Rural Project Examples Addressing Populations - Rural Health Information Hub

The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management

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 April 2025

Need: To support parents whose children have been removed from the home so that the parents can make the changes needed for the children to return safely home.
Intervention: A statewide program in Iowa pairs these parents with mentors who have successfully navigated their own child welfare cases.
Results: Participants' children were more likely to return home than non-participants' children, and participants were less likely to have another child removal within a year of the child coming home.

Updated/reviewed November 2024

Need: Legal barriers often prevent low-income people in Southern Illinois from obtaining positive health outcomes despite receiving medical care.
Intervention: The Medical Legal Partnership of Southern Illinois (MLPSI) was formed to create a system where medical providers can refer patients in need of legal assistance to local attorneys.
Results: Over 5,700 patients have utilized MLPSI since its founding in 2002. The program has relieved over $8.1 million in medical debt for both hospitals and patients.

Updated/reviewed February 2024

Need: To improve awareness of behavioral and mental health issues by students in rural, east central Mississippi.
Intervention: An intensive community mental health outreach program was implemented for students in rural Mississippi.
Results: As of 2018 and on a yearly basis, 6,000 7th and 8th grade students receive mental health education on a variety of topics which improves their ability to recognize mental health issues, high risk behaviors, and manage their own choices.

Updated/reviewed February 2026

Need: There is a lack of dementia-specific support for rural caregivers.
Intervention: Project C.A.R.E. was created to meet the needs of caregivers of those with Alzheimer's or other dementias, targeting rural North Carolina.
Results: Under Project C.A.R.E., rural families receive information and referrals as well as individualized care consultation from dementia-trained family consultants.

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.

Updated/reviewed November 2025

Need: Allow rural cancer patients in a region inclusive of 26 counties in Iowa, Minnesota, and South Dakota to have access to tertiary-level chemotherapy regimens administered in rural infusion centers.
Intervention: With telehealth-based oversight from a tertiary care oncology team, 3 rural infusion teams were trained to coordinate cancer treatment plans and administer complex chemotherapy regimens.
Results: The original grant-supported effort — with its results of saving 130 patients 65,000 trip miles and 1,800 travel hours – proved sustainable.

Updated/reviewed September 2025

Need: To improve the health and well-being of young people in the rural area of Massachusetts's Franklin County and North Quabbin, and to reduce youth drug and alcohol use.
Intervention: A community-based prevention coalition was formed to improve youth health and well-being and reduce youth drug and alcohol use. The coalition brings together stakeholders from across the community and uses the Communities That Care evidence-based community planning system.
Results: CTC has seen significant reductions in substance abuse among local youth in the 30 rural towns they serve.

Updated/reviewed September 2025

Need: To increase healthy eating and physical activity levels in Fairfield County, South Carolina.
Intervention: Community health advisors trained church committees and delivered telephone-based technical assistance to improve opportunities, guidelines, messages, and pastor support for physical activity and healthy eating.
Results: In a 2018 study, churchgoers reported seeing more opportunities for physical activity as well as more messages and pastor support for physical activity and healthy eating. Intervention churches also had fewer inactive churchgoers, compared to control churches.

Updated/reviewed September 2025

Need: An ongoing health need to alleviate early childhood obesity in the rural Kansas counties of Marshall and Nemaha.
Intervention: 5 distinct physical and nutritional programs were introduced to 9 preschool sites through the overarching Healthy Early Learning Project (HELP).
Results: HELP comprehensively increased children's physical activity and healthy food consumption and established a sustainable presence at each preschool site.