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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

Hidalgo Medical Services – Family Support Program
Updated/reviewed May 2021
  • 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.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed March 2021
  • 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.
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.

Promising Examples

funded by the Federal Office of Rural Health Policy 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.
funded by the Federal Office of Rural Health Policy The Health-able Communities Program
Updated/reviewed April 2021
  • Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
  • Intervention: Consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a diverse set of healthcare offerings to frontier area residents.
  • Results: Increased healthcare access, especially for cancer and chronic disease screening, along with providing education on a diverse array of health topics.