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Rural Health Information Hub

Rural Project Examples: Service delivery models

Effective Examples

funded by the Federal Office of Rural Health Policy Meadows Diabetes Education Program
Updated/reviewed September 2022
  • 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.
  • Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
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.
Wyoming Trauma Telehealth Treatment Clinic
Updated/reviewed February 2022
  • 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.
University of Vermont Medical Center's Nursing Home Telepsychiatry Service
Updated/reviewed September 2021
  • 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.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed March 2021
  • 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.
funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed February 2021
  • Need: In the 11 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.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
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.
funded by the Federal Office of Rural Health Policy Madison Outreach and Services through Telehealth (MOST) Network
Updated/reviewed December 2018
  • Need: More mental health and substance abuse prevention and treatment services in rural Texas.
  • Intervention: A network was formed to bring counseling services through telehealth systems and community health workers to Brazos Valley, Texas.
  • Results: The program improved health outcomes, increased general knowledge of the impact of substance abuse, and raised awareness of services among Hispanic residents.