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Rural Project Examples: Home and community-based services

Promising Examples

Northland PACE (Program of All-Inclusive Care for the Elderly)
Updated/reviewed January 2017
  • Need: Older adults who are nursing home eligible need assistance in order to remain living safely and independently in their own homes.
  • Intervention: Northland PACE (Program of All-Inclusive Care for the Elderly) offers, plans, and coordinates a wide range of healthcare, in-home, and day center services to promote independence at home.
  • Results: Older adults remain safely in their homes for a longer period of time with this support. The PACE program sites in North Dakota work to preserve, enhance, and, in many cases, restore the independence, health, and well-being of their participants.

Other Project Examples

SASH® (Support and Services at Home)
Updated/reviewed November 2017
  • Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, posed significant challenges for those who wanted to remain living independently at home.
  • Intervention: SASH® (Support and Services at Home), based in affordable housing communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
  • Results: Compared to their non-SASH peers, SASH participants report better health outcomes like fewer falls, lower rates of hospitalizations, and completion of more advance directives – all of which has the potential of saving millions of dollars.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
Added October 2017
  • Need: Provision of medical care access and follow-up for rural North Carolina HIV patients with mental health, substance abuse, and unstable housing/homelessness challenges.
  • Intervention: Medical home staff model expanded to a care coordination program with a core Network Navigator and Continuum of Care Coordinator assisting with medical, behavioral health, and basic life needs.
  • Results: To date, the program has advanced three aspects of medical home patient care for this target population: provided further understanding of the spectrum of homelessness, including “hidden” homelessness; implemented outreach with creation of new community partnerships and a community housing coalition; and integrated medical care and behavioral health care for HIV.
Fostering Futures in Menominee Nation
Updated/reviewed September 2017
  • Need: Since the late 1800’s, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
  • Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
  • Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 85% since 2008.
Care Partners of Cook County
Updated/reviewed April 2017
  • Need: To provide holistic, interdisciplinary palliative care to those with chronic illnesses in rural hospitals in Cook County, Minnesota.
  • Intervention: Care Partners of Cook County created a palliative care program that utilizes local healthcare professionals and volunteers to provide universal care to patients and caregivers, without Medicare hospice status.
  • Results: Since its inception in 2010, the program has assisted over 185 residents in need.
Pathways Vermont Housing First Program
Updated/reviewed February 2017
  • Need: To provide housing for the chronically homeless who face mental health and/or substance abuse challenges in the rural areas of Vermont.
  • Intervention: Pathways Vermont initiated a rural version of the Housing First program that provides access to permanent rental housing and numerous services to help sustain housing stability.
  • Results: Participants reported decreased time spent homeless, a significant improvement in their standard of living, and hundreds of thousands of dollars were saved on behalf of Vermont.
Senior CommUnity Care
Updated/reviewed January 2016
  • Need: Many older adults need some assistance in order to remain independent in their homes.
  • Intervention: A PACE (Program of All-Inclusive Care for the Elderly) provides healthcare services and support for older adults living in the western rural counties of Delta and Montrose in Colorado.
  • Results: Allows older people in western Colorado to maintain their independence in their own homes with a higher quality of life.