In order to increase public health access to underserved populations strategic interventions are often called for. A particularly successful intervention strategy for serving the hardly reached members of the community involves a team of community health nurses and community health advocates working in neighborhood based settings to connect people to available primary care resources while providing health education and screening services on site. This model is being piloted in the Dayton, Ohio community through the Center for Healthy Communities and the Combined Health District of Montgomery County. Teams of Community Health Nurses and Community Health Advocates completed initial and ongoing training and the program is being monitored across six neighborhood sites using the Omaha System for Community Health Nursing. Working with primarily African American and Appalachian community members, client participation is being evaluated in terms of self reported behavior change, changes in health status indicators such as blood pressure, cholesterol and blood sugar, client satisfaction, health and human services utilization and successful referral to a primary care provider and regular health care services. Preliminary results have demonstrated success particularly in CHIP enrollment and general services utilization.