Rural Project Examples Addressing Service delivery models

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 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 The program is no longer active.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 April 2025

Need: To provide psychotherapy to survivors of domestic violence and sexual assault.
Intervention: University of Wyoming psychology doctoral students provide psychotherapy via videoconferencing to crisis center clients in two rural locations.
Results: Clients, student therapists, and crisis center staff were satisfied with the quality of services, and clients reported reduced symptoms of depression and PTSD.

Updated/reviewed August 2024

Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
Intervention: A unique community health worker-based chronic care management program, created with philanthropy support.
Results: After a decade of use in attending to population health needs, health outcomes, healthcare costs, in 2024, the medical condition-agnostic model has a 4-year track record of financial sustainability with recent scaling to include 31 rural counties in a 3-state area of Appalachia and recent implementation in urban areas.

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 December 2023

Need: To improve the health status and access for rural nursing home patients in need of mental health services.
Intervention: The University of Vermont Medical Center provides telepsychiatry care and education to nursing homes in communities that face shortages of mental health professionals.
Results: These telepsychiatry consultations have eased the burden on nursing home residents by saving travel time, distance, and money it takes to travel to the nearest tertiary facility.

Updated/reviewed December 2025

Need: To properly address and treat patients who have concurrent substance use disorders and chronic healthcare issues.
Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.

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 May 2025

Need: To prevent new cases of HIV in rural Iowa.
Intervention: TelePrEP provides preventive care via telehealth and prescription delivery.
Results: Between February 2017 and August 2020, TelePrEP received 456 referrals, with 403 patients completing an initial visit.

Updated/reviewed April 2025

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.