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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

Chronic Disease Self-Management Program
Updated/reviewed October 2017
  • 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.
Fit & Strong!
Updated/reviewed August 2017
  • 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.
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.
Sickness Prevention Achieved through Regional Collaboration (SPARC, Inc.®)
Updated/reviewed July 2017
  • Need: Population-based rates of adult vaccinations and cancer screenings are low, with fewer than 40% of older adults up to date with routinely recommended prevention services. Delivery rates are lower still in low-income and minority communities.
  • Intervention: SPARC was established to develop and test new community-wide strategies to increase the delivery of clinical preventive services.
  • Results: Across the United States in both rural and urban communities, SPARC programs, which broaden the delivery of potentially life-saving preventive services, have been successfully launched, improving residents' health.
Project ENABLE (Educate, Nurture, Advise Before Life Ends)
Added May 2017
  • Need: To enhance palliative care access to rural patients with advanced cancer 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 lower rates of depression and burden along with higher quality of life.

Effective Examples

HoMBReS
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.
funded by the Health Resources Services Administration New Mexico Mobile Screening Program for Miners
Updated/reviewed December 2017
  • Need: To increase access to medical screening for miners in New Mexico.
  • Intervention: A mobile screening clinic with telemedicine capability screens miners for respiratory and other conditions.
  • Results: In a recent survey, 92% of miners reported their care as very good, while the other 8% reported it as good. Since 1989, the program has served 6,685 miners.
Heart-Healthy Lenoir Project
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.
funded by the Federal Office of Rural Health Policy One Community Health's Wellness Programs
Updated/reviewed October 2017
  • Need: Difficulties obtaining healthcare access to treat diabetes and obesity for low-income and Spanish-speaking residents of Oregon and Washington's Columbia River Gorge area.
  • Intervention: A local healthcare facility developed wellness programs using bilingual community health workers to provide education and support that improves diets, physical activity, and teaches stress management.
  • Results: Many participants in the wellness programs have maintained or lost weight and have seen reductions in their cholesterol levels, blood pressure, and blood sugar levels. Vegetable vouchers, cooking classes, and budgeting education has also helped patients afford healthy food.
funded by the Federal Office of Rural Health Policy Health Coaches for Hypertension Control
Updated/reviewed September 2017
  • Need: A cost-effective approach to help rural patients with hypertension learn to manage their condition.
  • Intervention: Community volunteers trained as health coaches provided an 8-session hypertension management training program to hypertension patients older than 60, with an optional supplemental 8 sessions focused on nutrition and physical activity.
  • Results: Just 16 weeks after the program, participants had improved systolic blood pressure, weight, and fasting glucose, greater knowledge of hypertension, and improved self-reported behaviors.
Children's Mercy Allergy, Asthma, and Immunology Telemedicine
Added August 2017
  • Need: To increase access to an allergy/asthma/immunology specialist for children in rural Kansas and Missouri.
  • Intervention: Children's Mercy Kansas City offers a telemedicine option for allergy/asthma/immunology visits.
  • Results: In 2017, Children's Mercy had 338 encounters from patients in rural counties. Patients and their families report satisfaction with the telemedicine visits, which a six-month study found to be as effective as in-person visits.
Hidalgo Medical Services – Family Support Program
Updated/reviewed June 2017
  • Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
  • Intervention: Community health workers work 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.
funded by the Federal Office of Rural Health Policy Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
Updated/reviewed June 2017
  • 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.
Kentucky Homeplace
Updated/reviewed May 2017
  • 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 address the lifestyle choices, inadequate health insurance, and environmental factors that are believed to contribute to these diseases.
  • Results: From July 2001 to June 2016, over 152,262 rural residents have been served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.
Strong African American Families-Teen (SAAF-T)
Updated/reviewed April 2017
  • Need: There is a lack of interventions that addresses teenager behavioral problems, particularly for rural African American adolescents.
  • Intervention: Rural, locally trained leaders administered five 2-hour meetings for teenagers and their primary caregivers. Trainings focused on reducing risks that prevent positive development, specifically sexual risk-taking that can lead to HIV and other STIs.
