Rural Project Examples Addressing Population health

Updated/reviewed November 2025

Need: A cost-effective approach to help rural patients with hypertension learn to manage their condition.
Intervention: Community volunteers trained as health coaches provided an 8-session hypertension management training program to hypertension patients older than 60, with an optional supplemental 8 sessions focused on nutrition and physical activity.
Results: Just 16 weeks after the program, participants had improved systolic blood pressure, weight, and fasting glucose, greater knowledge of hypertension, and improved self-reported behaviors.

Updated/reviewed October 2025

Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
Results: From July 2001 to June 2025, over 202,000 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Updated/reviewed October 2025

Need: The U.S. Associated Pacific Islands (USAPI) needed an efficient, effective, integrated method to improve primary care services that addressed the increased rates of non-communicable disease (NCD), the regional-specific phrase designating chronic disease.
Intervention: Through specialized training, multidisciplinary teams from five of the region's health systems implemented the Chronic Care Model (CCM), an approach that targets healthcare system improvements, uses information technology, incorporates evidence-based disease management, and includes self-management support strengthened by community resources.
Results: Aimed at diabetes management, teams developed a regional, culturally-relevant Non-Communicable Disease Collaborative Initiative that addresses chronic disease management challenges and strengthens healthcare quality and outcomes.

Updated/reviewed September 2025

Need: To provide diabetes care and education services to those in rural southeast Georgia.
Intervention: Diabetes outreach screening, education, and clinical care services were provided to participants in Toombs, Tattnall, and Montgomery counties. The program is no longer active.
Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.

Updated/reviewed March 2025

Need: Due to West Virginia's high ranking for its use of smokeless tobacco, prevention and cessation education efforts were needed.
Intervention: Development and implementation of the Spit It Out-West Virginia program.
Results: Supported by a 2008-2010 grant allowing the program to be delivered to hundreds of people, 5 workplaces became tobacco free. The program continues to be delivered across the state and reaches hundreds with its face-to-face presentations and thousands with its specific media prevention and cessation messages.

Updated/reviewed August 2024

Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
Intervention: With early federal grant-funding, a consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a comprehensive set of health-related interventions to frontier area residents.
Results: With additional private grant funding, success continued to build into the current model of an established and separate CHW division within the health system's population health department.

Updated/reviewed November 2018

Need: To reduce obesity among adults in rural east central Ohio.
Intervention: Fit for Life Replication Project for Expansion was developed to make it possible to lose weight through practicing healthier lifestyle behaviors.
Results: Out of the 443 adults who have completed the program, 81% experienced weight loss, a tangible result of the program's overarching goal to enhance levels of health and fitness.

Updated/reviewed March 2026

Need: To reduce smoking rates of pregnant adult and adolescent women in Appalachian regions of eastern Kentucky and Ohio.
Intervention: In 2009, a web-based smoking cessation program offered monetary incentives to reduce smoking.
Results: Participants significantly reduced smoking rates or quit altogether.

Updated/reviewed February 2026

Need: To increase physical activity and quality of life in rural Cuba, New Mexico.
Intervention: Step Into Cuba works to make the community more pedestrian-friendly by creating and improving hiking trails and other places to walk.
Results: This program has led to new or improved trails, sidewalks and crosswalks, lighting on streets, walking groups, and walking events, among other achievements.

Updated/reviewed January 2026

Need: Improve the oral health of children age 3-17 in rural areas of Louisiana.
Intervention: Leveraging 2012-2018 federal grant support, participating Federally Qualified Health Centers with school-based nurse practitioners were trained in oral health assessments and fluoride varnish application. When needed, dental referrals were also made. Interventions were tracked by dental case managers.
Results: After grant cycle completion, these oral health interventions are now fully integrated into routine school-based care health examinations with intervention data included in required annual reporting.

Rural Project Examples: Population health