Need: The U.S. Associated Pacific Islands (USAPI) needed an efficient, effective, integrated method to improve primary care services that addressed the increased rates of non-communicable disease (NCD), the regional-specific phrase designating chronic disease.
Intervention: Through specialized training, multidisciplinary teams from five of the region's health systems implemented the Chronic Care Model (CCM), an approach that targets healthcare system improvements, uses information technology, incorporates evidence-based disease management, and includes self-management support strengthened by community resources.
Results: Aimed at diabetes management, teams developed a regional, culturally-relevant Non-Communicable Disease Collaborative Initiative that addresses chronic disease management challenges and strengthens healthcare quality and outcomes.
Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.
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.
Need: To reduce falls and improve chronic care management for adults 50 or older in rural Cross County, Arkansas.
Intervention: The ARcare Aging Well Outreach Network, run by an FQHC, provided services like falls prevention assessments, transportation to appointments, medication management, and senior-specific exercise opportunities.
Results: From May 2015 to April 2018, the network served 639 patients through 1,580 medical encounters.