Rural Project Examples Addressing Chronic disease management

Chronic Disease Self-Management Program
Updated/reviewed December 2019

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.

Montana "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
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

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.

Meadows Diabetes Education Program
Updated/reviewed September 2022

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.

Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
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

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

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.

The Health-able Communities Program
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.

ARcare Aging Well Outreach Network
Updated/reviewed March 2021

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.

Pacific AIDS Education and Training Center-Nevada
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.

Rural Project Examples: Chronic disease management