Rural Project Examples Addressing Service delivery models

Cross-Walk: Integrating Behavioral Health and Primary Care

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.

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.

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.

Updated/reviewed April 2020

Need: Allow rural cancer patients in a of 26-county region 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.

Updated/reviewed May 2025

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 April 2025

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 120,000 patients in Maine. In addition, it has implemented shared savings arrangements/contracts with different Medicare Advantage and other private health payers.

Updated/reviewed April 2025

Need: Lack of access to oral healthcare for children from limited-income families in the rural and urban areas of South Dakota.
Intervention: Delta Dental of South Dakota launched the Delta Dental Mobile Program in 2004 to expand access to oral healthcare services to children throughout the rural state.
Results: The Delta Dental Mobile Program has provided over $44 million in dental care to more than 73,000 South Dakota children.

Updated/reviewed April 2025

Need: To improve and increase prevention and care services for HIV, STDs, hepatitis C, and other infectious diseases.
Intervention: PAETC-NV provides clinical and didactic trainings, conferences, technical assistance, capacity building, webinars, and other services to providers and healthcare organizations statewide.
Results: In 2024, PAETC-NV trained more than 1,800 healthcare providers across Nevada to increase clinical capacity in the care, screening, and prevention of HIV, other sexually transmitted diseases, and hepatitis C.

Updated/reviewed April 2025

Need: To improve maternal health in northeastern New Mexico.
Intervention: The Rural OB Access & Maternal Service program provides obstetric and maternal fetal medicine telehealth, home telehealth kits, and free access to lactation consultants and family navigators.
Results: ROAMS has worked with 2,000 unique individuals since July 2021.