Skip to main content

Rural Project Examples: Chronic disease management

Other Project Examples

Boone County Health Center Pulmonary Rehabilitation Program
Added June 2021
  • Need: Evidenced-based intervention to improve function and quality of life for patients with chronic obstructive pulmonary disease and other chronic lower respiratory conditions.
  • Intervention: Pulmonary rehabilitation program implementation in 1989.
  • Results: Compared to a national average of only about 3% of referred Medicare beneficiaries actually enrolling in pulmonary rehabilitation, 60% of the program's referred patients enroll. Averaging around 15 patients/year completing the program, a large combined cardiac and pulmonary rehabilitation maintenance population averages 8,000 visits/year.
funded by the Federal Office of Rural Health Policy Facing Diabetes: Quality Improvement in Rural South Dakota Project
Updated/reviewed May 2021
  • 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.
Avita Health System Comprehensive Cardiology Program
Added April 2021
  • Need: Population health approach to decreasing area deaths from cardiovascular disease.
  • Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
  • Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.
funded by the Health Resources Services Administration Pacific AIDS Education and Training Center-Nevada
Updated/reviewed January 2021
  • 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 fiscal year 2018, PAETC-NV provided over 1,300 hours in 38 trainings for more than 800 healthcare providers throughout Nevada.
Health Advocacy Summit
Updated/reviewed June 2020
  • Need: To help young adults with chronic or rare conditions access health and educational resources and build a community of peers and advocates.
  • Intervention: Health Advocacy Summits bring together young adults, medical professionals, patient advocates, and others for a free one-day conference. HAS also facilitates programming such as the Crohn's and Colitis Young Adults Network.
  • Results: HAS currently has summits in six states. HAS reported that it was one of the first advocacy interventions for young adults with chronic conditions in south Texas.
funded by the Federal Office of Rural Health Policy Community Healthcare Integrated Paramedicine Program (CHIPP)
Updated/reviewed January 2020
  • Need: To reduce 911 use and improve older adults' health in rural Santa Cruz County, Arizona.
  • Intervention: Community paramedics make scheduled visits to patients and connect them to other community resources.
  • Results: CHIPP has assisted over 150 people so far, and 911 calls have decreased.
funded by the Health Resources Services Administration University of Mississippi Medical Center's Center for Telehealth
Updated/reviewed January 2020
  • Need: Rural areas in Mississippi often lack adequate access to specialty healthcare services such as emergency medicine, stroke neurology, pediatric specialists and psychiatrists.
  • Intervention: The University of Mississippi Medical Center created the Center for Telehealth to deliver quality specialty services through telehealth video conferencing and remote monitoring tools to the underserved areas of Mississippi.
  • Results: The program has been successfully implemented throughout many of the state's rural hospitals and has reduced transfers and geographic barriers for patients.
AmeriCorps Community Health Workers Program
Updated/reviewed December 2019
  • Need: Chronic diseases, diabetes, and opioid misuse has caused significant health disparities in Ohio and West Virginia.
  • Intervention: A program recruiting AmeriCorps members to serve as community health workers helps bring health services and education to local residents.
  • Results: As a result of the program, community members have reported weight loss, increased physical activity, reduction in medication, and improvements in self-management of chronic diseases.
funded by the Federal Office of Rural Health Policy Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management
Updated/reviewed December 2019
  • Need: Decrease hospital readmissions and emergency room visits for patients in rural Tidewater, Virginia.
  • Intervention: After inpatient admission or ER visit, identify at-risk patients to offer enrollment in remote monitoring and disease self-management education and coaching, with a special focus on behavioral health wellness.
  • Results: Decreased readmissions and ER visits paired with high patient satisfaction scores.
Scheffe Prescription Shop's Medication Synchronization Program
Updated/reviewed December 2019
  • Need: For adults with chronic conditions, skipping a dose or two is common, but can also be risky. Frequent medication in-adherence has accounted for emergency department visits, hospitalizations, and even death.
  • Intervention: The Scheffe Prescription Shop in Enid, Oklahoma started a medication synchronization program. Pharmacists serve as care coordinators for patients by prepackaging pills, scheduling recheck appointments, and providing pickup reminders and medication education over the phone.
  • Results: The program has reduced the number of trips patients have to take to the pharmacy to pick up their pills and has increased medication adherence rates over 4 years.