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Rural Health Information Hub

Rural Health Information Hub

 

Rural Project Examples: Integrated service delivery

Promising Examples

funded by the Federal Office of Rural Health Policy Physical and Behavioral Health Integrated Care Project
Updated/reviewed October 2020
  • Need: To provide unified and seamless access to primary care to adult patients in Pennsylvania's rural Clearfield and Jefferson counties who have been diagnosed with Serious and Persistent Mental Illness.
  • Intervention: A "one-stop shop" of healthcare services addressed the physical and behavioral health and medication needs of adults in the region.
  • Results: Results indicated better behavioral and physical health outcomes for participants as well as increased adherence to medications.
funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed December 2019
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: The Healthy Outcomes Integration Team was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.
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 Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2018
  • Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
  • Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
  • Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.

Other Project Examples

Queen Anne's County Mobile Integrated Community Health (MICH) Program
Added February 2021
  • Need: To connect patients to resources in order to reduce use of emergency services, emergency department visits, and hospital readmissions.
  • Intervention: Patients receive support (by in-person visit, phone call, or telehealth visit) from a paramedic, community health nurse, peer recovery specialist, and pharmacist.
  • Results: Between July 2016 and June 2019, the MICH program enrolled 233 patients and demonstrated a total savings of $3,393,908 in healthcare costs.
Family Wellness Warriors Initiative
Updated/reviewed November 2020
  • Need: Decrease rates of domestic violence, child sexual abuse, and child neglect for Alaska Native people in remote villages.
  • Intervention: An evidence-based model inclusive of traditional culture trains local communities on methods of prevention and treatment for domestic and interpersonal violence.
  • Results: Self-sustaining local system with improved family and spiritual well-being and decreased healthcare access needs.
Morrison County Accountable Community for Health
Updated/reviewed August 2020
  • Need: To combat prescription drug misuse in rural Morrison County, Minnesota.
  • Intervention: The Morrison County ACH brings together primary care, social services, law enforcement, and other partners to make sure that patients receive treatment and support.
  • Results: One pharmacy saw a 40% reduction in the number of prescribed opioids, and the ACH was able to taper 684 patients off opioids completely.
funded by the Health Resources Services Administration MORE Care
Updated/reviewed July 2020
  • Need: To improve rural residents' oral healthcare.
  • Intervention: MORE Care creates interprofessional oral health networks to 1) better integrate oral health into primary healthcare and 2) coordinate oral health between primary and dental healthcare.
  • Results: MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.
Optimal Health Behavioral Health Home Models
Updated/reviewed December 2019
  • Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
  • Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
  • Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.
funded by the Federal Office of Rural Health Policy Families Plus Comprehensive Health and Mentoring for Underserved Youth
Added March 2019
  • Need: Pediatric behavioral health services in Delta County, Colorado.
  • Intervention: Multi-organizational and community-wide effort to increase healthcare access for underserved children and to integrate behavioral health care into the area's primary care clinics.
  • Results: Sustainable increases in access to pediatric behavioral health services.

For examples from other sources, see: