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.
Need: To provide Lakota elders with tools and opportunities for advance care planning.
Intervention: An outreach program in South Dakota helps Lakota elders with advance care planning and wills by providing bilingual brochures and advance directive coaches.
Results: Care for Our Elders saw an increase in the number of Lakota elders understanding the differences between a will and a living will and the need to have end-of-life discussions with family and healthcare providers.
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 nine recovery doulas (or doulas-in-training) employed by One Health offer services in ten rural Montana counties. Recovery doulas have provided essential support to women with substance use disorder, survivors of sexual abuse, unhoused individuals, and individuals facing other complex challenges.
Need: To address food insecurity and limited access to healthy foods among Indigenous elders living in tribal nations in Wisconsin.
Intervention: The Tribal Elder Food Box Program distributes biweekly boxes filled with culturally relevant, locally-sourced meat, produce, and shelf-stable foods to elders in all 11 federally recognized tribal nations in Wisconsin – 10 of which are located in rural areas.
Results: In 2022, the program distributed 24,400 boxes and purchased a majority of food products from Indigenous producers and growers.
Need: Hawai'i is experiencing a huge 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.
Need: Patients who identify as LGBTQ+ in rural settings may face barriers to receiving appropriate care, including a knowledge gap among healthcare providers regarding HIV prevention, hormone replacement therapy, and other types of care.
Intervention: A partnership between a Critical Access Hospital, statewide residency program, nonprofit organization and other regional entities provides training, virtual consultations, and resources to rural providers across Idaho.
Results: Physicians experienced in gender-affirming care have performed virtual consultations for rural physicians and patients around the state, and the number of local providers trained in PrEP management has doubled.
Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 94% since 2008.