Rural Project Examples Addressing Chronic disease management

Updated/reviewed November 2025

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.

Updated/reviewed September 2026

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.

Updated/reviewed March 2026

Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
Intervention: A unique community health worker-based chronic care management program, created with philanthropy support.
Results: After a decade of use in attending to population health needs, health outcomes, and healthcare costs, in 2024, the medical condition-agnostic model has a 4-year track record of financial sustainability with recent scaling to include 31 rural counties in a 3-state area of Appalachia and recent implementation in urban areas.

Updated/reviewed October 2025

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 2025, over 202,000 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Updated/reviewed October 2025

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.

Updated/reviewed August 2024

Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
Intervention: With early federal grant-funding, a 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 comprehensive set of health-related interventions to frontier area residents.
Results: With additional private grant funding, success continued to build into the current model of an established and separate CHW division within the health system's population health department.

Updated/reviewed September 2026

Need: Indiana's rural communities face significant behavioral health and primary care shortages. Providers require trained frontline workers who can support care navigation, address social drivers of health, and expand access to prevention, intervention, and recovery services.
Intervention: A statewide training and workforce development model that certifies Community Health Workers (CHWs) and dual CHW/PRSS (Peer Recovery Support Specialists) to serve in rural settings.
Results: ASPIN has trained and certified 2,235 Community Health Workers, expanded PRSS training opportunities, and supported rural partners statewide through CHW training and workforce development programs.

Added July 2026

Need: To improve kidney care for patients in rural Indiana.
Intervention: A nurse-led, interdisciplinary kidney care program redesigned clinical workflows to identify patients earlier, provide education, address barriers to treatment, and support informed decision-making.
Results: From 2023 to 2025, 80% to 92% of patients received Kidney Care Options education before initiating kidney replacement therapy.

Added May 2026

Need: To make sure patients with chronic conditions are educated about, and able to manage, their medical prescriptions and care.
Intervention: A rural primary care-based program that uses a multidimensional team approach to connect rural patients with clinical pharmacists via telehealth.
Results: More than 250 patients have participated in the program.

Updated/reviewed March 2026

Need: Population health approach to decrease cardiovascular disease deaths in a rural Ohio healthcare delivery system's service area.
Intervention: A rural health system's investment in level II cardiac catheterization services and the required specialized cardiology workforce.
Results: In August 2018, Avita Health System started their cardiovascular service offerings in rural north central Ohio. Early results included decreased tertiary care hospital transfers. Building on the success of their increased ability to provide acute care, care coordination for patients with significant cardiovascular risks, preventive education with risk factor identification and modification, the health system continues to expand its local cardiovascular care.

Rural Project Examples: Chronic disease management