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Rural Project Examples: Home health

Effective Examples

funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed February 2020
  • Need: In the 11 rural southeast Georgia counties, high-risk pregnant individuals potentially face adverse birth outcomes, including maternal or infant mortality, low birthweight, very low birthweight, or other medical or developmental problems.
  • Intervention: An in-home nursing case management program for high-risk pregnant individuals in order to maximize pregnancy outcomes for mothers and their newborns.
  • Results: Mothers carry their babies longer and the babies are larger when born, leading to improved health outcomes.

Promising Examples

funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed December 2019
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.
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

funded by the Federal Office of Rural Health Policy Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management
Updated/reviewed December 2019
  • Need: Decrease hospital readmissions and emergency room visits for patients in rural Tidewater, Virginia.
  • Intervention: After inpatient admission or ER visit, identify at-risk patients to offer enrollment in remote monitoring and disease self-management education and coaching, with a special focus on behavioral health wellness.
  • Results: Decreased readmissions and ER visits paired with high patient satisfaction scores.