These stories feature model programs and successful rural projects that can serve as a
source of ideas. Some of the projects or programs may no longer be active. Read about the
criteria and evidence-base
for programs included.
Updated/reviewed October 2023
- Need: The U.S. Associated Pacific Islands (USAPI) needed an efficient, effective, integrated method to improve primary care services that addressed the increased rates of non-communicable disease (NCD), the regional-specific phrase designating chronic disease.
- Intervention: Through specialized training, multidisciplinary teams from five of the region's health systems implemented the Chronic Care Model (CCM), an approach that targets healthcare system improvements, uses information technology, incorporates evidence-based disease management, and includes self-management support strengthened by community resources.
- Results: Aimed at diabetes management, teams developed a regional, culturally-relevant Non-Communicable Disease Collaborative Initiative that addresses chronic disease management challenges and strengthens healthcare quality and outcomes.