Rural Project Examples Addressing Diabetes - Rural Health Information Hub

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.

Project ECHO® – Extension for Community Healthcare Outcomes
Updated/reviewed October 2022

Need: Increase medical management knowledge for New Mexico primary care providers in order to provide care for the thousands of rural and underserved patients with hepatitis C, a chronic, complex condition that has high personal and public health costs when left untreated.
Intervention: Project leveraging an audiovisual platform to accomplish "moving knowledge, not patients" that used a "knowledge network learning loop" of disease-specific consultants and rural healthcare teams learning from each other and learning by providing direct patient care.
Results: In 18 months, the urban specialist appointment wait list decreased from 8 months to 2 weeks due to Hepatitis C patients receiving care from the project's participating primary care providers. Improved disease outcomes were demonstrated along with cost savings, including those associated with travel. The project model, now known as Project ECHO® – Extension for Community Healthcare Outcomes — has evolved into a telementoring model used world-wide.

Kentucky Homeplace
Updated/reviewed October 2023

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 provide health coaching, increased access to health screenings, and other services.
Results: From July 2001 to June 2023, over 189,338 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed October 2023

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.

Meadows Diabetes Education Program
Updated/reviewed September 2023

Need: To provide diabetes care and education services to those in rural southeast Georgia.
Intervention: Diabetes outreach screening, education, and clinical care services were provided to participants in Toombs, Tattnall, and Montgomery counties.
Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.

Hidalgo Medical Services – Family Support Program
Updated/reviewed April 2023

Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
Intervention: Community health workers worked 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.

Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed August 2022

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.

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.

Health without Borders
Updated/reviewed December 2022

Need: To improve the health of communities in the south central region of New Mexico.
Intervention: A program was developed to specifically address diabetes prevention and control, behavioral healthcare, and immunization in Luna County.
Results: During the program, 1,500 immunizations were distributed, baseline measurements of participants improved, and 935 new patients were seen for behavioral health issues.

Northeast Louisiana Regional Pre-Diabetes Prevention Program
Updated/reviewed October 2021

Need: To prevent or slow the progression of diabetes for at-risk residents in Rural Northeast Louisiana.
Intervention: The North Louisiana Regional Alliance developed a program that offered screenings, education, and an intense course for participants throughout the Northeast Louisiana region to lower the risk of diabetes.
Results: The program saw an overall decrease in blood sugar levels in residents who participated in their initiatives.

Rural Project Examples: Diabetes