  • Results: Teens reported reduced conduct problems, depressive symptoms, and substance abuse. Families were strengthened, and SAAF-T reduced unprotected intercourse and increased condom efficacy.
Salud es Vida Cervical Cancer Education
Updated/reviewed January 2017
  • Need: Hispanic women have the highest incidence rates of cervical cancer among any ethnicity in the United States.
  • Intervention: The development of a lay health worker (promotora) curriculum that provides information on cervical cancer, HPV, and the HPV vaccine to Hispanic farmworker women living in rural southern Georgia.
  • Results: Significant increases in post-test scores relating to cervical cancer knowledge and increases in positive self-efficacy among promotoras.
Franklin Cardiovascular Health Program (FCHP)
Added March 2015
  • 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.

Promising Examples

funded by the Federal Office of Rural Health Policy Healthy People: Healthy Communities
Updated/reviewed November 2017
  • Need: Spotlight chronic disease risks in rural south central Kentucky, specifically stroke and heart disease.
  • Intervention: A case management program for Kentucky counties of Boyle, Garrard, Lincoln, and Mercer.
  • Results: Decreased the risk of stroke and heart disease among program participants.
HeartBeat Connections
Updated/reviewed November 2017
  • Need: Provide cardiovascular disease (CVD) primary prevention services to residents of New Ulm, Minnesota, in an effort to reduce CVD risk factors and heart attacks.
  • Intervention: Coaching by telephone to promote lifestyle behavioral changes and preventive medication management via a facility-approved protocol for individuals who were identified as being high risk for CVD.
  • Results: Early results indicate this approach is effective at promoting lifestyle changes to decrease the risk of CVD in rural and other underserved areas.
funded by the Federal Office of Rural Health Policy Heartland Rural Health Network
Updated/reviewed November 2017
  • Need: To assist diabetic patients in rural Florida with chronic disease management.
  • Intervention: Heartland Rural Health Network set out to expand the Diabetes Master Clinician Program and implement healthy eating in 4 Florida counties.
  • Results: Initial participating clinics exceeded national averages of successful management of diabetes. The program remains active and successful.
funded by the Federal Office of Rural Health Policy The Health Wagon
Updated/reviewed November 2017
  • Need: Healthcare access for the medically underserved in Central Appalachia.
  • Intervention: A mobile clinic that provides free healthcare in 11 rural Virginia communities.
  • Results: The Health Wagon provides comprehensive healthcare services to over 4,000 patients annually.
funded by the Federal Office of Rural Health Policy Community Health Coaches for Successful Care Transitions
Updated/reviewed September 2017
  • Need: To help older patients with chronic conditions learn to manage their illnesses and thereby reduce hospital readmissions in Oconee County, South Carolina.
  • Intervention: Community volunteers trained as health coaches mentor discharged patients with certain chronic conditions, to help them transition from home health care to self-care.
  • Results: Participants had improved health behaviors and reduced readmissions.
Texas C-STEP Project: Cancer Screening, Training, Education and Prevention Program
Added September 2017
  • Need: Improve screening rates for rural uninsured/underinsured patients in counties surrounding Bryan-College Station, Texas.
  • Intervention: An academic center's nursing and family medicine training programs partnered with its public health program to obtain state grant funds for execution of a coordinated cancer prevention and detection program.
  • Results: In 5 years of colorectal screening efforts, 18 cases of colorectal cancer were diagnosed in addition to detection of precancerous lesions in 25% of nearly 2000 screening colonoscopies. In 3 years of women’s health screening, 18 cases of breast cancer and 141 precancerous cervical lesions were also detected.
Proactive Palliative Care and Palliative Radiation Model: Making MyCourse Better
Updated/reviewed July 2017
  • Need: To provide palliative care to patients with stage 4 cancer.
  • Intervention: The Emily Couric Clinical Cancer Center in Charlottesville, Virginia, has implemented a three-part program to help these patients manage their symptoms.
  • Results: The Proactive Palliative Care and Palliative Radiation Model enrolled 646 patients during its three-year funding period of 2012-2015.
funded by the Federal Office of Rural Health Policy Health without Borders
Updated/reviewed June 2017
  • Need: To improve the health of communities in the south central region of New Mexico.
