Skip to main content
Rural Health Information Hub

Formerly the
Rural Assistance Center

Rural Project Examples: Medical homes

funded by the Federal Office of Rural Health Policy Western Appalachian Health Care Access Consortium: The Bridge Program
Updated/reviewed November 2017
  • Need: Access to primary medical, dental, and mental health services for rural Appalachia Kentuckians.
  • Intervention: Community Health Workers provide outreach, education, navigation, and care coordination services to 5 counties in the Western Appalachian area of Kentucky through The Bridge Program.
  • Results: Emergency room visits have decreased throughout the course of the program and referrals to healthcare services have increased. Increases in self-efficacy and decreases in A1c levels have reached statistical significance.
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.
Safety Net Medical Home Initiative
Updated/reviewed October 2017
  • Need: To help healthcare providers serving underserved and vulnerable populations become patient-centered medical homes (PCMH).
  • Intervention: A 5-year project was launched to develop a replicable model for practice transformation for safety net providers, including rural practices.
  • Results: Eighty-three percent of participating safety net clinics earned state or national PCMH recognition as of September, 2013.
funded by the Federal Office of Rural Health Policy Medical Home Plus
Updated/reviewed September 2017
  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.
Clinic for Special Children
Updated/reviewed June 2017
  • Need: Healthcare for the genetically vulnerable children of the rural, uninsured Amish and Mennonite communities in southern Pennsylvania.
  • Intervention: A clinic that serves as a comprehensive care medical home for children (primarily from the Amish and Mennonite communities) with rare, inherited disorders.
  • Results: In 2016, over 1,000 active patients with more than 200 unique genetic mutations were treated at the Clinic for Special Children.
Patient Centered Medical Home Practicum in Primary Care
Updated/reviewed May 2017
  • Need: Improvement in service quality and patient experience in primary care practices in North Carolina's Blue Ridge region.
  • Intervention: A practicum for healthcare management students to help rural practices achieve Patient Care Medical Home (PCMH) status and identify quality improvement strategies.
  • Results: Rural primary practices have achieved PCMH status and Blue Quality Physician Program Recognition.
SAMA HealthCare Services, a Patient-Centered Medical Home
Added December 2015
  • Need: The traditional model where providers work independently from one another in treating patients proved to lack care continuity at SAMA Healthcare Services in rural Arkansas
  • Intervention: The family practice clinic shifted to a team-based model of care where the medical staff works together in pods in order to create a patient-centered medical home
  • Results: SAMA doubled the amount of patients seen in 1 day and at least 90% of patients receive medical treatment from a provider within their pod
funded by the Federal Office of Rural Health Policy Chautauqua Health Connects (CHC)
Added September 2015
  • Need: To address care coordination and the integration of services in a rural, aging population
  • Intervention: This program uses health information technology and dedicated staff to manage clinical and community services for complex patients.
  • Results: Hospital readmissions have decreased, follow-up rates have increased, and patients' perceived health status has improved.