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Rural Project Examples: Service delivery models

Other Project Examples

Optimal Health Behavioral Health Home Models
Updated/reviewed December 2019
  • Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
  • Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
  • Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.
funded by the Health Resources Services Administration Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed December 2019
  • 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.
Scheffe Prescription Shop's Medication Synchronization Program
Updated/reviewed December 2019
  • Need: For adults with chronic conditions, skipping a dose or two is common, but can also be risky. Frequent medication in-adherence has accounted for emergency department visits, hospitalizations, and even death.
  • Intervention: The Scheffe Prescription Shop in Enid, Oklahoma started a medication synchronization program. Pharmacists serve as care coordinators for patients by prepackaging pills, scheduling recheck appointments, and providing pickup reminders and medication education over the phone.
  • Results: The program has reduced the number of trips patients have to take to the pharmacy to pick up their pills and has increased medication adherence rates over 4 years.
Trinity Pioneer ACO
Updated/reviewed December 2019
  • Need: Transitioning from fee-for-service models to valued-based payment models in rural Iowa.
  • Intervention: In 2011, the Trinity ACO was formed in rural Iowa after being selected by the Center for Medicare and Medicaid Innovation as 1 of the 32 planned Medicare Pioneer Accountable Care Organizations.
  • Results: Now part of the Next Generation ACO, Trinity continues to bring attention to rural-specific organizations using its focus on palliative medicine and effective strategies to distribute value-based services.
funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration ASPIN's Certified Recovery Specialist Program
Updated/reviewed November 2019
  • 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 (CHW) to be certified health insurance enrollment navigators and provide mental health services.
  • Results: This year, ASPIN trained 61 CHWs, cross-trained 37 behavioral health case managers as CHWs, and 26 individuals in the Indiana Navigator Pre-certification Education.
Heartland OK
Updated/reviewed November 2019
  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK, which began in 5 rural counties, is a care coordination model.
  • Results: Using a team-based care model increases patients' ability to reduce their blood pressure or achieve blood pressure control.
funded by the Federal Office of Rural Health Policy Indiana Veterans Behavioral Health Network
Updated/reviewed November 2019
  • 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.
Super-Utilizer Pilot Project
Updated/reviewed November 2019
  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker use technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.
funded by the Health Resources Services Administration Health-e-Schools
Updated/reviewed October 2019
  • 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.
funded by the Federal Office of Rural Health Policy Family Advocacy Network
Updated/reviewed September 2019
  • Need: A service to address the high number of child abuse cases reported in Nebraska in the late 1990s.
  • Intervention: The Family Advocacy Network (FAN) was developed to assist in the investigations of child abuse cases. FAN provides forensic interviews, forensic medical examinations, hair follicle testing, case coordination, advocacy, and education to help prevent revictimization.
  • Results: FAN helped over 600 children and 23 adults in 2016, as well as educated hundreds of healthcare and community professionals.