  • Intervention: A program was developed to specifically address diabetes prevention and control, behavioral healthcare, and immunization in Luna County.
  • Results: During the program, 1,500 immunizations were distributed, baseline measurements of participants improved, and 935 new patients were seen for behavioral health issues.
funded by the Federal Office of Rural Health Policy Sweet Dreams
Updated/reviewed January 2017
  • Need: To prevent and control Type 2 diabetes in rural, south central Georgia.
  • Intervention: Irwin County Board of Health developed Sweet Dreams to educate residents about the damaging effects of Type 2 diabetes and how to manage it.
  • Results: Participants have been able to improve their weight, body mass index, blood pressure, and hemoglobin A1C levels throughout the program.
funded by the Federal Office of Rural Health Policy Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2016
  • Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
  • Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
  • Results: The collaborative efforts strengthened care management services in local healthcare facilities as 344 patients were referred to a behavioral health specialist.
Patient Care Connect
Added September 2016
  • Need: Cancer patients living in the Deep South encounter multiple barriers in accessing regular cancer treatment.
  • Intervention: The University of Alabama at Birmingham Comprehensive Cancer Center developed a program that uses lay patient navigators to support and direct patients to appropriate resources to overcome barriers to accessing care.
  • Results: The program has become a model for improving cancer care quality, decreasing unnecessary utilization (ER visits and hospitalizations), removing barriers to care, and enhancing patient satisfaction.
funded by the Federal Office of Rural Health Policy Northeast Louisiana Regional Pre-Diabetes Prevention Program
Added November 2015
  • Need: To prevent or slow the progression of diabetes for at-risk residents in Rural Northeast Louisiana.
  • Intervention: The North Louisiana Regional Alliance developed a program that offers screenings, education, and an intense course for participants throughout the Northeast Louisiana region to lower the risk of diabetes.
  • Results: The program saw an overall decrease in blood sugar levels in residents who participated in their initiatives.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Added October 2015
  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers were utilized to create a system of coordinated care in the counties of Montrose, Ouray, and San Miguel.
  • Results: 1,192 people were screened for diabetes and cardiovascular disease. As a result, many at-risk patients lowered their cholesterol levels and blood pressure through this program.
funded by the Federal Office of Rural Health Policy Project ADEPT (Applied Diabetes Education Program using Telehealth)
Added September 2015
  • Need: To provide diabetes education services to the people of rural southeast Georgia.
  • Intervention: A telehealth diabetes education program was implemented in the Georgia counties of Candler, Emanuel, Tattnall, and Toombs.
  • Results: Participants showed improved control of diabetes and BMI.

Other Project Examples

Medical Advocacy and Outreach
Updated/reviewed November 2017
  • Need: Rural Alabama residents with HIV face stigmas, poverty, and transportation barriers, limiting their access to expert HIV health care. Health professional shortages and an increase in the number of new diagnoses contribute to the lack of care available as well.
  • Intervention: Telemedicine is utilized to remove these barriers and offer cost-effective care to rural patients with HIV.
  • Results: This telehealth network is expanding its services to numerous rural communities in Alabama and patients are staying enrolled in this care due to its convenience and cost-effectiveness.
Rapid HCV Testing as an HIV Testing Strategy in Rural Areas
Updated/reviewed November 2017
  • Need: To provide HIV testing in rural areas while navigating around HIV stigma.
  • Intervention: A pilot study to provide HCV (Hepatitis C Virus) rapid tests and then offer an HIV rapid test as well.
  • Results: An increase in the number of people tested for HCV and HIV.
funded by the Health Resources Services Administration NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
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.
TeleTEAM Care for Diabetes Program
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.
It's a Girl Thing: Making Proud Choices
Added September 2017
  • Need: Teen pregnancy and sexually transmitted diseases, including HIV, in young girls were concerns for members of Union Parish, Louisiana.
  • Intervention: Union General Hospital, a Critical Access Hospital, created the program It's a Girl Thing: Making Proud Choices to teach prevention, self-confidence, and personal responsibility to teen girls.
