Rural Project Examples: Chronic disease management
Evidence-Based Examples
Chronic Disease Self-Management Program
Updated/reviewed September 2023
Updated/reviewed September 2023
- Need: To help people with chronic conditions learn how to manage their health.
- Intervention: A small-group 6-week workshop for individuals with chronic conditions to learn skills and strategies to manage their health.
- Results: Participants have better health and quality of life, including reduction in pain, fatigue, and depression.
Effective Examples

Updated/reviewed September 2023
- Need: To provide diabetes care and education services to those in rural southeast Georgia.
- Intervention: Diabetes outreach screening, education, and clinical care services were provided to participants in Toombs, Tattnall, and Montgomery counties.
- Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.
Montana "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
Updated/reviewed November 2022
Updated/reviewed November 2022
- Need: To help rural Montana patients manage their blood pressure levels.
- Intervention: Pharmacists distributed "Team Up. Pressure Down." materials from the Million Hearts Initiative and provided consultations.
- Results: 89% of patients were able to adhere to their blood pressure medication, compared to 73% before the intervention.
Kentucky Homeplace
Updated/reviewed September 2022
Updated/reviewed September 2022
- Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
- Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
- Results: From July 2001 to June 2022, over 182,783 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Updated/reviewed August 2022
- Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
- Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
- Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed March 2021
Updated/reviewed March 2021
- 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.
Community Health Worker-based Chronic Care Management Program
Added May 2020
Added May 2020
- 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.
Promising Examples

Updated/reviewed April 2021
- 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.
Other Project Examples

Updated/reviewed May 2023
- Need: To help adults and children in rural South Dakota prevent or manage their diabetes.
- Intervention: The Facing Diabetes Project offered medical visits for adults and provided prevention and education sessions for the local 4th and 5th graders.
- Results: Many adults and children in the region felt better equipped to choose healthy foods, exercise regularly, and manage their stress: all factors that can help prevent diabetes or decrease its effects.

Updated/reviewed February 2023
- Need: To improve and increase prevention and care services for HIV, STDs, hepatitis C, and other infectious diseases.
- Intervention: PAETC-NV provides clinical and didactic trainings, conferences, technical assistance, capacity building, webinars, and other services to providers and healthcare organizations statewide.
- Results: In 2022, PAETC-NV trained more than 1,400 healthcare providers across Nevada to increase clinical capacity in the care, screening, and prevention of HIV, other sexually transmitted diseases, COVID-19, and hepatitis C.
For examples from other sources, see: