Skip to main content

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

Sickness Prevention Achieved through Regional Collaboration (SPARC, Inc.®)
Updated/reviewed July 2021
  • Need: Population-based rates of adult vaccinations and cancer screenings are low. 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.
StrongPeople™ Program
Added July 2021
  • 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

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.
Hidalgo Medical Services – Family Support Program
Updated/reviewed May 2021
  • 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.
The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management
Updated/reviewed March 2021
  • 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.
Community-Based Pulmonary Rehabilitation Program
Updated/reviewed February 2021
  • Need: More evidenced-based chronic lower respiratory disease management options for rural Appalachia patients, where lung disease rates are among the highest in the country.
  • Intervention: Implementation of outpatient pulmonary rehabilitation programs in 2 Federally Qualified Health Centers and a Critical Access Hospital in West Virginia.
  • Results: Improved health outcomes for patients with chronic lower respiratory disease, including those with chronic obstructive pulmonary disease.

Last Updated: 10/29/2021