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Rural Health Information Hub

Rural Project Examples: Chronic respiratory conditions

Evidence-Based Examples

Project ENABLE (Educate, Nurture, Advise, Before Life Ends)

Updated/reviewed February 2024

  • Need: To enhance palliative care access to rural patients with advanced cancer or heart failure and their family caregivers.
  • Intervention: Project ENABLE consists of: 1) an initial in-person palliative care consultation with a specialty-trained provider and 2) a semi-structured series of weekly, phone-delivered, nurse-led or palliative care coach/navigator sessions designed to help patients and their caregivers enhance their problem-solving, symptom management, and coping skills.
  • Results: Patients and caregivers report higher quality of life and lower rates of depression and (caregiver) burden.

Chronic Disease Self-Management Program

Updated/reviewed September 2023

  • 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

Community Health Worker-based Chronic Care Management Program

Updated/reviewed August 2024

  • 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, 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.

Community-Based Pulmonary Rehabilitation Program

Updated/reviewed January 2024

  • Need: More evidenced-based chronic lower respiratory disease management options for rural Appalachia patients, where lung disease rates are among the highest in the country.
  • Intervention: Implementation of outpatient pulmonary rehabilitation programs in 2 Federally Qualified Health Centers and a Critical Access Hospital in West Virginia.
  • Results: Improved health outcomes for patients with chronic lower respiratory disease, including those with chronic obstructive pulmonary disease.

New Mexico Mobile Screening Program for Miners

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

Updated/reviewed December 2022

  • Need: To increase access to medical screening for miners in New Mexico.
  • Intervention: A mobile screening clinic with telemedicine capability screens miners for respiratory and other conditions.
  • Results: In a survey, 92% of miners reported their care as very good, while the other 8% reported it as good. The program has expanded to three other states.

Other Project Examples

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.

COPD Readmission Prevention Program

Updated/reviewed December 2019

  • Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
  • Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
  • Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.