Need: Provision of medical care access and follow-up for rural North Carolina HIV patients with mental health, substance abuse, and unstable housing/homelessness challenges.
Intervention: Medical home staff model expanded to a care coordination program with a core Network Navigator and Continuum of Care Coordinator assisting with medical, behavioral health, and basic life needs.
Results: To date, the program has advanced three aspects of medical home patient care for this target population: provided further understanding of the spectrum of homelessness, including "hidden" homelessness; implemented outreach with creation of new community partnerships and a community housing coalition; and integrated medical care and behavioral health care for HIV.
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.
Need: Farmers are highly susceptible to permanent hearing loss due to prolonged exposure to loud machinery and livestock.
Intervention: Faculty and students from the audiology department at the University of Wisconsin-Madison supplied earplugs, free hearing testing, and hearing loss prevention education to attendees and participants at an annual tractor pull event.
Results: Between 2014 and 2019, the audiology team distributed more than 16,000 pairs of earplugs; attendees were receptive to the hearing loss prevention education provided by the team.