Marshall University — Huntington, WV


Marshall University is working to establish a system that fosters collaboration between local health clinics and community resources to better serve people with diabetes from rural communities in West Virginia, Kentucky, and Ohio who have limited access to care.

The program is implementing a sustainable care coordination model that includes CHWs on the care team who conduct home visits and connect people with diabetes to community services that address the social determinants of health. The University is also exploring, with the Center for Health Law & Policy Innovation at Harvard University, options for financing this model in a sustainable way.


Transform the delivery of rural primary care by implementing a sustainable care coordination model for high risk diabetes patients that includes community health workers (CHWs) on the care team.

  • Work with clinical partners in distressed counties in Ohio and Kentucky to replicate care coordination model developed in rural West Virginia.
  • Enroll high risk patients with diabetes in care coordination programs.
  • Calculate savings from claims data for patients enrolled in care coordination by the end of year five.

Link clinical interventions with existing multilevel health care programs that have been developed by the local diabetes coalition in these rural communities

  • Establish a system for clinic-community collaboration that directly engages patients in community programs that address medical, social, and environmental determinants of health by the end of year two.

Establish a health insurance reimbursement mechanism that provides sustainable funding for care coordination and CHWs by the end of year five

Richard Crespo, PhD

Professor, Joan C. Edwards School of Medicine,
Department of Family and Community Health

Richard Crespo, Ph.D., is a professor in the Department of Family and Community Health, Joan C. Edwards School of Medicine at Marshall University. His degree is from Michigan State University in curriculum research and development. He is involved in community health programs in West Virginia and the Appalachian region.

Dr. Crespo and his team have developed an innovative program for establishing diabetes coalitions in rural, underserved counties in the Appalachian Region. Currently there are 77 coalitions in nine Appalachian states. As part of this program, they have trained more than 120 leaders throughout the Appalachian Region as leaders of the Stanford Chronic Disease Self-Management Program. They have also created a series of self-management tools for consumers.

Currently Dr. Crespo is working on a project to establish payment models for chronic care management that will support community health workers as members of the care management teams.

Contact Richard Crespo