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Rural Project Examples: Chronic disease management

Evidence-Based Examples

Chronic Disease Self-Management Program
Updated/reviewed October 2018
  • 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

Montana "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
Updated/reviewed November 2019
  • 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 May 2019
  • 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 address the lifestyle choices, inadequate health insurance, and environmental factors that are believed to contribute to these diseases.
  • Results: From July 2001 to June 2018, over 161,968 rural residents have been served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed January 2019
  • 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 April 2018
  • 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.

Promising Examples

funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed December 2019
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.
funded by the Federal Office of Rural Health Policy ARcare Aging Well Outreach Network
Updated/reviewed March 2019
  • 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, provides services like falls prevention assessments, transportation to appointments, medication management, and senior-specific exercise opportunities.
  • Results: From May 2015 to December 2017, the network served 584 patients.
funded by the Federal Office of Rural Health Policy The Health-able Communities Program
Added March 2019
  • 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.
funded by the Federal Office of Rural Health Policy Healthy People: Healthy Communities
Updated/reviewed November 2017
  • Need: Spotlight chronic disease risks in rural south central Kentucky, specifically stroke and heart disease.
  • Intervention: A case management program for Kentucky counties of Boyle, Garrard, Lincoln, and Mercer.
  • Results: Decreased the risk of stroke and heart disease among program participants.
funded by the Federal Office of Rural Health Policy Heartland Rural Health Network
Updated/reviewed November 2017
  • Need: To assist diabetic patients in rural Florida with chronic disease management.
  • Intervention: Heartland Rural Health Network set out to expand the Diabetes Master Clinician Program and implement healthy eating in 4 Florida counties.
  • Results: Initial participating clinics exceeded national averages of successful management of diabetes. The program remains active and successful.