River Valley Health (RVH), formerly Cherokee Health Systems, is a federally qualified health center (FQHC) and community mental health center (CMHC) serving rural eastern Tennessee. RVH operates care facilities in 13 counties that serve individuals from 23 counties across the state, as well as neighboring communities in Georgia and Kentucky. Across its facilities, RVH uses multidisciplinary care teams to improve community health and well-being through high-quality, integrated primary care, behavioral health, dental, vision, pharmacy, and related services.

Many RVH patients have complex physical, behavioral health, and social needs and live in rural areas where they face significant barriers to accessing care, including long distances to care settings and a shortage of licensed medical and behavioral health providers. To address these challenges and extend the capacity of its limited workforce, RVH relies on community-based workforce roles such as peer recovery specialists (peers) and community health workers (CHWs) to engage patients in care and provide effective services. Far from being supplemental, these roles are integral to RVH’s integrated care model, enabling the organization to expand access, strengthen trust and engagement, and reduce strain on an overstretched clinical workforce.

This profile focuses on RVH’s behavioral health services and the role of the community-based workforce in supporting more accessible, responsive, and effective care. RVH’s experience demonstrates how community-based workers can help providers in rural communities address both clinical and non-clinical barriers to care. It also highlights how these roles can strengthen ties between health care organizations and the communities they serve and create local employment opportunities.

Implementation Approach

River Valley Health developed its community-based workforce strategy to address two primary challenges: barriers to access and workforce challenges. Many individuals served by RVH have complex health and social needs and face significant challenges to accessing care. Recognizing that traditional clinical encounters alone were not sufficient, RVH adopted a high-touch approach that incorporates the community-based workforce into its care model to help patients address barriers to treatment and engage in care. Individuals may need help with transportation, housing, medication access, care transitions, employment, recovery support, and the day-to-day problem solving required to engage consistently in care. Community-based workers are well positioned to meet these needs because they often bring lived experience, local knowledge, cultural familiarity, and practical problem-solving skills. Their credibility and familiarity can help patients feel understood and bridge the gap between the health care organization and the community.

Tennessee, particularly in rural areas, has long faced a shortage of licensed behavioral health providers. RVH rapidly lost licensed clinical staff during the COVID-19 pandemic as some relocated and others left the health care workforce due to burnout and related challenges. The organization quickly found itself without sufficient licensed clinicians to adequately serve its patient population. Prior to 2020, RVH employed community case managers, so there was an existing foundation on which to build.

Programs and Services

RVH’s community-based workforce is embedded across its behavioral health care programs and services. Peers, CHWs, community health coordinators, and other non‑clinical community-based staff help identify behavioral health needs during primary care visits and connect people to care and supports. Working alongside licensed clinical staff, these community-based team members play an important role in delivering coordinated, person centered-services. Examples include:

• Integrated Behavioral Health Services in Primary Care: Licensed behavioral health providers and community-based staff work alongside primary care providers to address mental health and/or substance use issues during primary care visits.

• Extended Outpatient Program: Licensed providers and community-based staff often co-facilitate group therapy sessions for patients struggling with substance use issues.

• Psychiatric Day Treatment Program: Licensed clinicians and community-based workforce staff jointly operate this program, which focuses on skill building activities for people with mental health issues aimed at increasing independent living, community integration, and personal wellness goals.

• Medication-Assisted Treatment: Licensed prescribers provide naltrexone and buprenorphine for patients with substance use disorder deemed appropriate for medication-assisted treatment, while community-based staff assist with care engagement and navigation.

• Community Health Coordination: Community Health Coordinators provide comprehensive case management services to patients, including arranging transportation to appointments and coordinating care among multiple providers.

• Independent Placement & Support Services: Community-based staff help individuals obtain and maintain employment through services such as resume development, job search, and ongoing support.

Staffing Model

RVH currently employs more than 100 licensed or license-eligible clinicians and over 40 community-based workforce staff to provide its comprehensive behavioral health services (see table below for staff roles).

River Valley Health Staff Roles and Responsibilities

Funding Strategy

RVH generates most of its revenue through TennCare (Tennessee’s Medicaid program) and commercial insurance payment for clinical services. Grant funding helps support services and workforce roles not fully reimbursable through traditional payment mechanisms, including many community-based workforce positions.

Although most community-based workforce roles are not directly reimbursable, some contribute to performance-based payment models that support the organization’s financial sustainability. For example, RVH receives funding through the Tennessee Department of Human Services’ Division of Vocational Rehabilitation, earning payments when participants in Independent Placement and Support Services (IPSS) achieve employment milestones, such as obtaining and maintaining employment. IPSS specialists play a central role in helping participants reach these milestones through job search assistance, employment preparation, and ongoing workplace support.

Tennessee’s Medicaid Health Homes program, TN Health Link, coordinates care for TennCare members with significant behavioral health needs and offers bonus payments to participating providers that meet quality benchmarks, such as reduced ED visits and improved medication adherence. Community Health Coordinators providing case management through TN Health Link play a key role helping RVH achieve these outcomes and receive bonuses. RVH has earned bonus payments in recent years, demonstrating the value of investing in the community-based workforce.

Impact

In 2025, RVH served more than 64,000 patients through over 175,000 primary care visits and 114,000 behavioral health visits. According to RVH leadership, the community-based workforce has been a key driver of increased patient engagement, improved care coordination, expanded staffing capacity, and reduced provider burnout.

Our peer support center specialist contacts referrals who are too anxious or afraid to come into the clinic for services, and she encourages them to let her check in with them by phone for a few months. Over time, she is able to assess their need for services while getting to know the patient during those check-ins. Often she gains enough trust for the patient to attend in person, which gives them increased access to mental health, case management, and primary care. She has done this on many occasions, and it has opened up multiple services for people who were very reluctant to come in.