  • Results: Teen pregnancy rates in Union Parish have dropped by 18%, exceeding the program's initial goal of 5%. Graduation rates have also increased the longer girls remain in the program.
funded by the Federal Office of Rural Health Policy Medical Home Plus
Updated/reviewed September 2017
  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.
AmeriCorps Members as Community Health Workers
Updated/reviewed August 2017
  • Need: A significant number of people struggle with obesity, diabetes, and high blood pressure in the Mid-Ohio Valley of West Virginia, yet there was a limited number of health department staff available to address these issues.
  • Intervention: The Mid-Ohio Valley Health Department utilized AmeriCorps members to serve as community health workers, educating people on health topics in the areas in which they live.
  • Results: AmeriCorps members have motivated people to exercise, lose weight, and self-manage their chronic diseases, leading to healthier residents of the Mid-Ohio Valley.
funded by the Federal Office of Rural Health Policy Connecting the Chronically Ill
Updated/reviewed August 2017
  • Need: Baker County, Florida, had many residents living with chronic illnesses and limited access to healthcare services.
  • Intervention: Connecting the Chronically Ill was started to provide Baker County's most vulnerable, chronically ill residents with medical services and health education.
  • Results: The program provided services to almost 400 residents and health education to nearly 900 residents, and it helped reform the area's judicial system for inmates with substance abuse and mental health issues.
Kansas Asthma Initiative
Updated/reviewed August 2017
  • Need: Many of Kansas's rural residents have low incomes and are medically underserved, putting them at a potential increased risk for uncontrolled asthma.
  • Intervention: The Kansas Asthma Initiative is a partnership that provides education and professional development opportunities via telehealth for healthcare providers and caregivers of asthma patients.
  • Results: The partnership has developed a better methodology for working with physicians. Telehealth technology is helping facilitate a positive collaboration among providers in Kansas in order to decrease the burden of asthma.
funded by the Federal Office of Rural Health Policy Visiting School Nurse Program
Updated/reviewed August 2017
  • Need: Students in rural communities lacked access to healthcare services, resulting in poor school performance.
  • Intervention: The Visiting School Nurse program was created to improve access to health care for 6,000 students in Fulton County, Illinois.
  • Results: After the three years of the grant-funded program, the program continues to serve one school district and staff with a variety of health services and educational campaigns.
Love Your Heart
Added July 2017
  • Need: To reduce heart disease in rural West Virginia.
  • Intervention: Love Your Heart trains local organizations to host community events about heart health.
  • Results: Since 2015, the program has reached 196,124 participants through 267 programs held in 33 counties (24 of which are rural).
Mobile Women's Health Unit
Updated/reviewed July 2017
  • Need: Breast cancer is a leading cause of cancer deaths for the American Indian and Alaska Native (AI/AN) female population, and those living in remote areas have difficulties getting screening mammograms.
  • Intervention: The Great Plains Area Indian Health Service Mobile Women's Health Unit provides mammograms to women on multiple reservations across four states.
  • Results: Approximately 1,000 women are screened annually for breast cancer in the mobile unit.
funded by the Health Resources Services Administration Roane County Hypertension Control
Updated/reviewed July 2017
  • Need: Nearly one in three Americans has hypertension, and rural community members lack access to clinics and means for monitoring and treatment of their high blood pressure.
  • Intervention: Roane County Family Health Care (RCFHC) uses community-oriented, outcome- and team-based care to combat their rural community members' high rates of hypertension.
  • Results: In 2014, RCFHC succeeded in achieving hypertension control rates in at least 70% of patients, and was named a 2014 Hypertension Control Champion by the U.S. Department of Health and Human Services.
Telehealth Collaborative Care
Added July 2017
  • Need: To increase access to specialty care for rural veterans with HIV.
  • Intervention: The Telehealth Collaborative Care (TCC) study connects these patients with HIV specialists via telehealth and works to create shared care relationships with primary care teams in rural areas.
  • Results: TCC provides HIV specialty care to 600 rural veterans in Georgia and Texas.
