Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Dianne Slager

Second Advisor

Cynthia Coviak

Third Advisor

Ali Saheb


Introduction: American Indian/Alaska Native (AI/AN) people have some of the greatest health disparities of any other citizen group in the U.S. (National Indian Health Board [NIHB], 2018). As liaisons between community members and health services, community health workers (CHWs) play an important role in reducing disparities in AI/AN communities (Indian Health Service [IHS], 2018). CHWs in the organization of interest are not being used to their full potential as the documentation of their care is not accessible to the primary care providers (PCPs) for care coordination and the program is threatened by issues related to sustainability.

Objectives: The purpose of this project was to develop a strategic plan to increase efficiency and sustainability of a CHW program located in a rural Native American community in the Midwest U.S. The long-term goals of this project are to improve care coordination and program sustainability.

Methods: The Cultural Care Theory and Pathways HUB Model guided development of this project. The overall project is a multi-phase quality improvement project involving replication of the Pathways Community HUB model in the target organization. The proposed project will be conducted in multiple phases including strategic planning, implementation, and evaluation.

Results: This project represents the first phase of the overall project, which is was the development and delivery of a strategic plan to guide implementation of the proposed practice changes.

Implications: It is anticipated that the implementation of an evidence-based model of care coordination will increase CHW documentation completion rates and provide a standardized measurement tool to efficiently evaluate patient outcomes and CHW performance. It is also expected that there will be better communication and care coordination across multiple health and social services, thereby increasing efficiency, quality of care, and sustainability of the target organization’s CHW program.