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Rural Health Information Hub
Rural Health Information Hub

Rural Project Examples: Chronic disease management

Other Project Examples

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration 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.
funded by the Federal Office of Rural Health Policy 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.
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 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.
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.

For examples from other sources, see: