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 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: As of 2025, there are five telehealth care stations open located in LaFayette, Boligee, Akron, Catherine, and Gainesville, Alabama. These stations have impacted over 3,400 individuals, with 187 community events, 1207 patient consultations, and 43 new health ambassadors.

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.