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Rural Project Examples: Home and community-based services

Promising Examples

SASH® (Support and Services at Home)
Updated/reviewed February 2021
  • Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, poses significant challenges for those who want to remain living independently at home.
  • Intervention: SASH® (Support and Services at Home), based in affordable-housing communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
  • Results: Compared to their non-SASH peers, SASH participants have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and lower Medicare and Medicaid expenditures.
funded by the Federal Office of Rural Health Policy TeleStroke/Vascular Neurology Patient Navigator Program
Added March 2019
  • Need: Improve post-hospital stroke care access in order to improve physical function and well-being for stroke patients living in a 6-county area in rural Minnesota.
  • Intervention: Implementation of an evidence-based patient navigator program paired with telehealth services for post-hospital care of rural stroke patients.
  • Results: In addition to other successes, more than 120 individuals enrolled in the navigator program, the Modified Rankin Score assessments at baseline and 6 months showed functional improvements.

Other Project Examples

Hospital2Home
Updated/reviewed April 2021
  • Need: To prevent readmissions and improve the recovery process for older adults in rural southern Ohio.
  • Intervention: Hospital2Home identifies high-risk individuals and provides vouchers for services like personal care and home-delivered meals.
  • Results: In the four years the program has been in operation, 86.5% of participants have not readmitted to the hospital in the first two months after hospital discharge.
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.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
Updated/reviewed November 2020
  • 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.
Age-Friendly and Dementia-Friendly Winnemucca and Humboldt County
Updated/reviewed September 2020
  • Need: To make a rural community more inclusive for older adults.
  • Intervention: Winnemucca, Nevada, holds monthly meetings around topics like health, housing, social events, and transportation.
  • Results: So far, these meetings have led to more accessible transportation and parking. The effort went countywide in 2017.
CAPABLE (Community Aging in Place—Advancing Better Living for Elders)
Updated/reviewed July 2020
  • Need: To help older adults age in place.
  • Intervention: For five months, CAPABLE participants receive home visits from a registered nurse, occupational therapist, and home repair services.
  • Results: The CAPABLE site in rural Bath, Maine, has helped 15 clients so far, one of whom went from 15 falls and one hospitalization in the 6 months prior to starting the program to one fall and no hospitalizations. The site in Hawaii has served three clients in the last year and has reconnected clients with their families and communities.
Care Partners of Cook County
Updated/reviewed July 2019
  • Need: To provide holistic, interdisciplinary palliative care to those with chronic illnesses in rural hospitals in Cook County, Minnesota.
  • Intervention: Care Partners of Cook County created a palliative care program that utilizes local healthcare professionals and volunteers to provide universal care to patients and caregivers, without Medicare hospice status.
  • Results: Since its inception in 2010, the program has assisted over 185 residents in need.
Fostering Futures in Menominee Nation
Updated/reviewed September 2018
  • Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
  • Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
  • Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 85% since 2008.