Two years of rural CHW 4Ms training, development, and leadership in Texas

The National Rural Health Association (NRHA), in partnership with The John A. Hartford Foundation, continues to advance rural age-friendly care through the National Rural Age-Friendly Initiative (NRAFI). The foundation of this work is strengthening the role of community health workers (CHWs), who are trusted advocates in rural communities, to ensure older adults can age in place. 

Through NRAFI’s collaboration with the University of Texas at Arlington (UTA) and the Institute for Healthcare Improvement (IHI), NRHA has trained 182 CHWs (both virtually and in-person) across rural and border Texas during the planning grant and year 1 of the implementation grant to equip CHWs to deliver the 4Ms of Age-Friendly Care: What Matters, Medication, Mentation, and Mobility.

IHI led the evaluation of the 4Ms curriculum, while Dr. Densie Hernandez and Alexandra Amaya served as on-site facilitators throughout both the planning and implementation phases of the grants. Originally developed to be implemented in a clinical setting, the 4Ms training was adapted by UTA to be delivered in a community-based setting. An evaluation tool was also developed to analyze and quantify the impact of the training, track participants, and determine topics for further education. The training curriculum received approval by the Texas Department of State Health Services CHW Program Office for CHW and CHW instructor continuing education credits. Texas CHWs are required to obtain continuing education for recertification.

During the training, participants were provided with pre- and post-assessments to help determine the effectiveness of the training. After careful review of all pre- and post-assessments, participants' demographic information, knowledge gained, confidence level, and feedback were gathered to gain a better understanding of how much knowledge each participant grasped from the training.

Planning grant: 2024 CHW training in El Paso, Texas

In 2024, NRAFI, UTA, and IHI developed the first bilingual (English/ Spanish) age-friendly CHW curriculum, offering both in-person and virtual options and bilingual evaluations to ensure accessibility for Spanish-speaking CHWs, who make up the majority in El Paso. The curriculum was piloted through two in-person trainings in El Paso and a statewide virtual session.

Key outcomes from the planning grant evaluations:

• Increase awareness and knowledge of the age-friendly care 4Ms framework.
• Enhanced confidence in applying the 4Ms in practice.
• Positive feedback on interactive learning and bilingual access.
  
  

These evaluation outcomes positioned the NRAFI for broader implementation in 2025.

Implementation grant year 1: 2025 CHW training in South Texas

From July 2024 to May 2025, NRHA coordinated with UTA, IHI, and JAHF to expand the bilingual in-person CHW training to two locations in South Texas: Laredo and Alamo. The training was originally planned as a two-day training at one site, but Texas Department of Health leaders from South Texas suggested splitting the sessions across two locations to maximize participation. The two locations are about three hours apart. NRHA, UTA, and the Texas Department of Health staff finalized logistics, including venue, catering, and registration.

The results indicate a drastic increase in knowledge post-training, with more than 90 percent of post-training response questions answered correctly.

Participant feedback

• “Great presentation and the speaker was wonderful. She kept us engaged.”
• “Overall, I appreciate the time and resources in this, but all this also needs to be implemented at the health care level, clinics, doctors, and nurses.”
• “It’s important to continue with these types of training that equip CHWs with the objective to give our all in the older adult community” (translated from Spanish)
• “This is very helpful information to know what we as CHW will be able to use to help and direct these patients to the correct places where they can be helped.”
• “I am taking a lot of knowledge, I would like it if, in the future, this presentation is done again.”

NRHA and UTA are proud to have trained 133 CHWs in person over two years, exceeding the original goal of 100 participants (50 per year). Throughout the two years, CHWs have demonstrated significant increases in knowledge and confidence to support rural older adults in safely aging in their preferred homes and communities.

Implementation grant year 2 & 3 next steps

In-person rural CHW 4Ms training and evaluation project

• Train an additional 100 CHWs during implementation grant years 2 and 3 (in early 2026 and 2027, respectively).
• Years 2 and 3 facilitators will adapt the curriculum for their specific communities.
• Strengthen evaluation.
  
  

NRAFI Rural CHW Training Virtual Academy

• 3 virtual CHW training sessions with 225 CHWs to be trained through NRHA’s Learning Management System (LMS) Virtual Academy each year (75 per year).
• NRHA and UTA/Dr. Denise Hernandez will work with other age-friendly/older adult-focused partners to expand access to training materials for rural CHWs across the country and make the Rural CHWs 4Ms training available through NRHA’s learning management system. 
• UTA will provide the developed training asynchronously through NRHA’s learning management system, which is home to the Rural CHWs Training Virtual Academy for any interested CHW.
  • UTA will also translate and record the asynchronous training in Spanish.
  • Virtual version will also be submitted for certification in Texas for Texas CHWs.
  • NRHA and UTA will work to have it certified in at least four other states. 
• Using the in-person evaluations, NRHA expects to subcontract with IHI and appropriate subject matter experts on the topics CHWs request. The subcontractors will develop an additional module and record it for NRHA’s Rural CHW Training Virtual Academy.
  
  

Additional age-friendly CHW resources, impact stories, and updates are available on the National Rural Age-Friendly Initiatives Resources Hub.

• Read the 2024 CHW in-person training report
• Read the 2025 CHW in-person training report
  
  

For more information, contact NRHA’s NRAFI team including Laura Hudson and co-author Rebecca Yeboah, as well as co-author Dr. Denise Hernandez from the UTA team.