Introduction
As rural hospital closures and uncompensated care pressures grow, health systems need scalable ways to reach uninsured and underinsured patients without duplicating existing community resources. Since 2021, Ballad Health’s Appalachian Highlands Care Network (AHCN) has used a “broker, don't build” model to connect patients across 21 counties to primary care, specialty care, and social needs support through community health workers, navigators, and safety-net partners.
Read below to learn how AHCN is reducing total cost of care and preventable inpatient utilization for rural uninsured patients.
Case Study Snapshot
Footprint: Headquartered in Johnson City, TN; 20 hospital health system across the rural Appalachian Highlands region (KY, NC, TN, VA)
Timeframe: 2021-Present
Challenge: Uninsured and underinsured individuals in Ballad Health's Appalachian region lacked reliable, proactive access to primary care, specialty care, chronic disease management, and health-related social needs support. As a result, many were delaying care until preventable conditions became severe and surfaced in the ED.
Solution: AHCN—a multi-pronged care model leveraging community health workers (CHWs), community navigators, and safety-net partnerships to improve outcomes for patients living within a 21-county service area that are either uninsured or have income below 225% of the federal poverty level.
Key Partners:
Ballad Health
Project Access
Safety-net clinics
Community-based organizations (CBOs)
Challenges Addressed
Rethinking Workforce Innovation
AHCN’s staffing model leverages capacity extenders, such as CHWs and community navigators, while aligning staffing intensity with patient acuity so each patient receives support that reflects the complexity of their needs.
Addressing SDOH in Rural-Specific Contexts
“Broker, don’t build” grassroots approach to developing AHCN, relying on a network of community partners to understand where Ballad could optimally deploy resources to fill in infrastructure gaps rather than duplicating existing services that address social needs.
Key Outcomes (as of April 2026)
"Broker, Don't Build" Approach Underpins Collaborative Program Delivery
Program launch facilitated by embedding within existing community infrastructure across 3 different program components
Patient Identification & Enrollment
After finding cold outreach via telephone to be ineffective, co-located CHWs and community navigators directly within trusted community partner organizations to enroll eligible patients.
Later added an additional enrollment mechanism of allowing self-referrals from CBO partners
Regional Care Network Expansion
Expanded access to primary care by tapping into each region's existing free clinic infrastructure
Partnered with Project Access, a non-profit organization, to expand access to low and no cost specialty care across a network of independent specialists
Removed barriers to access for all Ballad Health services by allowing seamless referrals through AHCN
Social Care Integration
Participation in a closed-loop referral network through the UniteUs platform, connecting patients to regional agencies addressing social and behavioral needs, such as transportation, food, and behavioral health
AHCN's Program Design Matches Care Intensity to Patient Need
Although the program began with a high-fidelity CHW model, low panel sizes and CHW certification costs made it financially unsustainable to deploy this workforce at scale. AHCN introduced community health navigators—a complementary, similarly trained role—to support lower-acuity patients. CHWs now focus on the highest need, most complex cases, transitioning patients to navigators as needs stabilize, or handing off to other roles within the system (e.g., care managers for recovery support) as appropriate.
Continued Monitoring & Ongoing Assessment
Rather than graduating high-needs patients from the program, AHCN redeploys them into a monitoring program as acuity shifts. Escalation and de-escalation pathways are available to re-engage patients in active services as needs change, avoiding costly “yo-yoing” in and out of the system.
Lessons Learned for Health Systems
1. High-fidelity programs managing complex social and medical needs lend themselves well to rural contexts, but consider where workforce & resource constraints may hinder program scalability.
High-touch nature of CHW-dependent programs combined with CHW certification costs initially created barriers to scaling.
Ballad Health introduced a more cost-effective, tiered staffing approach that leverages community navigators, care managers, and partners (e.g., Project Access) to manage patients based on specific needs and acuity.
2. A value-based approach to managing uninsured populations can be a strategy for proactively mitigating the disproportionate impact of the impending uncompensated care crisis on rural health outcomes.
Focusing on the “three-legged stool” of managing health-related social needs, healthcare access, and chronic disease management represents a unique opportunity to reduce uncompensated care.
Although AHCN does not generate direct revenue, it creates value via its downstream impact on resource savings elsewhere in the system that offset program costs, e.g., preserving inpatient capacity or shifting utilization to appropriate, lower-cost settings.
What's Next?
Explore how telehealth and innovative digital strategies can mitigate SDOH barriers and support increased access to AHCN services
Utilize evidence-based, outcomes-driven agentic AI capabilities to overcome workforce shortages and expand program capacity to deliver prevention and disease management services
