Other Case Studies and Collections of Program Examples: Chronic disease management
In addition to RHIhub's Rural Health Models and Innovations rural program examples, you may also want to browse other case studies, databases, and websites with collections of health programs.
Each resource listed below uses its own criteria for selecting program examples, which may range from programs known to be effective based on research to anecdotal accounts. In each resource, you may want to review information on the level of evidence required for a program's inclusion.
May include non-rural programs that could be applicable to rural health delivery.
Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Remote Patient Monitoring Helps Rural Patients Recover at Home
Features Essentia Health's remote patient monitoring program, which allows patients to recover at home while still having access to medical attention. Describes how the program was used to treat COVID-19 patients, with plans to continue the program to treat other chronic diseases.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 07/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features Essentia Health's remote patient monitoring program, which allows patients to recover at home while still having access to medical attention. Describes how the program was used to treat COVID-19 patients, with plans to continue the program to treat other chronic diseases.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 07/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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CHWs At Work: Making a Difference for Oklahoma's Marshallese Community
Highlights an Oklahoma program that uses community health workers (CHWs) for outreach to the Marshallese community in a three-county area. Provides a brief history and overview of the Marshallese population and discusses the health concerns the CHWs address.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 03/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Highlights an Oklahoma program that uses community health workers (CHWs) for outreach to the Marshallese community in a three-county area. Provides a brief history and overview of the Marshallese population and discusses the health concerns the CHWs address.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 03/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Pennsylvania Hospital Transitions HRSA-Funded Program to Online Services and Addresses COVID-19 Stress
Features Butler Memorial Hospital and how it adapted to the COVID-19 pandemic. Highlights the switch to online delivery for a chronic disease project funded by a HRSA Rural Health Care Services Outreach grant. Also describes initiatives to address healthcare workforce stress, help patients use tablets to visit with loved ones, and distribute healthy food to the community.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 07/2020
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features Butler Memorial Hospital and how it adapted to the COVID-19 pandemic. Highlights the switch to online delivery for a chronic disease project funded by a HRSA Rural Health Care Services Outreach grant. Also describes initiatives to address healthcare workforce stress, help patients use tablets to visit with loved ones, and distribute healthy food to the community.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 07/2020
Type: Document
Sponsoring organization: Rural Health Information Hub
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Rural Patients with Chronic Disease: A Nonprofit Organization and a Health Department Leverage Federal Funding to Provide Health Education and Care Coordination
Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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New Mexico Mobile Screening Program for Miners Brings Care to the Patients
Highlights a New Mexico program that uses screenings, specialty care via telehealth, and collaboration to meet the healthcare needs of miners with occupational lung disease. Services are provided via a mobile screening clinic housed in a semi that goes to 12 locations in the state.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 02/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Highlights a New Mexico program that uses screenings, specialty care via telehealth, and collaboration to meet the healthcare needs of miners with occupational lung disease. Services are provided via a mobile screening clinic housed in a semi that goes to 12 locations in the state.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 02/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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Medical-Legal Partnership Addresses Social Determinants of Health
Explores how FirstHealth of the Carolinas, a private, nonprofit healthcare network based in Pinehurst, North Carolina, reduced emergency department utilization and hospital readmission rates systemwide through the use of transitional care clinics (TCCs) and medical-legal partnerships (MLPs). Highlights how addressing non-medical factors can affect health outcomes.
Date: 08/2017
Type: Document
Sponsoring organization: Rural Health Value
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Explores how FirstHealth of the Carolinas, a private, nonprofit healthcare network based in Pinehurst, North Carolina, reduced emergency department utilization and hospital readmission rates systemwide through the use of transitional care clinics (TCCs) and medical-legal partnerships (MLPs). Highlights how addressing non-medical factors can affect health outcomes.
Date: 08/2017
Type: Document
Sponsoring organization: Rural Health Value
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North Sunflower Medical Center Successfully Addressing Chronic Care Management
Documents North Sunflower Medical Center's (NSMC) progress as part of the Small Rural Hospital Transition (SRHT) project, particularly in the areas of discharge planning and follow-up, placing patients in the correct level of care, and chronic disease management. NSMC is a 25-bed Critical Access Hospital located in Ruleville, Mississippi.
Date: 09/2016
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Documents North Sunflower Medical Center's (NSMC) progress as part of the Small Rural Hospital Transition (SRHT) project, particularly in the areas of discharge planning and follow-up, placing patients in the correct level of care, and chronic disease management. NSMC is a 25-bed Critical Access Hospital located in Ruleville, Mississippi.
Date: 09/2016
Type: Document
Sponsoring organization: National Rural Health Resource Center
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