This ecological perspective enables community health systems to comprehensively assess, coordinate, deliver, and ensure that the health needs of the community are known and met.

Urban and rural community health systems alike face a daunting array of constraints to doing this, with very little incentive and resources to do so. In urban areas, the challenge may be the complexity, fragmentation, and gaps among systems, providers, and consumers of care and services. In rural and frontier communities, a health ‘system’ may be an isolated, stand-alone community health center in a health workforce shortage area that is 30 or 60 or 90 miles from the nearest specialist, tertiary, emergency, pharmacy, ancillary, and social services. Rural communities are likely underserved by educational and food systems as well, which are critical determinates of community health.

Rural or urban, tribal or border, health extension aims to support the capacity, quality, and effectiveness of local health systems in understanding and meeting community health needs in this time of rapid change in the health care landscape.

Health Extension as a Vital Resource for Managed Care Organizations & Health Centers

Health extension can share an array of practices and resources with community health systems – such as developing partnerships and sharing resources among health and human system elements and sectors, integrating prevention, health education, and behavioral health services into primary care, identifying and addressing health literacy and cultural competency gaps, improving the quality and experience of care, linking to valuable university resources and expertise, and building health teams that can support the bio-psycho-social well-being of people, families, and communities. As health improvement practitioners who are place-based, health extension agents bring with them diverse relationships, knowledge and experience that can leveraged to community health or practice improvement effort.

VIGNETTE FROM A HEALTH EXTENSION AGENT: “I had rural primary care practice contact me for assistance in thinking through development of their health home model. After assessing the priorities and capacities of the practice, I offered a “menu” of possible assistance, focused on expanding key staff roles in care-management, developing related processes, decision support tools, and referral pathways across distant, and fragmented systems.”

Click on the image below to learn more about the Expanded Chronic Care Model:

Triple AIM

“When we pay in fragments, we buy fragments”
D. Berwyk in JAMA November 24, 2010

The Triple Aim initiative calls for redesigning the health care delivery system to simultaneously accomplish 3 primary objectives: improve the health of the population, enhance patient care (including quality of, access to, and reliability of care), and reduce or at least control the per capita cost of care. Triple Aim builds off the Institute of Medicine’s 6 aims for improvement in the delivery of health care in the United States as outlined in a 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century”.

More information on the Triple AIM can be found using the links below, as well as in key articles found in “Related Literature and Tools”, below.

Diffusing Innovation among Health Systems & Payors

With diverse backgrounds as health professionals, and being community-based, health extension agents easily move across sectors and systems to work effectively with health improvement collaborators and stakeholders, from the back-roads to boardrooms. In this way, health extension agents are powerful informants and allies to integration efforts in all directions – a kind of “ninja”integrator, nudging, attracting, and brokering system connections. As cross-pollinators of good ideas, disseminators of promising practices, and boots-on-the-ground ‘intel’, health extension agents work with systems and payors on planning, problem-solving, and assessing integration efforts, and related programming.

VIGNETTE FROM A HEALTH EXTENSION AGENT: A Medicaid Managed Care organization sought means to reduce high ER use and hospitalizations by a subset of high-risk Medicaid patients in a four-county, rural area served by a Federally Qualified Health Center. The Regional Health Extension Coordinator worked with Medicaid MCO to contract with the FQHC primary care clinic network to hire and train a small group of Community Health Workers to serve as the clinics’ community-based extenders, helping these high risk patients navigate the complex health system, increase adherence to prescribed treatment plans, arrive at appointments, and help address underlying social problems (ex. transportation, low health literacy, unemployment, poor nutrition) impeding optimal healthcare. The cost to the MCO for these assigned high-risk patients dropped by half in the first year and the primary care-linked Community Health Worker program has expanded.

Innovative Health Systems Supported by Health Extension

UNMHSC and its community partners who created the HERO program came together to develop an advanced medical home model over five years ago. The “Health Commons” model provides patients and their families in either urban neighborhoods or rural communities with an integrated, one-stop-shop for primary care, behavioral health, oral health, case management, public health, and enabling services via community health workers or “promotoras” working back-and-forth from the clinic setting to community. Currently, six Health Commons exist in the state, and more are planned. Each integrates programs around local data- identified health issues and priority community needs while contributing to local economic development by way of hiring and building capacity among community members.

VIGNETTE FROM A HEALTH EXTENSION AGENT: “With all our work in developing PCMHs, it never occurred to me what it might look like when someone’s actual home is their health home. But when I met with a rural home health agency in my region, that’s exactly what they ask me for assistance with. They were especially interested in integrating community health workers into their system, but had no idea how to do that. After listening closely we dove in for about 18 months and helped them re-design existing roles, train the CHWs, and develop the programming and tracking around specific priorities – care transitions and self-management. When I think back, I don’t know how we did it, but among other things, we trained 90 home health homemakers to do brief health coaching interventions around goal setting with clients. It was amazing.”

Related Literature & Tools

“The Triple Aim: Care, Health, and Cost”

“The Triple Aim Journey: Improving Population Health and Patients’ Experiece of Care, While Reducing Costs”

“The Triple Improvement Community”

Useful Tools:


THRIVE is a tool to help you understand and prioritize the factors within your own community that can help improve health and safety. The tool can help answer questions such as: How can I identify key factors in my community and rate their importance? How are these factors related to health outcomes? What can I do to address each factor? Where can I go for more information?

“Improvement Tracker”

The Improvement Tracker allows you to track any of the measures currently available in the Topics area of Just select the measure you want to track (or create your own custom measure), set your aim, and enter your data. The Improvement Tracker automatically graphs your data. It lets you create reports, and even customize them for various audiences — your team, your CEO, your community.



Metrics and Evaluation Financing Message Mapping Building a Movement Chp6 Sustainability Diverse Populations Critical Health Literacy CHWs Chp5 Population Health Beyond PCMH Shared Resources Community Health Systems Small Practices PCEP Chp4 Primary Care Health Outcomes Core HERO Functions Engagement Perspective HERO Model Chp3 Health Extension Model Public Health Cooperative Extension Academic Health Centers Primer for Engagement Chp2 Engagement What is a Hero General Overview Using the Toolkit Chp1 Getting Started