Rural Project Examples Addressing Service delivery models

Added August 2024

Need: Solutions for Medicare beneficiaries' post-acute care recovery gaps in Arkansas's southeast Delta Region.
Intervention: Supported by federal funding and their membership organization, seven hospitals implemented an evidence-supported Critical Access Hospital transitional care model.
Results: Participating hospitals found a significant increase in swing bed services revenue, an all-cause low readmission rate, high percentage of patients discharged to home or to an assisted living environment, and positive patient satisfaction surveys.

Updated/reviewed May 2024

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 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.

Added July 2026

Need: To improve kidney care for patients in rural Indiana.
Intervention: A nurse-led, interdisciplinary kidney care program redesigned clinical workflows to identify patients earlier, provide education, address barriers to treatment, and support informed decision-making.
Results: From 2023 to 2025, 80% to 92% of patients received Kidney Care Options education before initiating kidney replacement therapy.

Updated/reviewed June 2026

Need: To expand healthcare access in rural Alabama communities.
Intervention: The Auburn University Rural Health Initiative is working with communities across Alabama to develop a healthcare model that includes primary care, substance use disorder treatment and mental health treatment via state-of-the-art telehealth technologies, coupled with health and wellness programs and services provided by faculty and students.
Results: To date, there are five telehealth care stations open, located in LaFayette, Boligee, Akron, Catherine, and Gainesville, Alabama. These stations have impacted over 8,207 individuals, with 284 community events, 3,565 patient consultations, and 50 new health ambassadors.

Added May 2026

Need: To make sure patients with chronic conditions are educated about, and able to manage, their medical prescriptions and care.
Intervention: A rural primary care-based program that uses a multidimensional team approach to connect rural patients with clinical pharmacists via telehealth.
Results: More than 250 patients have participated in the program.

Updated/reviewed May 2026

Need: To connect patients to resources in order to reduce use of emergency services, emergency department visits, and hospital readmissions.
Intervention: Patients receive support (by in-person visit, phone call, or telehealth visit) from a paramedic, community health nurse, peer recovery specialist, and pharmacist.
Results: Between July 2016 and March 2024, the program made 1,098 patient contacts and continued to see a reduction in emergency department and inpatient visits and costs.

Updated/reviewed May 2026

Need: Out of 79 Critical Access Hospitals (CAHs) surveyed in Minnesota in 2015, behavioral health was the most frequently cited service requested.
Intervention: In response, Rural Health Innovations launched the Minnesota Integrative Behavioral Health Program. This initiative engaged representatives across all sectors in health integration between hospital, primary care, and community services.
Results: Strategy sessions resulted in the creation of resource directories to improve care coordination, evaluation measurements to document results, and an overall better understanding of integrative care challenges.

Updated/reviewed April 2026

Need: To increase access and quality of care for patients in rural Maine.
Intervention: Community hospitals and Federally Qualified Health Centers in Maine formed the Community Care Partnership of Maine Accountable Care Organization (CCPM ACO).
Results: CCPM serves about 250,000 patients in Maine every year. In addition, it has implemented shared savings arrangements/contracts with different Medicare Advantage and other private health payers.

Updated/reviewed March 2026

Need: Population health approach to decrease cardiovascular disease deaths in a rural Ohio healthcare delivery system's service area.
Intervention: A rural health system's investment in level II cardiac catheterization services and the required specialized cardiology workforce.
Results: In August 2018, Avita Health System started their cardiovascular service offerings in rural north central Ohio. Early results included decreased tertiary care hospital transfers. Building on the success of their increased ability to provide acute care, care coordination for patients with significant cardiovascular risks, preventive education with risk factor identification and modification, the health system continues to expand its local cardiovascular care.

Rural Project Examples: Service delivery models