Need: In 12 rural southeast Georgia counties, high-risk pregnant individuals 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 individuals 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.
Need: To increase access to telemental health services for rural veterans, especially women, with a history of trauma.
Intervention: STAIR (Skills Training in Affective and Interpersonal Regulation) is a 10-week program designed to reduce PTSD and depression symptoms and increase emotional regulation and social functioning in clients.
Results: Therapists reported that clients attended more sessions when offered via teleconferencing, and clients reported satisfaction with the program.
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.
Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.
Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, poses significant challenges for those who want to remain living independently at home.
Intervention: SASH® (Support and Services at Home), based in affordable housing and their surrounding communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
Results: Compared to their non-SASH peers, SASH participants have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and lower Medicare and Medicaid expenditures.