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Rural Health Information Hub

Chronic Disease in Rural America – Models and Innovations

These stories feature model programs and successful rural projects that can serve as a source of ideas and provide lessons others have learned. Some of the projects or programs may no longer be active. Read about the criteria and evidence-base for programs included.

Evidence-Based Examples

StrongPeople™ Program
Updated/reviewed July 2022
  • Need: Few older adults, particularly women and those in rural areas, participate in healthy living interventions.
  • Intervention: Health educators lead community-based healthy living classes, which include strength training, aerobic exercise, dietary skill building, and/or civic engagement, depending on the program.
  • Results: StrongPeople™ programs have been shown to improve weight, diet, physical activity, strength, cardiovascular health profile, physical function, pain, depression, and/or self-confidence in midlife and older adults.
Fit & Strong!®
Updated/reviewed August 2020
  • Need: Osteoarthritis is a chronic condition which often causes multiple related disabilities in older adults.
  • Intervention: An 8-week physical activity, behavior change, and falls prevention program geared to older adults with osteoarthritis.
  • Results: Participants gained confidence with increased exercise, lessened stiffness, improved joint pain and improved lower extremity strength and mobility.
Chronic Disease Self-Management Program
Updated/reviewed December 2019
  • Need: To help people with chronic conditions learn how to manage their health.
  • Intervention: A small-group 6-week workshop for individuals with chronic conditions to learn skills and strategies to manage their health.
  • Results: Participants have better health and quality of life, including reduction in pain, fatigue, and depression.
Project ENABLE (Educate, Nurture, Advise, Before Life Ends)
Updated/reviewed October 2019
  • Need: To enhance palliative care access to rural patients with advanced cancer or heart failure and their family caregivers.
  • Intervention: Project ENABLE consists of: 1) an initial in-person palliative care consultation with a specialty-trained provider and 2) a semi-structured series of weekly, phone-delivered, nurse-led coaching sessions designed to help patients and their caregivers enhance their problem-solving, symptom management, and coping skills.
  • Results: Patients and caregivers report higher quality of life and lower rates of depression and (caregiver) burden.
Project ECHO® – Extension for Community Healthcare Outcomes
Updated/reviewed July 2017
  • Need: To increase the capacity for more effective treatment of chronic, complex conditions in rural and underserved communities.
  • Intervention: Through a specially-designed project, remote primary care providers work with academic specialists as a team to manage chronic conditions of rural patients, expanding remote providers' knowledge base through shared case studies.
  • Results: Patient management and care provided by rural providers through ongoing education and mentoring from Project ECHO® has proved as effective as treatment provided by specialists at a university medical center.

Effective Examples

funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed August 2022
  • Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
  • Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
  • Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.
Hidalgo Medical Services – Family Support Program
Updated/reviewed April 2022
  • Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
  • Intervention: Community health workers worked with clients to help them better manage their health and promote awareness of healthy lifestyle options in the community.
  • Results: Better health outcomes for patients.
Franklin Cardiovascular Health Program (FCHP)
Updated/reviewed February 2022
  • Need: To develop sustainable, community-wide prevention methods for cardiovascular diseases in order to change behaviors and healthcare outcomes in rural Maine.
  • Intervention: Local community groups and Franklin Memorial Hospital staff studied mortality and hospitalization rates for 40 years in this rural, low-income area of Farmington to seek intervention methods that could address cardiovascular diseases.
  • Results: A decline in cardiovascular-related mortality rates and improved prevention methods for hypertension, high cholesterol, and smoking.
HoMBReS
Updated/reviewed February 2022
  • 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.
Heart Healthy Lenoir
Updated/reviewed October 2021
  • 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.

Last Updated: 8/12/2022