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Rural Project Examples: Service delivery models

Other Project Examples

funded by the Federal Office of Rural Health Policy Community Care Partnership of Maine Accountable Care Organization
Updated/reviewed February 2020
  • Need: To increase access and quality of care for Medicare, Medicaid, uninsured, and commercial patients in rural Maine.
  • Intervention: Hospitals and Federally Qualified Health Centers in Maine formed the Community Care Partnership of Maine Accountable Care Organization (CCPM ACO).
  • Results: CCPM serves about 100,000 patients in Maine. In addition, it implemented ACO shared savings plans with Maine Medicaid, Medicare, and five commercial health insurance and Medicare Advantage plans in the state.
funded by the Federal Office of Rural Health Policy Medical Home Plus
Updated/reviewed February 2020
  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.
funded by the Federal Office of Rural Health Policy Community Healthcare Integrated Paramedicine Program (CHIPP)
Updated/reviewed January 2020
  • Need: To reduce 911 use and improve older adults' health in rural Santa Cruz County, Arizona.
  • Intervention: Community paramedics make scheduled visits to patients and connect them to other community resources.
  • Results: CHIPP has assisted over 150 people so far, and 911 calls have decreased.
funded by the Health Resources Services Administration Nevada AIDS Education and Training Center
Added January 2020
  • Need: To provide trainings so health professionals can better treat people with HIV/AIDS, hepatitis C, and other infectious diseases.
  • Intervention: NAETC provides clinical preceptorships, conferences, technical assistance, webinars, and other services.
  • Results: In fiscal year 2018, NAETC provided over 1,300 hours in 38 trainings for more than 800 healthcare providers throughout Nevada.
funded by the Health Resources Services Administration University of Mississippi Medical Center's Center for Telehealth
Updated/reviewed January 2020
  • Need: Rural areas in Mississippi often lack adequate access to specialty healthcare services such as emergency medicine, stroke neurology, pediatric specialists and psychiatrists.
  • Intervention: The University of Mississippi Medical Center created the Center for Telehealth to deliver quality specialty services through telehealth video conferencing and remote monitoring tools to the underserved areas of Mississippi.
  • Results: The program has been successfully implemented throughout many of the state's rural hospitals and has reduced transfers and geographic barriers for patients.
AmeriCorps Community Health Workers Program
Updated/reviewed December 2019
  • Need: Chronic diseases, diabetes, and opioid misuse has caused significant health disparities in Ohio and West Virginia.
  • Intervention: A program recruiting AmeriCorps members to serve as community health workers helps bring health services and education to local residents.
  • Results: As a result of the program, community members have reported weight loss, increased physical activity, reduction in medication, and improvements in self-management of chronic diseases.
funded by the Federal Office of Rural Health Policy Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management
Updated/reviewed December 2019
  • Need: Decrease hospital readmissions and emergency room visits for patients in rural Tidewater, Virginia.
  • Intervention: After inpatient admission or ER visit, identify at-risk patients to offer enrollment in remote monitoring and disease self-management education and coaching, with a special focus on behavioral health wellness.
  • Results: Decreased readmissions and ER visits paired with high patient satisfaction scores.
COPD Readmission Prevention Program
Updated/reviewed December 2019
  • Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
  • Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
  • Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.
Lutheran Social Services of North Dakota Abound Counseling
Updated/reviewed December 2019
  • Need: To provide mental health services to rural residents in North Dakota and Minnesota.
  • Intervention: Abound Counseling of LSSND provides in-person counseling services in 8 communities and telehealth counseling services to other areas.
  • Results: In the first year of practice, Abound Counseling has brought greater access to quality mental healthcare for young children.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
Updated/reviewed December 2019
  • Need: Provision of medical care access and follow-up for rural North Carolina HIV patients with mental health, substance abuse, and unstable housing/homelessness challenges.
  • Intervention: Medical home staff model expanded to a care coordination program with a core Network Navigator and Continuum of Care Coordinator assisting with medical, behavioral health, and basic life needs.
  • Results: To date, the program has advanced three aspects of medical home patient care for this target population: provided further understanding of the spectrum of homelessness, including "hidden" homelessness; implemented outreach with creation of new community partnerships and a community housing coalition; and integrated medical care and behavioral health care for HIV.