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Rural Health Information Hub

Rural Clinical Models for Health Promotion and Disease Prevention

Healthcare providers and facilities play an instrumental role in improving the health of rural residents. Healthcare providers and hospital staff can use many of the strategies and theories included in this module to improve the health outcomes of their patients. Healthcare settings in rural areas have also adopted clinical models that support systems change and the way that care is delivered to patients managing and preventing chronic conditions and disease. These models include:

Chronic Disease Management: The Chronic Disease Self-Management Program is a workshop given for two and a half hours, once a week, for six weeks, in community settings such as senior centers, churches, libraries, and hospitals. People with different chronic health problems attend together. Workshops are facilitated by two trained leaders, one or both of whom are non-health professionals with chronic diseases themselves. Subjects covered include:

  1. Techniques to deal with problems such as frustration, fatigue, pain, and isolation
  2. Appropriate exercise for maintaining and improving strength, flexibility, and endurance
  3. Appropriate use of medications
  4. Communicating effectively with family, friends, and health professionals
  5. Nutrition
  6. Decision making
  7. How to evaluate new treatments

Community Health Worker/Promotoras de Salud: This model uses community members with a shared cultural background to assist individuals with health issues and disease management. Community Health Workers (CHWs) assist people with information, provide care coordination services, and provide support to adopt healthy behaviors and lifestyles.

Patient-Centered Medical Home: A patient-centered medical home focuses on strengthening the clinician-patient relationship. This is achieved through improved access, managed and coordinated care, increased support, and is designed to help prevent, manage, and decrease the impact of various chronic diseases.

Resources to Learn More

Promoting Preventive Services for Adults 50-64: Community and Clinical Partnerships
Promotes lifesaving clinical preventive services for adults aged 50 to 64. Includes health prevention statistics, and identifies recommended practices for implementing community and clinical prevention programs.
Organization(s): Centers for Disease Control and Prevention, American Medical Association, and AARP
Date: 11/2009

Community Health Workers

Addressing Chronic Disease through Community Health Workers: A Policy and Systems-Level Approach
Provides guidance and resources for implementing recommendations to integrate community health workers (CHWs) into community-based efforts to prevent chronic disease.
Organization(s): Centers for Disease Control and Prevention
Date: 4/2015

Community Health Workers Evidence-Based Models Toolbox
Identifies promising practice models and evidence-based models for developing CHW programs in rural communities. Includes literature reviews on CHW program models as well as training approaches, implementation of programs, and program planning.
Organization(s): Health Resources and Services Administration (HRSA)
Date: 8/2011

Promoting Community Health Workers to Reduce Health Disparities in Minnesota
Discusses the impacts and outcomes from a CHW education program in Minnesota, and summarizes past projects relating to CHWs, program results, and lessons learned.
Organization(s): Robert Wood Johnson Foundation
Date: 12/2012

Report on Community Health Worker Programs
Presents examples of CHW programs in numerous states, and information gathered assisting in establishment of a CHW program in North Dakota, Minnesota, Massachusetts, New Mexico, New York, Colorado, Washington, and Wisconsin.
Author(s): Dickson, L. & Yahna, R.M.
Organization(s): University of North Dakota Center for Rural Health
Date: 6/2012

Patient Centered Medical Homes

Defining the PCMH
Defines the patient-centered medical home (PCMH) as encompassing five key attributes: 1) comprehensive care, 2) patient-centered; 3) coordinated care; 4) accessible services; and 5) quality and safety.
Organization(s): Agency for Healthcare Research and Quality (AHRQ)