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Utilizing a nurse/community health worker team model, a Midwest institution's community health care division developed a 12-month managed care program for underserved individuals diagnosed with heart failure and/or diabetes. A study of 277 patients was conducted to determine whether this model could be utilized in rural settings. The program was evaluated using the Institute for Healthcare Improvement's Triple Aim criteria; HEDIS measures and other health indicators quantified each patient's performance. Study participants showed improved outcomes and a reduction in the total cost of care. Hospital admissions decreased (203.4 inpatient days were saved), and the return-on-investment value realized was 1.37 for emergency department and inpatient visits in the rural communities.