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Rural Health Information Hub

Module 3: Program Clearinghouse

This section provides examples of rural organizations that have implemented chronic disease management programs to improve health and well-being. The Health Resources and Services Administration (HRSA) Federal Office of Rural Health Policy (FORHP) has funded several programs in rural areas with the goal of improving chronic disease management as part of the Rural Health Care Services Outreach Program through the Outreach Track and Healthy Rural Hometown Initiative Track. This program focuses on expanding access to healthcare services in rural areas with the goal of addressing health disparities and improving health outcomes.

This module provides examples of federal grantees and other organizations that have developed promising programs designed to improve chronic disease outcomes in rural communities. For more information about evidence-based and promising approaches for managing chronic disease, see Module 2.

  • Access East
    Synopsis: Access East is implementing the HealthAssist program to help improve health outcomes and quality of life for qualifying uninsured and underinsured residents in eastern North Carolina with chronic diseases. HealthAssist has developed three different programs to help patients access needed medications to manage their illnesses, acquire supplies for diabetes treatment, and meet other healthcare needs.
  • Avera Health
    Synopsis: Avera Health, located in rural South Dakota, offers a care transitions program that uses remote patient monitoring to support patients with congestive heart failure after hospital discharge.
  • Delta Health Alliance
    Synopsis: The Delta Health Alliance's BLUES (Better Living Utilizing Engagement Strategies) Diabetes Initiative provides chronic disease management through telehealth endocrine counseling and mobile primary care services to patients with diabetes in rural Mississippi.
  • Great Mines Health Center: Mobile Integrated Healthcare
    Synopsis: The Mobile Integrated Healthcare (MIH) initiative in rural Missouri uses a community paramedicine model to deliver care. MIH takes highly skilled emergency medical services staff into the homes of people living with chronic diseases, allowing them to receive quality medical care in their home and avoid expensive hospital visits.
  • Lake County Tribal Health Consortium, Inc.
    Synopsis: Lake County Tribal Health Consortium offers chronic disease and diabetes self-management programs for Native American and Latino populations in rural Lakeport, California.
  • Mainline Health Systems
    Synopsis: Mainline Health Systems uses a patient-centered medical home model and trained nurses, pharmacists, and community health workers to provide intensive chronic disease case management, medication management, and other chronic disease programs to improve the health of residents of rural Southeast Arkansas.
  • South Carolina Center for Rural and Primary Healthcare
    Synopsis: The Center for Rural and Primary Healthcare is a partnership between the University of South Carolina School of Medicine and the state's Department of Health and Human Services. The center funds programs to expand access to healthcare services, including chronic disease management, for rural communities in South Carolina.
  • Sullivan 180
    Synopsis: Sullivan 180 is a nonprofit organization dedicated to building a healthy community through people, places, and policy. The Hands4Health Network was created to bring together county partners to review and select a community health worker program for Sullivan County residents living with a chronic disease. The purpose of these community health workers would be to improve health and well-being while reducing the impact of social determinants of health.
  • West Virginia School of Osteopathic Medicine Center for Rural and Community Health (WVSOM CRCH)
    Synopsis: The West Virginia School of Osteopathic Medicine Center for Rural and Community Health (WVSOM CRCH) empowers communities to reach their highest level of health and wellness through education, research, and evidence-based programs. The center offers training services to become a Community Health Education Resource Person (CHERP) and conducts workshops across West Virginia in chronic disease self-management, chronic pain self-management, and diabetes self-management.