Rural Project Examples Addressing Service delivery models

Outer Cape Health Services Community Resource Navigator Program

Updated/reviewed March 2023

Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance use disorder services while reducing the burden and costs to town agencies and hospital emergency rooms.
Intervention: The Community Resource Navigator Program works with local social services, town agencies, faith-based institutions, hospitals, the criminal justice system, and others to identify and connect clients to needed services.
Results: Clients are gaining access to the care they were once lacking, as measured by improvements in self-sufficiency. The program also helps community partners and stakeholders work together to reduce the impact of risks associated with behavioral health symptoms, substance use disorder, and social determinants of health.

Added February 2023

Need: Black women living with HIV in rural southeastern Louisiana face challenges in accessing care and other needed resources, often while dealing with other life stressors such as poverty, physical and mental health comorbidities, and a history of trauma.
Intervention: Implementing three evidence-informed interventions simultaneously ensures success in linking, treating, and retaining Black women in HIV care to improve health outcomes.
Results: As of February 2023, Stepping Stones has recruited 38 participants.

Updated/reviewed October 2022

Need: Rural school children lack proper healthcare resources within the school setting.
Intervention: Health-e-Schools provides health services to students via telehealth using video conferencing and special equipment.
Results: Health-e-Schools increases access to primary healthcare, increases attendance in the classroom, and decreases the amount of time that parents or guardians must take off of work to bring their child to health-related appointments.

Updated/reviewed October 2022

Need: To address the lack of mental healthcare options for rural veterans.
Intervention: A telebehavioral health hub network was created to connect community mental health centers to the VA Medical Center.
Results: More than 3,000 telehealth appointments have been made, saving hundreds of veterans time and money.

Updated/reviewed September 2022

Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's underserved rural counties.
Intervention: A network was established that trained community health workers (CHWs) to be certified health insurance enrollment navigators and provide mental health services.
Results: This year, ASPIN trained 230 CHWs, cross-trained 70 behavioral health case managers as CHWs, and 35 individuals in the Indiana Navigator Pre-certification Education.

Updated/reviewed August 2022

Need: Since the late 1800s, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 94% since 2008.

Added August 2022

Need: With the nearest hospital more than an hour away, the local community health center in rural Jackman, Maine struggled to maintain its ability to offer 24/7 care to due to staffing and budgetary challenges.
Intervention: Critical Access Integrated Paramedics provide urgent care to patients after hours and on weekends.
Results: The Jackman Community Health Center has been able to offer round-the-clock care to clinic patients, while also increasing the level of EMS service available to the community.

Updated/reviewed June 2022

Need: Evidenced-based intervention to improve function and quality of life for patients with chronic obstructive pulmonary disease and other chronic lower respiratory conditions.
Intervention: Pulmonary rehabilitation program implementation in 1989.
Results: Compared to a national average of only about 3% of referred Medicare beneficiaries actually enrolling in pulmonary rehabilitation, 60% of the program's referred patients enroll. Averaging around 15 patients/year completing the program, a large combined cardiac and pulmonary rehabilitation maintenance population averages 8,000 visits/year.

Added April 2021

Need: Population health approach to decreasing area deaths from cardiovascular disease.
Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.

Updated/reviewed November 2020

Need: Decrease rates of domestic violence, child sexual abuse, and child neglect for Alaska Native people in remote villages.
Intervention: An evidence-based model inclusive of traditional culture trains local communities on methods of prevention and treatment for domestic and interpersonal violence.
Results: Self-sustaining local system with improved family and spiritual well-being and decreased healthcare access needs.