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Rural Project Examples: Chronic disease management

Evidence-Based Examples

Chronic Disease Self-Management Program
Updated/reviewed October 2017
  • Need: To help people with chronic conditions learn how to manage their health.
  • Intervention: A small-group 6-week workshop for individuals with chronic conditions to learn skills and strategies to manage their health.
  • Results: Participants have better health and quality of life, including reduction in pain, fatigue, and depression.

Effective Examples

funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed June 2017
  • Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
  • Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
  • Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.

Promising Examples

funded by the Federal Office of Rural Health Policy Healthy People: Healthy Communities
Updated/reviewed November 2017
  • Need: Spotlight chronic disease risks in rural south central Kentucky, specifically stroke and heart disease.
  • Intervention: A case management program for Kentucky counties of Boyle, Garrard, Lincoln, and Mercer.
  • Results: Decreased the risk of stroke and heart disease among program participants.
funded by the Federal Office of Rural Health Policy Heartland Rural Health Network
Updated/reviewed November 2017
  • Need: To assist diabetic patients in rural Florida with chronic disease management.
  • Intervention: Heartland Rural Health Network set out to expand the Diabetes Master Clinician Program and implement healthy eating in 4 Florida counties.
  • Results: Initial participating clinics exceeded national averages of successful management of diabetes. The program remains active and successful.
funded by the Federal Office of Rural Health Policy Community Health Coaches for Successful Care Transitions
Updated/reviewed September 2017
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.

Other Project Examples

Montana "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
Added November 2017
  • Need: To help rural Montana patients manage their blood pressure levels.
  • Intervention: Pharmacists distributed "Team Up. Pressure Down." materials from the Million Hearts Initiative and provided consultations.
  • Results: 89% of patients were able to adhere to their blood pressure medication, compared to 73% before the intervention.
Rugby Community Paramedic Program
Added November 2017
  • Need: Low patient volumes, a shortage of EMS volunteers, and an aging population in a 5-county North Dakota region required a change in the way the Rugby EMS team delivered care.
  • Intervention: Through the Rugby Community Paramedic Program, EMS staff bring medical care to patients transitioning back into their homes, including those with chronic conditions and hospice patients.
  • Results: The program's early intervention methods helped reduce the number of emergency room admissions and the escalation of medical conditions. Patient satisfaction has improved and the program has gained the trust of patients and medical staff in Rugby and surrounding areas.
AmeriCorps Members as Community Health Workers
Updated/reviewed August 2017
  • Need: A significant number of people struggle with obesity, diabetes, and high blood pressure in the Mid-Ohio Valley of West Virginia, yet there was a limited number of health department staff available to address these issues.
  • Intervention: The Mid-Ohio Valley Health Department utilized AmeriCorps members to serve as community health workers, educating people on health topics in the areas in which they live.
  • Results: AmeriCorps members have motivated people to exercise, lose weight, and self-manage their chronic diseases, leading to healthier residents of the Mid-Ohio Valley.
funded by the Health Resources Services Administration Roane County Hypertension Control
Updated/reviewed July 2017
  • Need: Nearly one in three Americans has hypertension, and rural community members lack access to clinics and means for monitoring and treatment of their high blood pressure.
  • Intervention: Roane County Family Health Care (RCFHC) uses community-oriented, outcome- and team-based care to combat their rural community members' high rates of hypertension.
  • Results: In 2014, RCFHC succeeded in achieving hypertension control rates in at least 70% of patients, and was named a 2014 Hypertension Control Champion by the U.S. Department of Health and Human Services.
funded by the Federal Office of Rural Health Policy Facing Diabetes: Quality Improvement in Rural South Dakota Project
Updated/reviewed June 2017
  • Need: To help adults and children in rural South Dakota prevent or manage their diabetes.
  • Intervention: The Facing Diabetes Project offered group medical visits for adults and provides prevention and education sessions for the local 4th-5th graders.
  • Results: Many adults and children in the region feel better equipped to choose healthy foods, exercise regularly, and manage their stress: all factors that can help prevent diabetes or decrease its effects.