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Rural Project Examples from CMS Health Care Innovation Award

Effective Examples

Kitsap Mental Health Services: Race to Health!
Updated/reviewed August 2020
  • Need: To improve the physical health of individuals seeking mental healthcare.
  • Intervention: Race to Health! in Washington integrated mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
  • Results: Race to Health! helped reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).
Project Lazarus
Updated/reviewed January 2018
  • Need: To reduce overdose-related deaths among prescription opioid users in rural Wilkes County, North Carolina
  • Intervention: Education and tools are provided for prescribers, patients and community members to lessen drug supply and demand, and to reduce harm in prescription opioid use
  • Results: Opioid overdose death rates have decreased in Wilkes County
Patient Care Connect
Updated/reviewed December 2017
  • Need: Cancer patients living in the Deep South encounter multiple barriers in accessing regular cancer treatment.
  • Intervention: The University of Alabama at Birmingham Comprehensive Cancer Center developed a program that uses lay patient navigators to support and direct patients to appropriate resources to overcome barriers to accessing care.
  • Results: The program has become a model for improving cancer care quality, decreasing unnecessary utilization (ER visits and hospitalizations), removing barriers to care, and enhancing patient satisfaction.

Promising Examples

Proactive Palliative Care and Palliative Radiation Model: Making MyCourse Better
Updated/reviewed July 2021
  • Need: To provide palliative care to patients with stage 4 cancer.
  • Intervention: The Emily Couric Clinical Cancer Center in Charlottesville, Virginia, implemented a three-part program to help these patients manage their symptoms.
  • Results: The Proactive Palliative Care and Palliative Radiation Model enrolled 646 patients during its three-year funding period of 2012-2015.
Reducing Hospitalizations in Medicare Beneficiaries
Updated/reviewed May 2021
  • Need: To reduce hospital readmissions for Medicare patients in rural Kentucky and Tennessee.
  • Intervention: Two quality improvement tools called IMPACT and INTERACT helped older patients transition from Vanderbilt University Medical Center to a skilled nursing facility.
  • Results: Practitioner follow-up visits increased, while emergency department visits decreased.
Atlantic General Hospital Patient Centered Medical Home
Updated/reviewed August 2020
  • Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
  • Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
  • Results: From the program's care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.
Felton Early Psychosis Program
Updated/reviewed April 2019
  • Need: A treatment model for those showing early signs of schizophrenia.
  • Intervention: The Felon Early Psychosis Program program was started in rural and urban California counties. The program encourages schizophrenia remission in clients through medication and psychosocial initiatives.
  • Results: Clients' hospitalization and psychiatric emergency room visits were reduced by 70% after 1 year of treatment. Schizophrenia symptoms also reduced significantly among their clients.

Other Project Examples

Delta Dental Mobile Program
Updated/reviewed March 2021
  • Need: Lack of access to oral healthcare for children from limited-income families in the rural and urban areas of South Dakota.
  • Intervention: Delta Dental of South Dakota launched the Delta Dental Mobile Program in 2004 to expand access to oral healthcare services to children throughout the rural state.
  • Results: The Delta Dental Mobile Program has provided over $31 million in dental care to more than 58,000 South Dakota children.