Community Health Center: CareSouth Carolina | Hartsville, SC |
Contact: Karen Butler, Community Development Project Coordinator | Todd Shifflet, Director of Community Development

Tracking and evaluating outreach programs enables organizations to measure success, identify areas for improvement, and maintain accountability to funders, staff, clients, and the community. CareSouth Carolina utilizes tracking and performance improvement methods to strengthen and sustain its outreach efforts.


Currently, CareSouth Carolina has five outreach workers that fulfill two different roles. The first role is the Health Outreach Coach, responsible for patient follow-up and case management. They work within a specific county and visit patients in their homes when needed. The second is the Community Care Coordinator, a role that focuses on building community partnerships, providing community-based health education, and providing clinical outreach such as health screenings. All outreach workers are hired from the community they serve, and they pride themselves on working as a team with one another, patients, and their health center care teams. For CareSouth Carolina, outreach is about facilitating access to care and expanding services to the people who need them most.

Together, CareSouth’s outreach team has five basic functions:

  1. Health screenings, including blood pressure, blood sugar levels, cholesterol, etc.
  2. Health education in the community
  3. Social service navigation
  4. Outreach referral (the facilitation of getting people into care that are not already in care)
  5. Care management (helping people set and achieve self-management goals)

The outreach program measures all five functions. Each has a specific code in the practice management system, a software that manages the day-to-day operations of the health center such as appointment scheduling, billing, and report generation. The system reports data on outreach activities on a monthly basis, which allows the program to track its success on a number of outreach objectives. The program monitors five metrics when considering its success and areas for improvement: 1) outreach, 2) partnerships, 3) marketing, 4) community health, and 5) fundraising. The outreach team has specific goals related to each of the metrics. For example, they aim to build one community partnership per month, help 40 individuals make a lifestyle change per month, and successfully connect to care at least 90% of the people they refer.

caresouth_iop2The Director of Community Development reports on the five metrics in three ways: monthly to the board of directors, monthly at performance improvement meetings, and quarterly to the executive team. This program tracking and monitoring not only demonstrates the value of the program, but also enables the measurement of performance improvement efforts. All departments are involved in the performance improvement meeting, where most of the work happens to make improvement a reality. CareSouth Carolina uses the Plan, Do, Study, Act (PDSA) model for performance improvement. Through this model, the outreach program often engages in testing and revising practices to make them more effective and efficient.

For other programs that want to start systematically tracking outreach, CareSouth Carolina’s Director of Community Development recommends starting with one goal to measure. He suggests choosing whatever is the most valuable or the most important goal the program is trying to accomplish. For example, if the most important goal for an outreach program is to raise awareness about the health center’s services, begin with identifying how to measure raising awareness and begin collecting the data. Once the program has done this, it can begin to build in additional measures. Much of this process involves simply deciding what the program aims to accomplish with its resources. Once this has been decided, appropriate metrics can be identified.

CareSouth Carolina is a community health center that serves five counties in northeastern, rural South Carolina. It serves 33,000 patients, 45-49% of whom are uninsured and 60% of whom are minorities. CareSouth Carolina is also a Ryan White HIV/AIDS program grantee and a designated Area Agency On Aging. CareSouth Carolina is a proponent of integrated behavioral health and the chronic care model. Because of the recognized value of outreach, the organization has intentionally integrated outreach workers into the organization rather than having them solely tied to grant funding. The program anticipates having a greater focus on outreach and enrollment efforts in the near future.

HOP Tip: For resources on the Plan, Do, Study, Act (PDSA) model, visit: