Transforming Rural Health Through Community, Care, and Coordination

Activate Care helps states transform rural health by centering community voice, strengthening local care teams, and connecting health and social services. Our integrated model supports coordinated, evidence-based strategies that improve access, outcomes, and sustainability in rural communities.

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An Integrated Approach: From Insight to Impact

 

 

CNAs provide clear, actionable insights into rural health needs and supporting RHTP implementation by generating decision-ready insights that guide program design, funding alignment, and operational deployment.

 

 

Path Assist is our intervention program designed to improve health outcomes and service access in rural communities through a tech-enabled CHW workforce, standardized screenings, and coordinated navigation across health and social service systems.

 

 

CareLink is Activate Care’s technology platform for closed-loop referral management, care coordination, and system-level visibility across health and social service providers in rural communities.

Community Needs Assessments

CNAs integrates three core components to assess community health:

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Community-Engaged Research

Focus groups, key informant interviews, and surveys to understand lived experiences, barriers and facilitators to care, and community priorities and strengths.

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Secondary Data

Rural-focused secondary data analysis to identify demographics, health outcomes and disparities, and social determinants of chronic disease, including food insecurity, access to care, housing, and others.

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Resource Mapping

Health and social service resource mapping to assess availability and proximity.

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Path Assist is delivered by a locally hired CHW workforce, trained to engage rural populations through flexible, high-touch outreach. We recruit, train, and certify local CHWs, directly supporting the RHTP goal of rural workforce development and economic sustainability. CHWs build trusted relationships, conduct standardized health and social needs screenings, develop individualized care plans, and provide ongoing education, coaching, and care coordination. Engagement occurs through telephonic, virtual, and in-person interactions.

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Addressing Social Determinants of Health

CHWs screen individuals for health-related social needs (HRSN) and help them access support for challenges like housing, food, transportation, internet connectivity, and other needs by connecting them to local, trusted resources.

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Chronic Disease Management

Path Assist supports chronic disease prevention and management through structured education, self-management coaching, and care coordination. CHWs help participants ensure they have a trusted PCP, understand their conditions, set achievable goals, navigate clinical care, and use home monitoring tools as needed. Interventions are tailored to rural settings, considering limited provider access, long travel distances, and daily demands.

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Food Is Medicine

We incorporate Food Is Medicine principles by combining nutrition screening, goal setting, and navigation to food access and medically supportive nutrition resources. CHWs connect participants to food programs available in rural areas, including community-based, mobile, and public benefits, and support behavior change based on available food options, storage capacity, and transportation.

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The MyPathAssist app extends Path Assist by providing a consumer-facing, self-service experience that reinforces goals, education, and resource access between CHW interactions.

Designed for rural use, the app supports low-bandwidth environments and serves as a force multiplier for CHW-led interventions. Participants can track progress, access information and resources, and stay engaged over time, strengthening continuity, self-efficacy, and sustained behavior change.

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CareLink is Activate Care’s technology platform for closed-loop referral management, care coordination, and system-level visibility across rural health and social service providers. Built to support RHTP implementation, CareLink reduces administrative burden while helping states coordinate services, track outcomes, and meet CMS reporting requirements.

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Closed-Loop Referrals and Care Coordination

CareLink connects CHWs, clinical providers, community organizations, and state partners through a shared system for standardized screening, referrals, and follow-up. Real-time tracking improves continuity of care and accountability across rural service networks.

 

CareLink Billing Services

Billing & Revenue Cycle Support

CareLink includes integrated billing and revenue cycle capabilities designed for rural health and value-based payment models. From credentialing and encounter documentation to medical and non-medical claim submission, CareLink helps providers and community partners reduce administrative burden, improve reimbursement accuracy, and support sustainable, outcomes-driven care delivery.

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CMS-Aligned Reporting and System-Level Visibility

CareLink delivers automated reporting aligned with CMS RHTP requirements, reducing manual effort and supporting ongoing funding compliance. Aggregated data helps states identify gaps, assess equity, and guide continuous improvement.

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Built for Rural Delivery and Flexible Deployment

Designed for rural environments, CareLink supports low-bandwidth connectivity, hybrid service delivery, and varying provider capacity. It powers Path Assist and can also be used independently by local agencies for referral tracking and care coordination.

 

 

Nevada Community Health Equity Project

Discover how Activate Care partnered with CareSource to conduct a Community Health Equity Project, gathering insights on social drivers of health, behavioral health, housing, maternal health, and more to drive meaningful change.

 

 

Community Health Workers at the Heart of Food Is Medicine in Rural America

How CHWs turn nutrition interventions into real health improvements for rural families.

 

 

Closing the Gap: Meeting Rural Mothers Where They Are

How CHWs and digital engagement can close the distance in maternity care deserts.

Let’s Talk About Your RHTP Priorities

Activate Care partners with states to design and implement RHTP initiatives that are community-informed, operationally feasible, and built for measurable impact.

We can tailor Community Needs Assessments, Path Assist interventions, and CareLink configurations to your state’s priorities, geographies, and timelines.

Contact us to explore how Activate Care can support your RHTP goals.