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.
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.
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.
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.
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.
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.
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.