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Rural Health Information Hub

Rural Project Examples: Service delivery models

Effective Examples

Perinatal Health Partnership Southeast Georgia

funded by the Federal Office of Rural Health Policy

Updated/reviewed February 2023

  • 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.

STAIR (Skills Training in Affective and Interpersonal Regulation)

Updated/reviewed January 2023

  • 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.

New Mexico Mobile Screening Program for Miners

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration

Updated/reviewed December 2022

  • Need: To increase access to medical screening for miners in New Mexico.
  • Intervention: A mobile screening clinic with telemedicine capability screens miners for respiratory and other conditions.
  • Results: In a survey, 92% of miners reported their care as very good, while the other 8% reported it as good. The program has expanded to three other states.

Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care

funded by the Federal Office of Rural Health Policy

Updated/reviewed August 2022

  • Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
  • Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
  • Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.

NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless

funded by the Health Resources Services Administration

Updated/reviewed November 2020

  • 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.

Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder

Updated/reviewed August 2020

  • Need: Increase access to medication-assisted treatment for opioid use disorder in rural Vermont.
  • Intervention: Statewide hub-and-spoke treatment access system.
  • Results: Increased treatment capacity and care coordination.

Community Health Worker-based Chronic Care Management Program

Added May 2020

  • 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.

Livingston County Help For Seniors

funded by the Federal Office of Rural Health Policy

Updated/reviewed May 2020

  • Need: Meeting the health needs of geriatric patients in rural Livingston County, New York.
  • Intervention: The Help for Seniors program was developed and using its 'vodcasts,' local EMTs were trained in geriatric screening methods and health needs treatment.
  • Results: In addition to developing a successful model for educating EMS personnel, the program screened over 1200 individuals and identified various risks among the geriatric population.

Medical Advocacy & Outreach's Telehealth Services

funded by the Health Resources Services Administration

Updated/reviewed November 2018

  • Need: Rural Alabama residents with HIV/AIDS face stigma, poverty, and transportation barriers, limiting their access to expert HIV/AIDS healthcare.
  • Intervention: Medical Advocacy & Outreach utilizes telemedicine to remove these barriers and offers cost-effective care to rural patients living with HIV/AIDS.
  • Results: This telehealth network has expanded to reach rural patients in 12 Alabama counties. Patients are staying engaged due to its convenience and cost-effective nature.

Promising Examples

SASH® (Support and Services at Home)

Updated/reviewed March 2023

  • 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.