Rural Project Examples Addressing Culture - Rural Health Information Hub

The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management

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 January 2026

Need: Improve health and wellness outcomes for those affected by trauma and adverse experiences.
Intervention: A language, traditions, and customs-specific evidence-based peer support model that trains local communities on education and prevention strategies to address and heal the effects of trauma.
Results: Peer-reviewed results show decreases in emergency room visits and hospitalizations, over 50% reduction of trauma symptomology, decreases in unhealthy substance use, and improvements in family and spiritual well-being. Model elements have adapted in Canada and several Lower 48 states.

Updated/reviewed January 2026

Need: In 2006, Pennsylvania agricultural producers and farmworker population needed guidance for Environmental Protection Agency agricultural pesticide safety compliance.
Intervention: In collaboration with Pennsylvania State University agriculture and pesticide experts, the Pennsylvania Office of Rural Health developed a comprehensive education and technical assistance outreach program with materials — including videos — to provide updated compliance information in a language- and custom-appropriate format.
Results: Continuing today with funding through the Pennsylvania Department of Agriculture, the program is delivered by a Worker Protection Standard (WPS) Specialist who provides the following: WPS technical and compliance assistance to nearly 2,000 farms, greenhouses, nurseries, orchards and other agricultural production sites and conference and event presentations and exhibits reaching thousands.

Updated/reviewed November 2025

Need: To improve veterans' access to healthcare in rural Michigan.
Intervention: I-REACH connects veterans to healthcare services and other programs and helps healthcare facilities and providers become more veteran-friendly.
Results: The program has received positive feedback from Veteran Service Officers in counties where there were outreach events.

Updated/reviewed November 2025

Need: To support pregnant and parenting women with a history of substance use, mental health, or co-occurring disorders in rural areas of Montana.
Intervention: One Health, a consortium of Federally Qualified Health Centers (FQHCs), developed a team of "recovery doulas" – individuals who are dual-certified as doulas and peer-support specialists. The One Health recovery doula program offers group and individual services to women and their partners from pregnancy through the first years of parenthood.
Results: A team of four recovery doulas (or doulas-in-training) employed by One Health offer services in 8 rural eastern Montana counties. One Health has also successfully trained and certified 35 Peer Recovery Doulas statewide through their Peer Recovery Doula certification curriculum.

Updated/reviewed December 2024

Need: To develop teen leaders, build self-confidence, and lower teen pregnancy rates in Marlboro County, South Carolina.
Intervention: Tea Time with Teens brings together community leaders, mothers, and daughters to build life skills and make healthy decisions. In addition, the program sponsors a middle school club and has an extension program for young women.
Results: Since 2009, the program has been educating teens on making healthy choices and adults on having meaningful conversations with teens.

Updated/reviewed January 2024

Need: Hawai'i is experiencing a severe shortage of family medicine physicians.
Intervention: The Hawai'i Island Family Medicine Residency (HIFMR) program uses an interprofessional team-based approach so residents learn how to care for many types of patients in different healthcare settings.
Results: Since 2017, HIFMR has graduated a class of 3 to 6 Board-certified family medicine physicians annually. Most graduates have remained in the state to practice medicine; those who have left have entered fellowship programs and plan to return to Hawai'i Island to practice.

Updated/reviewed July 2022

Need: The Seneca Nation of Indians has experienced disproportionate rates of opioid, alcohol, and substance misuse.
Intervention: The Seneca Nation Government and Executives founded Seneca Strong, a recovery peer advocate program, with the goal of reducing substance misuse across the Nation.
Results: Seneca Strong has since grown in personnel and capacity to meet the needs of the Allegany and Cattaraugus territories of the Seneca Nation.