Rural Project Examples Addressing Chronic disease management

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.

Volunteers of America Southeast Louisiana's Stepping Stones Program
Added February 2023

Need: Black women living with HIV in rural southeastern Louisiana face challenges in accessing care and other needed resources, often while dealing with other life stressors such as poverty, physical and mental health comorbidities, and a history of trauma.
Intervention: Implementing three evidence-informed interventions simultaneously ensures success in linking, treating, and retaining Black women in HIV care to improve health outcomes.
Results: As of February 2023, Stepping Stones has recruited 38 participants.

ASPIN's Certified Recovery Specialist Program
Updated/reviewed September 2022

Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's underserved rural counties.
Intervention: A network was established that trained community health workers (CHWs) to be certified health insurance enrollment navigators and provide mental health services.
Results: This year, ASPIN trained 230 CHWs, cross-trained 70 behavioral health case managers as CHWs, and 35 individuals in the Indiana Navigator Pre-certification Education.

Boone County Health Center Pulmonary Rehabilitation Program
Updated/reviewed June 2022

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.

Community Healthcare Integrated Paramedicine Program (CHIPP)
Updated/reviewed January 2022

Need: To reduce 911 use and improve older adults' health in rural Santa Cruz County, Arizona.
Intervention: Community paramedics made scheduled visits to patients and connected them to other community resources.
Results: CHIPP assisted over 150 people, and 911 calls decreased.

Generation Patient
Updated/reviewed June 2021

Need: To help young adults with chronic or rare conditions access health and educational resources and build a community of peers and advocates.
Intervention: Generation Patient summits bring together young adults with chronic medical disabilities, including chronic and rare conditions. The nonprofit organization also facilitates programming such as the Crohn's and Colitis Young Adults Network.
Results: Generation Patient facilitates about six virtual meetings per month in addition to programming around higher education, civic engagement, and more. The organization also facilitates a Virtual International Summit for young adults with chronic and rare conditions.

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.

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.

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.

Rural Project Examples: Chronic disease management