Rural Project Examples: Service delivery models
Effective Examples

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
TelePrEP
Updated/reviewed January 2023
Updated/reviewed January 2023
- 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.
Maryland Faith Health Network
Updated/reviewed December 2022
Updated/reviewed December 2022
- Need: To coordinate formal and informal community-based caregivers for optimal patient experience.
- Intervention: The Maryland Faith Health Network unites places of worship and healthcare systems in Maryland. This program aims to decrease the amount of potentially avoidable hospitalizations, improve a patient's overall wellness, and cut down on the cost of medical services.
- Results: This model is currently running in 3 hospitals that serve both rural and urban residents in central Maryland. So far, 1,300 congregants from 70 congregations representing Christian, Jewish, and Muslim faiths have enrolled in the Network.

Updated/reviewed November 2022
- Need: To properly address and treat patients who have concurrent substance use 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.
Atlantic General Hospital Patient Centered Medical Home
Updated/reviewed August 2022
Updated/reviewed August 2022
- Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
- Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
- Results: From the program's care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.
Reducing Hospitalizations in Medicare Beneficiaries
Updated/reviewed May 2022
Updated/reviewed May 2022
- Need: To reduce hospital readmissions for Medicare patients in rural Kentucky and Tennessee.
- Intervention: Two quality improvement tools called IMPACT and INTERACT helped older patients transition from Vanderbilt University Medical Center to a skilled nursing facility.
- Results: Practitioner follow-up visits increased, while emergency department visits decreased.
SASH® (Support and Services at Home)
Updated/reviewed March 2022
Updated/reviewed March 2022
- 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 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.

Updated/reviewed October 2021
- Need: To address and treat substance use disorder (SUD) and depression in the Upper Great Lakes region.
- Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
- Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.

Updated/reviewed April 2021
- Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
- Intervention: 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 diverse set of healthcare offerings to frontier area residents.
- Results: Increased healthcare access, especially for cancer and chronic disease screening, along with providing education on a diverse array of health topics.

Updated/reviewed March 2021
- Need: To reduce falls and improve chronic care management for adults 50 or older in rural Cross County, Arkansas.
- Intervention: The ARcare Aging Well Outreach Network, run by an FQHC, provided services like falls prevention assessments, transportation to appointments, medication management, and senior-specific exercise opportunities.
- Results: From May 2015 to April 2018, the network served 639 patients through 1,580 medical encounters.
For examples from other sources, see: