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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

Project ECHO® – Extension for Community Healthcare Outcomes
Updated/reviewed October 2022
  • Need: Increase medical management knowledge for New Mexico primary care providers in order to provide care for the thousands of rural and underserved patients with hepatitis C, a chronic, complex condition that has high personal and public health costs when left untreated.
  • Intervention: Project leveraging an audiovisual platform to accomplish "moving knowledge, not patients" that used a "knowledge network learning loop" of disease-specific consultants and rural healthcare teams learning from each other and learning by providing direct patient care.
  • Results: In 18 months, the urban specialist appointment wait list decreased from 8 months to 2 weeks due to Hepatitis C patients receiving care from the project's participating primary care providers. Improved disease outcomes were demonstrated along with cost savings, including those associated with travel. The project model, now known as Project ECHO® – Extension for Community Healthcare Outcomes — has evolved into a telementoring model used world-wide.
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.

Effective Examples

Heart Healthy Lenoir
Updated/reviewed October 2022
  • 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.
Kentucky Homeplace
Updated/reviewed September 2022
  • Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
  • Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
  • Results: From July 2001 to June 2022, over 182,783 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
funded by the Federal Office of Rural Health Policy Meadows Diabetes Education Program
Updated/reviewed September 2022
  • Need: To provide diabetes care and education services to those in rural southeast Georgia.
  • Intervention: Diabetes outreach screening, education, and clinical care services were provided to participants in Toombs, Tattnall, and Montgomery counties.
  • Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.
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.

Last Updated: 10/4/2022