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Rural Project Examples: Health conditions

Other Project Examples

Heartland OK

Updated/reviewed November 2022

  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK, which began in 5 rural counties, was a care coordination model.
  • Results: Using a team-based care model increased patients' ability to reduce their blood pressure or achieve blood pressure control.

Win With Wellness

funded by the Federal Office of Rural Health Policy

Updated/reviewed October 2022

  • Need: To reduce risk of obesity and chronic disease in rural northwest Illinois.
  • Intervention: Win With Wellness (WWW) collaborates with community organizations and worksites to improve physical activity and eating behaviors and reduce weight among adults using a multi-component approach.
  • Results: From 2015 to 2018, the two participating counties initiated 28 Take Off Pounds Sensibly (TOPS) groups with 367 participants. In the second round of funding, WWW recruited 183 participants for 9 TOPS groups and 8 community Heart-to-Heart sites.

Boone County Health Center Pulmonary Rehabilitation Program

Updated/reviewed June 2022

  • Need: Evidenced-based intervention to improve function and quality of life for patients with chronic obstructive pulmonary disease and other chronic lower respiratory conditions.
  • Intervention: Pulmonary rehabilitation program implementation in 1989.
  • Results: Compared to a national average of only about 3% of referred Medicare beneficiaries actually enrolling in pulmonary rehabilitation, 60% of the program's referred patients enroll. Averaging around 15 patients/year completing the program, a large combined cardiac and pulmonary rehabilitation maintenance population averages 8,000 visits/year.

New Horizons Geriatric Counseling Program

Updated/reviewed June 2022

  • Need: Improved behavioral health care offerings for a community after losing 5 senior-aged men to suicide.
  • Intervention: A Critical Access Hospital in Yoakum, Texas, created a community-based program focusing on inpatient and outpatient behavioral health care for area residents age 50 and older.
  • Results: A financially-sustainable behavioral health care delivery model demonstrating positive impacts on physical health conditions, healthcare service utilization, and high patient satisfaction rates.

Avita Health System Comprehensive Cardiology Program

Added April 2021

  • Need: Population health approach to decreasing area deaths from cardiovascular disease.
  • Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
  • Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.

Pathways Vermont Housing First Program

Updated/reviewed April 2021

  • Need: Ending a local Vermont population's homelessness experience.
  • Intervention: In 2010, Pathways Vermont implemented a first-of-its-kind, rural-focused Housing First program in order to provide housing and support services to those with mental health and substance use conditions experiencing homelessness.
  • Results: Since its initial start-up, Pathways Vermont has assisted over 560 Vermonters — about 70% from rural areas — experiencing homelessness using the Housing First model. The organization has collaborated with the state mental health department, corrections department, local healthcare systems and providers, and other organizations to end homelessness. In addition, programmatic work has expanded to reach other local populations, including veterans and at-risk families.

Garrett County Regional Cancer Patient Navigator Program

funded by the Federal Office of Rural Health Policy

Updated/reviewed March 2020

  • Need: Comprehensive cancer services for residents of an 8-county, 3-state area in Appalachia.
  • Intervention: Using a Cancer Patient Navigation Tool Kit, a Maryland acute care facility led a multidisciplinary collaboration that provided the area's patients with expanded cancer treatment services.
  • Results: In addition to several new cancer-related programs, expanded services are now available for cancer patients, families, and cancer survivors.

Medical Home Plus

funded by the Federal Office of Rural Health Policy

Updated/reviewed February 2020

  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.

COPD Inpatient Navigator Program

Updated/reviewed December 2019

  • Need: Improve readmission rates for rural patients with Chronic Obstructive Pulmonary Disease (COPD).
  • Intervention: COPD Inpatient Navigator program implementation in a rural hospital in Oregon.
  • Results: With navigator assistance, COPD-associated readmission rate has decreased by almost 50%, with a continued improvement trend.

COPD Readmission Prevention Program

Updated/reviewed December 2019

  • Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
  • Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
  • Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.