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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 March 2019
  • Need: In the 11 rural southeast Georgia counties, high-risk pregnant women 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 women 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 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.
funded by the Federal Office of Rural Health Policy Health Coaches for Care Transition
Updated/reviewed September 2018
  • 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.

Other Project Examples

funded by the Federal Office of Rural Health Policy Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management
Added June 2018
  • 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.
Granville Health System's Transitional Care Program
Added April 2017
  • Need: To reduce hospital admissions and improve health for North Carolina patients.
  • Intervention: Granville Health System's Transitional Care Program helps hospital and ED patients schedule follow-up appointments. In addition, the program provides home visits and safety checks.
  • Results: From 2015 to 2016, the number of patients receiving home visits increased from 30 to 86. In addition, 2016 saw a $73,595 reduction in inpatient readmissions and an $11,500 reduction in self-pay readmissions of patients with high-risk diagnoses.
Eagle County Community Paramedic
Updated/reviewed February 2017
  • Need: Rural areas nationwide have shortages of primary care providers and home health programs.
  • Intervention: Eagle County Paramedic Services is utilizing community paramedics in the provision of non-acute home care and assistance with immunizations and screenings in rural areas where it is difficult for these services to be accessed.
  • Results: The pilot program was featured at the 2010 International Roundtable on Community Paramedicine. After 18 months of implementing the program, a net total of $288,028 in healthcare costs was saved.