Chronic Disease in Rural America – Models and Innovations

Chronic Disease Self-Management Program
Updated/reviewed September 2023

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.

StrongPeople™ Program
Updated/reviewed July 2023

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.

Project ENABLE (Educate, Nurture, Advise, Before Life Ends)
Updated/reviewed December 2022

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 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.

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.

Heart Healthy Lenoir
Updated/reviewed October 2023

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 October 2023

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 2023, over 189,338 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed October 2023

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.

Health Coaches for Hypertension Control
Updated/reviewed September 2023

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.

Meadows Diabetes Education Program
Updated/reviewed September 2023

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.

Evidence-Based Examples