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Rural Project Examples: Medical homes

Promising Examples

Patient Centered Medical Home Practicum in Primary Care
Updated/reviewed May 2019
  • Need: Improvement in service quality and patient experience in primary care practices in North Carolina's Blue Ridge region and across the state.
  • Intervention: A practicum for healthcare management students was developed to help rural practices achieve Patient Care Medical Home (PCMH) status, identify quality improvement needs, and develop strategies.
  • Results: With the help of practicum students, rural primary practices have have tackled a number of important quality improvement projects, achieved PCMH status and Blue Quality Physician Program Recognition.
Atlantic General Hospital Patient Centered Medical Home
Added September 2017
  • Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
  • Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
  • Results: From the program's care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.

Other Project Examples

Clinic for Special Children
Updated/reviewed July 2019
  • Need: To provide healthcare for the genetically vulnerable children of the rural, uninsured Amish and Mennonite communities in southern Pennsylvania.
  • Intervention: A clinic that serves as a comprehensive care medical home for children (primarily from the Amish and Mennonite communities) with rare, inherited disorders.
  • Results: In 2017, over 1,100 active patients with more than 225 unique genetic mutations were treated at the Clinic for Special Children.
funded by the Federal Office of Rural Health Policy Chautauqua Health Connects (CHC)
Updated/reviewed December 2018
  • Need: To address care coordination and the integration of services in a rural, aging population
  • Intervention: This program used health information technology and dedicated staff to manage clinical and community services for patients with complex needs.
  • Results: Hospital readmissions have decreased, follow-up rates have increased, and patients' perceived health status has improved.
funded by the Federal Office of Rural Health Policy The Bridge Program
Updated/reviewed November 2018
  • Need: Access to primary medical, dental, and mental health services for rural Appalachia Kentuckians.
  • Intervention: Community Health Workers provide outreach, education, navigation, and care coordination services to 5 counties in the Western Appalachian area of Kentucky through The Bridge Program.
  • Results: Emergency room visits have decreased throughout the course of the program and referrals to healthcare services have increased. Increases in self-efficacy and decreases in A1C levels have reached statistical significance.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
Updated/reviewed October 2018
  • 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.
Optimal Health Behavioral Health Home Models
Added July 2018
  • 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.
SAMA HealthCare Services's Patient-Centered Medical Home
Updated/reviewed February 2018
  • Need: The traditional model where providers work independently from one another in treating patients proved to lack care continuity at SAMA Healthcare Services in rural Arkansas.
  • Intervention: The family practice clinic shifted to a team-based model of care where the medical staff works together in pods in order to create a patient-centered medical home.
  • Results: SAMA doubled the amount of patients seen in 1 day and at least 90% of patients receive medical treatment from a provider within their pod.
funded by the Federal Office of Rural Health Policy Medical Home Plus
Updated/reviewed September 2017
  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.