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Rural Health
Resources by Topic: Chronic disease management

Community-based Palliative Care: Scaling Access for Rural Populations
Explains the role palliative care plays in meeting the needs of patients with serious illness and chronic medical conditions. Discusses challenges to accessing palliative care in rural areas and highlights work in Alaska, California, and Kansas to help address this need.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 10/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Improving Chronic Disease Self-Management by Older Home Health Patients through Community Health Coaching
Describes a pilot study using community volunteers trained as health coaches to assist rural older adults with chronic diseases discharged from home health services in effectively managing their chronic condition, with the intent to reduce their hospital readmission and emergency department use.
Author(s): Cheryl Dye, Deborah Willoughby, Begum Aybar-Damali, Carmelita Grady, Rebecca Oran, Alana Knudson
Citation: International Journal of Environmental Research and Public Health, 15(4), 660
Date: 04/2018
Type: Document
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COPD & Rural Health: A Dialogue on the National Action Plan
Video of rural health experts discussing the challenges, opportunities, and resources related to the COPD National Action Plan's 5 goals. Presentations feature data including county-level maps on prevalence of COPD and death rates.
Date: 03/2018
Type: Video/Multimedia
Sponsoring organizations: National Heart, Lung, and Blood Institute, National Institutes of Health
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New Mexico Mobile Screening Program for Miners Brings Care to the Patients
Highlights a New Mexico program that uses screenings, specialty care via telehealth, and collaboration to meet the healthcare needs of miners with occupational lung disease. Services are provided via a mobile screening clinic housed in a semi that goes to 12 locations in the state.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 02/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Connected Care Toolkit: Chronic Care Management Resources for Health Care Professionals and Communities
A guide for healthcare professionals to support them in offering chronic care management (CCM) services. Provides links to CMS resources, including guides targeted to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Also includes educational materials to help patients understand CCM services.
Date: 2018
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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Medical-Legal Partnership Addresses Social Determinants of Health
Explores how FirstHealth of the Carolinas, a private, nonprofit healthcare network based in Pinehurst, North Carolina, reduced emergency department utilization and hospital readmission rates systemwide through the use of transitional care clinics (TCCs) and medical-legal partnerships (MLPs). Highlights how addressing non-medical factors can affect health outcomes.
Date: 08/2017
Type: Document
Sponsoring organization: Rural Health Value
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Dissemination of Chronic Disease Self-Management Education (CDSME) Programs in the United States: Intervention Delivery by Rurality
Describes the distribution of chronic disease self-management education (CDSME) programs across the U.S. by participants enrolled, workshops delivered, and counties reached. Compares the CDSME program distribution by rural designation, for example metro, nonmetro areas adjacent and not adjacent to metro areas. Includes a map of CDSME program distribution by rurality for every county in the U.S. and provides statistics on CDSME workshops and participants by rurality and workshop type.
Author(s): Matthew Lee Smith, Samuel D. Towne, Jr., Angelica Herrera-Venson, et al.
Citation: International Journal of Environmental Research and Public Health, 14(6), 638
Date: 06/2017
Type: Document
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Rural Promising Practice Issue Brief: IMPROVE: Integrated Management and Polypharmacy Review of Vulnerable Elders
Highlights a model for delivering integrated care management for older rural veterans with co-occurring chronic diseases. Presents methods for rural providers to help patients manage their prescriptions and avoid polypharmacy.
Additional links: Overview
Date: 05/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Diabetes Self-Management Education Programs in Nonmetropolitan Counties — United States, 2016
Examines the availability of diabetes self-management education (DSME) programs in nonmetropolitan counties. Includes data on related characteristics for nonmetro counties with and without DSME programs, including diabetes incidence and prevalence, race/ethnicity, income, educational attainment, and other demographic information.
Author(s): Stephanie A. Rutledge, Svetlana Masalovich, Rachel J. Blacher, Magon M. Saunders
Citation: MMWR Surveillance Summaries, 66(10), 1-6
Date: 04/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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