North Carolina Models and Innovations
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 January 2018
- Need: To reduce overdose-related deaths among prescription opioid users in rural Wilkes County, North Carolina
- Intervention: Education and tools are provided for prescribers, patients and community members to lessen drug supply and demand, and to reduce harm in prescription opioid use
- Results: Opioid overdose death rates have decreased in Wilkes County
Updated/reviewed December 2017
- Need: To reduce the risk of HIV/STDs among Latino men living in rural regions of the United States.
- Intervention: Soccer team leaders are elected and trained as lay health advisors to promote sexual health education among team members.
- Results: Program participants report an increase in HIV testing, an increase in condom use, and an increase in awareness of how to prevent the transmission of HIV.
Updated/reviewed November 2017
- Need: In rural eastern North Carolina, Lenoir County residents experience significantly higher rates of cardiovascular disease, stroke, and obesity rates compared to other parts of the state and nation.
- Intervention: A community-based research project was designed to develop and test better ways to tackle cardiovascular disease from prevention to treatment.
- Results: The end goal includes the development of long-lasting strategies and approaches within the community to help decrease the risk and disparities in risk of cardiovascular disease.
Updated/reviewed May 2018
- Need: Improvement in service quality and patient experience in primary care practices in North Carolina's Blue Ridge region and across the state.
- Intervention: A practicum for healthcare management students to help rural practices achieve Patient Care Medical Home (PCMH) status and identify quality improvement needs and develop strategies.
- Results: With the help of practicum students, rural primary practices have achieved PCMH status and Blue Quality Physician Program Recognition as well as tackled a number of important quality improvement projects.
Updated/reviewed October 2017
- Need: To decrease the number of children entering kindergarten with untreated tooth decay in the rural Appalachian counties of Rutherford, Polk, and McDowell in western North Carolina.
- Intervention: A program to give children a dental home that included screenings, targeted outreach, and restorative services.
- Results: An overall decrease within the service area of children entering kindergarten with sub-par oral health.
Added August 2017
- Need: To reduce prescription opioid misuse and overdoses in North Carolina.
- Intervention: The ICPTTP standardizes and streamlines chronic pain management in primary care clinics.
- Results: The ICPTTP has reduced patients' average daily morphine equivalent dose, and 25% of program participants have stopped taking opioids altogether.
Other Project Examples
Updated/reviewed July 2018
- Need: People living in under-resourced rural communities in North Carolina have poorer health than those living in urban areas.
- Intervention: Funded by the Kate B. Reynolds Charitable Trust, Healthy Places NC is investing $100 million over 10 years in rural North Carolina counties to improve residents' health.
- Results: As of June 2017, the Trust has invested more than $32 million in seven Healthy Places NC counties.
Updated/reviewed June 2018
- Need: Children and youth with special healthcare needs (CYSHCN) face many barriers to coordinated, comprehensive, and culturally competent healthcare.
- Intervention: The North Carolina Innovative Approaches (IA) initiative works with families of CYSHCN and other community leaders to make systems changes in the state's healthcare system.
- Results: In eight years, IA has impacted 19 counties and has had a positive impact on increasing family engagement and community capacity for systems changes.
Updated/reviewed February 2018
- Need: An increased interest among young people to pursue a medical career in rural North Carolina
- Intervention: Two medical students started a program that gives high school seniors medical academic training, mentor relationships, and hands-on experience in rural North Carolina facilities.
- Results: Project PROMISE has graduated 10 high school students, 5 of whom are pursuing an undergraduate degree with an interest in studying medicine.
Updated/reviewed January 2018
- Need: Compared to the average North Carolinian, residents age 40 to 64 in rural Granville County were dying from heart disease and diabetes at a younger age.
- Intervention: Granville Greenways was created to promote active lifestyles and more walkable communities.
- Results: Three greenways were created, with plans and funding for creation of additional walking and biking trails throughout the community.
Added October 2017
- 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.
Updated/reviewed October 2017
- Need: The rate of diabetes and diabetes mortality in North Carolina is higher than in many other states, but is even higher in the eastern part of the state.
- Intervention: TeleTEAM provides integrated care for patients with diabetes during regular primary care visits, using telehealth to connect them with off-site behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist.
- Results: Patients who have received care from TeleTEAM providers have shown decreases in blood sugar, as well as in weight, depression, and diabetes-related distress.
Updated/reviewed September 2017
- Need: To change the health profile of North Carolina.
- Intervention: Partners in Health and Wholeness, an initiative of the NC Council of Churches, is a faith-based program that integrates healthy living within congregations while offering financial support to launch or expand health initiatives.
- Results: Since its founding in 2009, over 475 churches have become certified with PHW, many in rural areas, and over 350 mini-grants have been awarded to congregations.
Updated/reviewed September 2017
- Need: There is a lack of dementia-specific support for rural caregivers.
- Intervention: Project C.A.R.E. (Caregiver Alternatives to Running on Empty) was created to meet the needs of rural caregivers of those with Alzheimer's disease across North Carolina.
- Results: Under Project C.A.R.E., rural families receive information and referrals as well as individualized, modified care management from dementia-trained family consultants.
Updated/reviewed August 2017
- Need: Rural school children lack proper healthcare resources within the school setting.
- Intervention: Health-e-Schools provides health services to students via teleconferencing 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.
Added April 2017
- Need: To reduce hospital admissions and improve health for North Carolina patients.
- Intervention: Granville Health System's Transitional Care Program helps hospital and ED patients schedule follow-up appointments. In addition, the program provides home visits and safety checks.
- Results: From 2015 to 2016, the number of patients receiving home visits increased from 30 to 86. In addition, 2016 saw a $73,595 reduction in inpatient readmissions and an $11,500 reduction in self-pay readmissions of patients with high-risk diagnoses.
Updated/reviewed April 2016
- Need: For recently hospitalized patients with complex, chronic illnesses, telehealth remote patient monitoring allows for more effective management of patients' conditions between provider visits.
- Intervention: Telehealth remote patient monitoring gathers and trends vital signs and other data and delivers disease-specific education and surveys to homebound patients.
- Results: Telehealth remote patient monitoring has reduced hospitalizations, reduced emergency department visits, reduced healthcare costs, improved clinical outcomes, and improved quality of life for complex patients with chronic illnesses.
Last Updated: 7/10/2018