Need: To coordinate formal and informal community-based caregivers for optimal patient experience.
Intervention: The Maryland Faith Health Network unites places of worship and healthcare systems in Maryland. This program aims to decrease the amount of potentially avoidable hospitalizations, improve a patient's overall wellness, and cut down on the cost of medical services.
Results: This model is currently running in 3 hospitals that serve both rural and urban residents in central Maryland. So far, 1,300 congregants from 70 congregations representing Christian, Jewish, and Muslim faiths have enrolled in the Network.
Need: To reduce barriers to accessing healthcare for immigrant farmworkers in the rural areas of Vermont.
Intervention: Bridges to Health uses care coordination and health promoters to reduce barriers to accessing healthcare on an individual level. The program offers targeted technical assistance to address systemic barriers at health access points in areas with high numbers of immigrant farmworkers.
Results: Some barriers to accessing healthcare have been reduced or removed for immigrant farmworkers in certain counties.
Need: To increase local health services to rural elderly populations in long-term care facilities located in four Midwest states near a tertiary care organization.
Intervention: A non-profit healthcare organization implemented telehealth services to provide acute care evaluations for long-term residents in their home facilities.
Results: The program increased local care as evidenced by improved year-over-year provider-determined available transfer data: 33%, 50%, 63% program years 1 through 3, respectively. From the success of the initial pilot implementation, the program has further matured into a long-term care offering that now reaches many other rural facilities located in 10 states across the nation.
Need: To improve the oral health status of children ages 3 to 17 living in underserved rural areas of Louisiana.
Intervention: School-based nurse practitioners perform oral health assessments, apply fluoride varnishes when indicated, and make dental referrals, with completion rates of the latter tracked by dental case managers.
Results: Significant numbers of school children are receiving oral health examinations, fluoride varnish applications, and receiving care coordination to improve numbers of completed dental appointments.
Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.
Need: Allow rural cancer patients in a region inclusive of 26 counties in Iowa, Minnesota, and South Dakota to have access to tertiary-level chemotherapy regimens in rural infusion centers.
Intervention: With telehealth-based oversight from a tertiary care oncology team, 3 rural infusion teams were trained to coordinate cancer treatment plans and administer complex chemotherapy regimens.
Results: Almost 130 patients were transitioned to receive chemotherapy in a rural infusion center, translating to over 1,000 infusion visits and saving patients/families nearly 65,000 trip miles, 1,800 travel hours and $71,000.