Rural Project Examples Addressing Service delivery models

Montana "Team Up. Pressure Down." Blood Pressure Medication Adherence Project
Updated/reviewed November 2022

Need: To help rural Montana patients manage their blood pressure levels.
Intervention: Pharmacists distributed "Team Up. Pressure Down." materials from the Million Hearts Initiative and provided consultations.
Results: 89% of patients were able to adhere to their blood pressure medication, compared to 73% before the intervention.

Kentucky Homeplace
Updated/reviewed September 2022

Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
Results: From July 2001 to June 2022, over 182,783 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

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.

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.

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.

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.

Medical Advocacy & Outreach's Telehealth Services
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.

Rural Project Examples: Service delivery models