Rural Project Examples Addressing Service delivery models

Maryland Faith Health Network
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.

Nurse Navigator and Recovery Specialist Outreach Program
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

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.

Cross-Walk: Integrating Behavioral Health and Primary Care
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.

The Health-able Communities Program
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.

SD eResidential Facilities Healthcare Services Access Project
Updated/reviewed August 2020

Need: To increase local health services to rural elderly populations in long-term care facilities located in four Midwest states near a tertiary care organization.
Intervention: A non-profit healthcare organization implemented telehealth services to provide acute care evaluations for long-term residents in their home facilities.
Results: The program increased local care as evidenced by improved year-over-year provider-determined available transfer data: 33%, 50%, 63% program years 1 through 3, respectively. From the success of the initial pilot implementation, the program has further matured into a long-term care offering that now reaches many other rural facilities located in 10 states across the nation.

Prevention through Care Navigation Outreach Program
Updated/reviewed May 2020

Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.

The Rural Virtual Infusion Program
Updated/reviewed April 2020

Need: Allow rural cancer patients in a region inclusive of 26 counties in Iowa, Minnesota, and South Dakota to have access to tertiary-level chemotherapy regimens in rural infusion centers.
Intervention: With telehealth-based oversight from a tertiary care oncology team, 3 rural infusion teams were trained to coordinate cancer treatment plans and administer complex chemotherapy regimens.
Results: Almost 130 patients were transitioned to receive chemotherapy in a rural infusion center, translating to over 1,000 infusion visits and saving patients/families nearly 65,000 trip miles, 1,800 travel hours and $71,000.

Old Dominion University's Student-Run Mobile Health Clinic
Added November 2023

Need: To fill gaps in care for rural communities in southeastern Virginia while providing clinical placement opportunities for nursing students.
Intervention: A free mobile health clinic staffed by Old Dominion University nursing students that visits rural schools and other community centers.
Results: Hundreds of students have gained hands-on rural experience working in the clinic since its launch.

ADPH Telehealth Program
Updated/reviewed September 2023

Need: To increase access to healthcare throughout Alabama.
Intervention: The Alabama Department of Public Health (ADPH) has created telehealth communications at county health departments.
Results: ADPH telehealth services are currently available in 66 of 67 county health departments.

Rural Project Examples: Service delivery models