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Rural Health Models and Innovations Funded by the Federal Office of Rural Health Policy

A collection of rural health projects that received support from the Federal Office of Rural Health Policy:

TeleStroke/Vascular Neurology Patient Navigator Program
Added March 2019
  • Need: Improve post-hospital stroke care access in order to improve physical function and well-being for stroke patients living in a 6-county area in rural Minnesota.
  • Intervention: Implementation of an evidence-based patient navigator program paired with telehealth services for post-hospital care of rural stroke patients.
  • Results: In addition to other successes, more than 120 individuals enrolled in the navigator program, the Modified Rankin Score assessments at baseline and 6 months showed functional improvements.
The Health-able Communities Program
Added March 2019
  • Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
  • Intervention: Consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a diverse set of healthcare offerings to frontier area residents.
  • Results: Increased healthcare access, especially for cancer and chronic disease screening, along with providing education on a diverse array of health topics.
High Plains Community Health Center Care Teams
Updated/reviewed February 2019
  • Need: Meeting health care demands in a region with a limited number of physicians, where recruiting additional providers is considered impractical.
  • Intervention: Using the additional support of health coaches, implementation of care teams consisting of 3 medical assistants to support each provider.
  • Results: More patients seen per provider hour, with improved patient outcomes and clinic cost savings.
From CATCH to C.H.E.F.
Updated/reviewed January 2019
  • Need: To help children and families in Lincoln, rural Benton, and east Linn counties achieve higher-quality lives free of preventable diseases related to poor nutrition and obesity.
  • Intervention: Two programs were applied on a local level to provide physical activity, nutrition, and culinary education in a school and community setting.
  • Results: The physical activity rate surpassed the Department of Health and Human Services recommended rate by 5%, and schools started serving healthier options in their cafeterias.
Northeast Louisiana Regional Pre-Diabetes Prevention Program
Updated/reviewed January 2019
  • Need: To prevent or slow the progression of diabetes for at-risk residents in Rural Northeast Louisiana.
  • Intervention: The North Louisiana Regional Alliance developed a program that offered screenings, education, and an intense course for participants throughout the Northeast Louisiana region to lower the risk of diabetes.
  • Results: The program saw an overall decrease in blood sugar levels in residents who participated in their initiatives.
Northern Dental Access Center Patient Support and Outreach Program
Updated/reviewed January 2019
  • Need: To connect low-income people in rural northwest Minnesota to dental care and support services in order to address barriers to care.
  • Intervention: Partners work together to provide patient transportation, care coordination, and insurance navigation and enrollment.
  • Results: Patients accessing support services are more likely to complete dental treatment. Over 1,000 people a year have been assisted with Medicaid enrollment, and reported use of the emergency department for dental pain has been reduced.
Healthy Outcomes Integration Team
Updated/reviewed November 2018
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: The Healthy Outcomes Integration Team was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.
Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed November 2018
  • Need: To properly address and treat patients who have concurrent substance abuse and chronic healthcare issues.
  • Intervention: A referral system was created that utilizes community health workers (CHWs) in a drug and alcohol treatment setting.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.
Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2018
  • Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
  • Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
  • Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.
Physical and Behavioral Health Integrated Care Project
Updated/reviewed October 2018
  • Need: To provide unified and seamless access to primary care to adult patients in Pennsylvania's rural Clearfield and Jefferson counties who have been diagnosed with Serious and Persistent Mental Illness.
  • Intervention: A "one-stop shop" of healthcare services addressed the physical and behavioral health and medication needs of adults in the region.
  • Results: Results indicated better behavioral and physical health outcomes for participants as well as increased adherence to medications.