University of Mississippi Medical Center: Center for Telehealth
Updated/reviewed July 2017
  • Need: Many rural areas in Mississippi lacked adequate access to specialty healthcare services such as emergency medicine, stroke neurology, pediatric specialists and psychiatrists. Mississippi's health and economic future depended on the implementation of an innovative, culturally-appropriate, community-based effort to improve health outcomes.
  • Intervention: The University of Mississippi Medical Center created the Center for Telehealth to deliver quality specialty services through telehealth video conferencing and remote monitoring tools to the underserved areas of Mississippi.
  • Results: The program has been successfully implemented throughout many of the state's rural hospitals and has reduced transfers and geographic barriers for patients.
Women's Way
Updated/reviewed July 2017
  • Need: One in 8 women will be diagnosed with breast cancer in North Dakota. While breast and cervical cancer have high survival rates when detected early, many women are not able to access life-saving cancer screenings due to cost and lack of insurance.
  • Intervention: Women's Way of North Dakota was created to help women find a way to pay for breast and cervical cancer screenings.
  • Results: From the program’s beginnings in 1997 through May 2017, Women's Way has provided new first-time screening services for nearly 14,500 women and helped hundreds of women with positive results find treatment.
funded by the Federal Office of Rural Health Policy Facing Diabetes: Quality Improvement in Rural South Dakota Project
Updated/reviewed June 2017
  • Need: To help adults and children in rural South Dakota prevent or manage their diabetes.
  • Intervention: The Facing Diabetes Project offered group medical visits for adults and provides prevention and education sessions for the local 4th-5th graders.
  • Results: Many adults and children in the region feel better equipped to choose healthy foods, exercise regularly, and manage their stress: all factors that can help prevent diabetes or decrease its effects.
Putting Healthy Food on the Table
Updated/reviewed June 2017
  • Need: To reduce cancer rates in Appalachian Ohio by increasing fruit and vegetable intake.
  • Intervention: Ohio State University Extension-Vinton County established a community garden, container gardens, and classes to provide residents with fresh produce and healthy cooking/canning techniques.
  • Results: The number of gardeners has increased in Vinton County, providing residents with healthier food.
funded by the Federal Office of Rural Health Policy Santa Catalina Island Healthcare Consortium
Updated/reviewed June 2017
  • Need: The Catalina Island Medical Center created a telemedicine program to bring specialty services from the mainland to the island.
  • Intervention: The Catalina Island Medical Center created a healthcare consortium to offer health services to the isolated residents of the West End and a telemedicine program to bring specialty services to Avalon.
  • Results: Through telemedicine services, residents have enrolled in diabetic education classes, received eye screenings, and telepsychiatry services.
Granville Health System's Transitional Care Program
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.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Added April 2017
  • Need: The U.S. Associated Pacific Islands (USAPI) needed an efficient, effective, integrated method to improve primary care services that addressed the increased rates of non-communicable disease (NCD), the regional-specific phrase designating chronic disease.
  • Intervention: Through specialized training, multidisciplinary teams from five of the region’s health systems implemented the Chronic Care Model (CCM), an approach that targets healthcare system improvements, uses information technology, incorporates evidence-based disease management, and includes self-management support strengthened by community resources.
  • Results: Aimed at diabetes management, teams developed a regional, culturally-relevant Non-Communicable Disease Collaborative Initiative that addresses chronic disease management challenges and strengthens healthcare quality and outcomes.
Closing Preventive Care Gaps in Underserved Areas
Added March 2017
  • Need: Address the need to increase cancer screening rates as well as other preventive care measures in Appalachian Kentucky, a region with high cancer incidence and mortality rates, and noted health disparities.
  • Intervention: Federally Qualified Health Centers (FQHCs) and an academic center partnered to adapt and implement an office-based intervention, building on existing primary care resources to decrease gaps in preventive care measures, including cancer screenings.
  • Results: After intervention implementation, White House Clinics saw a marked increase in various preventive care measures, including screenings for cancer, human immunodeficiency virus (HIV) and hepatitis C (HVC).
Munson Healthcare Charlevoix Hospital School Nurse Program
Added February 2017
  • Need: School nurses to assess and care for students in rural Michigan schools who have limited access to healthcare.
