Updated/reviewed February 2023
- Need: In 12 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.
Other Project Examples
Added September 2023
- Need: To bring preventive care and other services to rural Missouri patients with chronic illnesses and difficulties accessing primary care.
- Intervention: Community paramedics and community health workers make home visits and provide basic care, home assessments, and medication reconciliation and facilitate telehealth visits.
- Results: Patients experienced improved access to care, health status, and compliance with medication regimens along with increased patient engagement, satisfaction, and access to community resources.
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.