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Rural Project Examples: Diabetes

Evidence-Based Examples

Chronic Disease Self-Management Program
Updated/reviewed December 2019
  • 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.
Project ECHO® – Extension for Community Healthcare Outcomes
Updated/reviewed July 2017
  • Need: To increase the capacity for more effective treatment of chronic, complex conditions in rural and underserved communities.
  • Intervention: Through a specially-designed project, remote primary care providers work with academic specialists as a team to manage chronic conditions of rural patients, expanding remote providers' knowledge base through shared case studies.
  • Results: Patient management and care provided by rural providers through ongoing education and mentoring from Project ECHO® has proved as effective as treatment provided by specialists at a university medical center.

Effective Examples

funded by the Federal Office of Rural Health Policy Meadows Diabetes Education Program
Updated/reviewed September 2020
  • Need: To provide diabetes care and education services to those in rural southeast Georgia.
  • Intervention: Diabetes outreach screening, education, and clinical care services are provided to participants in Toombs, Tattnall, and Montgomery counties.
  • Results: Patients successfully learn self-management skills to lower their blood sugar, cholesterol, and blood pressure.
Kentucky Homeplace
Updated/reviewed June 2020
  • Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
  • Intervention: Kentucky Homeplace was created as a community health worker initiative to address the lifestyle choices, inadequate health insurance, and environmental factors that are believed to contribute to these diseases.
  • Results: From July 2001 to June 2019, over 166,464 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
Community Health Worker-based Chronic Care Management Program
Added May 2020
  • Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
  • Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
  • Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed May 2020
  • Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
  • Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
  • Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed December 2019
  • 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.
Hidalgo Medical Services – Family Support Program
Updated/reviewed June 2019
  • Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
  • Intervention: Community health workers work with clients to help them better manage their health and promote awareness of healthy lifestyle options in the community.
  • Results: Better health outcomes for patients.

Promising Examples

funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Updated/reviewed May 2020
  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.
funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed December 2019
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.