  • Intervention: Munson Healthcare Charlevoix, a CAH in Northern Michigan, created the School Nurse Program to provide medical care and education to students, school staff, and families.
  • Results: The School Nurse Program brings healthcare to over 3,400 students in 8 schools every year and chronic absenteeism in participating schools has dramatically decreased.
funded by the Federal Office of Rural Health Policy Chautauqua Opportunities, Inc.
Updated/reviewed January 2017
  • Need: To reduce obesity and diabetes in children and adults of rural southwest New York.
  • Intervention: Chautauqua Opportunities, Inc. Rural Outreach Program was developed to bring diabetes and obesity services to Chautauqua and Cattaraugus county residents.
  • Results: The program saw a 50% improvement rate in Type 1 and prediabetic participants and just over 50% for Type 2 diabetics.
Project COPE (Cancer Outreach Prevention Education)
Updated/reviewed January 2017
  • Need: Comprehensive breast care services are unavailable in many rural regions of Kentucky, and many of the women in these areas lack financial means for adequate breast care.
  • Intervention: Project COPE was initiated to provide women with support at any and every stage of breast cancer treatment.
  • Results: Women in the service area no longer have to travel to urban areas for customary breast care services and now have numerous avenues of support when going through breast cancer treatment.
funded by the Federal Office of Rural Health Policy Reach Out Program
Updated/reviewed January 2017
  • Need: Diabetes is the most common health problem in the African American, Latino, and Native American populations of rural Lake County, California.
  • Intervention: A Promotores/Community Health Workers model is used to teach positive lifestyle habits to people of all ages in order to live healthier lives, specifically to manage or prevent Type 2 diabetes.
  • Results: Participants in the Reach Out Program have improved their habits relating to nutrition and physical activity, leading to healthier lives.
funded by the Federal Office of Rural Health Policy University of Virginia Diabetes Tele-Education Program
Updated/reviewed January 2017
  • Need: To educate people in the rural parts of Virginia who either have diabetes or are considered at high risk for developing it.
  • Intervention: Teleconferencing technology is used to offer diabetes education programs throughout the year to people with diabetes or those at high risk for developing diabetes.
  • Results: Participants reported better prevention techniques and/or self-management of diabetes after being thoroughly educated about this condition.
Heartland OK
Added October 2016
  • Need: Over 9,000 people in Oklahoma die from heart disease each year.
  • Intervention: Heartland OK, which began in 5 rural counties, is a care coordination model that works to reduce heart disease and stroke risks for patients.
  • Results: 25% of patients met their hypertension goals within 90 days.
funded by the Federal Office of Rural Health Policy Meadows Diabetes Education Program
Updated/reviewed September 2016
  • 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 Telehealth Monitoring in Home Health
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.
Level One Cardiac Care and Partnership
Updated/reviewed March 2016
  • Need: Fast diagnosis and stabilization in order to survive a cardiac emergency in the rural areas around Davenport, Washington.
  • Intervention: Lincoln Hospital is prepared to quickly assess needs, deliver medications, and air transport heart attack patients to Sacred Heart Medical Center in Spokane, Washington.
  • Results: Increased survival rates and other quality of life outcomes for heart attack patients from the rural areas of Lincoln County, Washington.
Black Corals Cancer Education
Added October 2015
  • Need: African American women in rural South Carolina are almost 40% more likely to die from breast cancer and over 3 times more likely to die from cervical cancer than Caucasian women in the state.
  • Intervention: St. James-Santee Family Health Center implemented a breast and cervical cancer screening promotion program called Black Corals.
  • Results: In 2 years, Pap smear and mammogram rates increased by over 10% and missed appointment rates were decreased by over 30%.
funded by the Federal Office of Rural Health Policy Downeast Maine Diabetes Prevention Program
Added September 2015
  • Need: To address the prevalence of diabetes in rural, Downeast Maine.
  • Intervention: A comprehensive continuum of care was developed that focuses on healthy lifestyle changes and diabetic self-management.
  • Results: BMI levels have been lowered, A1C levels have been reduced, and participants have lost weight, decreasing the risk of diabetes.

Last Updated: 12/5/2017