– Stella Melton, LPN, River Valley Health Psychological Services Coordinator

Improved Patient Engagement and Care Coordination

The community-based workforce at RVH has improved patient engagement by building trust, maintaining contact, and helping patients overcome practical barriers to care. Their shared lived experience, familiarity with local communities, and nonjudgmental approach can make it easier for patients to engage in services and remain connected to care. RVH leadership noted that, in the past, many patients did not complete referrals or connect with recommended services. The organization observed a marked improvement in successful connections to care after deploying CHWs to follow up with patients and support referral completion.

Expanded Staffing Capacity

Persistent behavioral health workforce shortages increase the demands on RVH’s licensed clinicians. By leading navigation, outreach, relationship-building, and care coordination, RVH’s community-based workforce allows clinicians to focus on responsibilities that require advanced training and credentials. As a result, RVH can maintain access in communities where recruiting and retaining licensed behavioral health providers is challenging.

Reduced Provider Burnout

Community-based workers help distribute responsibilities more effectively across care teams. RVH developed the behavioral health assistant role in part to address provider strain during the pandemic. By managing care coordination, follow-up activities, medication-related questions, and logistical barriers, these team members reduce the non-clinical workload for licensed providers. Leadership reported this team-based approach has reduced clinician burnout, improved responsiveness to patients, and contributed to a more sustainable care model.

Implementation Lessons

RVH’s experience reflects the importance of fully integrating the community-based workforce into care teams, recruiting staff who understand local needs, investing in training and supervision, and creating the organizational culture necessary for the community-based workforce to thrive.

• Fully integrate the community-based workforce into care teams. A defining feature of RVH’s model is the full integration of community-based workers into interdisciplinary care teams. Rather than operating separately from clinical care, RVH embeds community-based staff alongside licensed staff to assess patient needs, determine patient engagement and care strategies, and in some cases, co-facilitate services. RVH leadership deploys staff based on team needs, patient needs, and individual strengths and skill sets. Leadership seeks to align staff with their strengths and interests whenever possible, helping foster job satisfaction, commitment to the patients, and continued professional growth.

• Hire from the community. RVH’s community-based workforce approach depends heavily on hiring people who understand the communities where their patients live. Locally hired staff are more familiar with community resources, informal support networks, local employers, and understand the realities of rural life, allowing them to provide practical, culturally relevant support. Hiring from the community also creates economic benefits by opening career pathways for residents, including people with lived experience of recovery or behavioral health challenges.

• Develop internal talent and recruit strategically through partners. RVH identifies candidates for community-based workforce roles both internally and externally. Internally, staff in operational or administrative roles who demonstrate strong communication, empathy, and problem-solving skills may advance into community-based workforce roles. Externally, RVH recruits through local partner organizations, including substance use treatment programs. Referral bonuses further encourage staff to identify candidates who may be a strong fit for open roles.

• Invest in training and supervision. Community-based workforce staff may enter their roles with strong relationship-building and problem-solving skills but little familiarity with the health care system, clinical services provided by the organization, and necessary patient boundaries. Peer staff complete state-mandated certification, while other community-based workforce roles receive a combination of in-house and external training. Training topics may include motivational interviewing, care coordination workflows, documentation expectations, confidentiality, boundaries, and effective collaboration. Following initial training, RVH provides ongoing supervision to help the community-based workforce navigate complex patient situations, clarify role boundaries, and manage the emotional demands of their work.

• Clarify boundaries and confidentiality standards early on. In small rural communities, patients and staff may know one another outside the clinic. This makes confidentiality and boundaries especially important. RVH addresses patient privacy and confidentiality expectations during onboarding and revisits them through supervision. Licensed clinicians often receive extensive formal training on professional boundaries, while many community-based workers may be learning these expectations on the job. Establishing clear standards helps protect patients and community-based workforce staff and creates a culture of trust and respect.

• Establish a culture of mutual respect and collaboration. RVH leadership cultivates a culture of mutual respect between licensed clinicians and the community-based workforce, where every role is valued for its unique contributions to patient care. This commitment is critical to the success of the organization’s model. Without this mutual respect and trust, the community-based workforce cannot fully contribute their skills and expertise, reducing their contributions to patient outcomes and organizational functioning.

Looking Ahead

Moving forward, RVH plans to continue expanding its community-based workforce given its positive impact. However, sustainable financing will be critical to support this growth. RVH leadership sees promise in more flexible payment models, such as global budgets or per-member-per-month payments, that better support the full range of community-based workforce activities. Fee-for-service and encounter-based reimbursement are not well matched for roles that create value through outreach, relationship-building, care transitions, and social needs support. More flexible payment approaches could allow organizations to deploy community-based staff where they are most needed, rather than limiting work to narrowly reimbursable activities.

RVH’s approach offers a practical model for rural health care organizations seeking to improve access, engagement, and workforce sustainability. While grounded in integrated care, its success goes beyond co-locating services. RVH invests in people who know the community, trains them to work effectively within care teams, supports them through supervision, and aligns their roles with patient needs that traditional clinical models often struggle to meet. As policymakers, payers, and providers continue to look for ways to address behavioral health workforce shortages and improve access in rural communities, RVH’s experience points to the importance of an integrated community based workforce. When thoughtfully integrated into care delivery, these roles can improve patient outcomes, strengthen care access, and reduce system costs.

Acknowledgements

Thank you to Parinda Khatri, PhD, CEO of River Valley Health, who helped inform this profile.