Rural Project Examples Addressing Service delivery 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.

TelePrEP
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

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.

Reducing Hospitalizations in Medicare Beneficiaries
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

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.

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.

ARcare Aging Well Outreach Network
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.

Rural Project Examples: Service delivery models