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Rural Health
Resources by Topic: Chronic disease management

Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Challenges and Recommendations for Improving Access to Evidence-Based COPD Management among Rural Veterans: Rural Primary Care Provider Perspectives
Highlights a study on the perspectives of primary care providers serving rural veterans on the challenges of providing evidence-based COPD management care in rural communities. Details key barriers and makes policy recommendations.
Author(s): Talitha Wilson, R. Adams Dudley, Ken M. Kunisaki, et al.
Citation: Journal of General Internal Medicine, 38, 2843-2845
Date: 04/2023
Type: Document
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Pennsylvania State Health Improvement Plan, 2023-2028
Multi-year strategic plan developed by the Pennsylvania Department of Health and the Healthy Pennsylvania Partnership, a multi-sector partnership of stakeholders and collaborators. Outlines steps and partnerships needed to achieve health equity, chronic disease prevention, and whole person care, and encourages policymakers, healthcare providers, nonprofits, and residents to promote and support health improvements throughout Pennsylvania.
Date: 03/2023
Type: Document
Sponsoring organization: Pennsylvania Department of Health
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Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?
Describes a care model utilizing CHWs to engage patients by screening for diseases, and offering education and information to help them manage their chronic conditions in an accessible, non-traditional setting such as a food bank distribution center, county fair, livestock auction, and educational events in rural Idaho. Discusses the value of CHWs, along with a primary care team, in improving outcomes for populations at risk, and the absence of payment models to support this model.
Author(s): Kelly McGrath
Citation: Journal of General Internal Medicine, 38 (Suppl 1), 16-17
Date: 03/2023
Type: Document
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COVID-19 Impacts on Primary Care Clinic Care Management Processes
Examines the relationship between COVID-19 primary care disruptions and worsened health outcomes for patients with chronic diseases. Analyzes 269 primary care clinics in Minnesota in 2017, 2019, and 2021 to observe changes in care management processes (CMPs). Presents rural versus urban clinic data related to CMPs reported on the Physician Practice Connections Readiness Survey (PPC-RS).
Author(s): Leif I. Solberg, Caroline S. Carlin, Kevin A. Peterson
Citation: The Annals of Family Medicine, 21(1), 40-45
Date: 01/2023
Type: Document
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Rural Wisconsin Chronic Disease Toolkit 2023
Toolkit describing rural-relevant best practices that have been successful in improving chronic disease outcomes and population health. Provides resources to address communication, Body Mass Index, diabetes care, blood pressure control, chronic disease management, and more.
Date: 2023
Type: Document
Sponsoring organization: Rural Wisconsin Health Cooperative
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Supporting and Sustaining the Current and Future Workforce to Care for People with Serious Illness: Proceedings of a Workshop (2023)
Summarizes discussions from an April 2023 public workshop exploring strategies and approaches to address major workforce challenges, including health professional well-being, workforce shortages, workforce training and retention, and advancing the diversity, equity, and inclusion of the workforce. Includes a section on well-being of the clinical workforce in rural areas.
Author(s): Roundtable on Quality Care for People with Serious Illness
Date: 2023
Type: Document
Sponsoring organization: Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
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Engaging At-Risk Rural Residents in Secondary Lung Cancer Prevention
Presents the results of a qualitative study analyzing interview transcripts of rural residents in Maine at risk for lung cancer based on smoking history and age to identify key themes that influence their understanding and attitudes regarding lung cancer risk, low-dose computed tomography (LDCT) screening tests, and the role of patient-provider relationships.
Author(s): Erika Ziller, Jean A Talbot, Martha Elbaum, et al.
Citation: Journal of Primary Care & Community Health, 14
Date: 2023
Type: Document
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Rural Public Health Workforce Training Network Program: 2022 Grantee Directory
Provides contact information and brief descriptions for the 32 rural health networks funded by the Rural Public Health Workforce Training Network (RPHWTN) program during the 2022-2025 grant period to expand rural public health capacity. Includes information by state and organization type as well as by program track for community health support, health IT and/or telehealth technical support, community paramedicine, and case management and/or respiratory therapy.
Date: 12/2022
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Grantee Sourcebook: Rural Health Network Development Planning Program, 2021
Detailed descriptions of 20 Rural Health Network Development Planning Program grant projects funded in fiscal year 2021. Reports on each grantee's network infrastructure development, plans for sustaining the network after the grant, and program activities addressing topics such as integrated service delivery, creating efficiencies, integrating health services, chronic disease management, and care coordination. Grantee profiles identify the geographic areas served, network partners, and primary contact person.
Date: 07/2022
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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