Chronic Disease in Rural America – Models and Innovations

Effective Examples

The Pacific Care Model: Charting the Course for Non-communicable Disease Prevention and Management

Updated/reviewed October 2025

• 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 January 2024

• Need: More evidence-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.

Promising Examples

TelePrEP

Updated/reviewed May 2025

• Need: To prevent new cases of HIV in rural Iowa.
• Intervention: TelePrEP provides preventive care via telehealth and prescription delivery.
• Results: Between February 2017 and August 2020, TelePrEP received 456 referrals, with 403 patients completing an initial visit.

Health without Borders

Updated/reviewed January 2025

• Need: To improve the health of communities in the south central region of New Mexico.
• Intervention: A program was developed to 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.

Northeast Louisiana Regional Pre-Diabetes Prevention Program

Updated/reviewed March 2024

• 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 offered 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.

Other Project Examples

ASPIN's Certified Recovery Specialist Program

Updated/reviewed September 2026

• Need: Indiana's rural communities face significant behavioral health and primary care shortages. Providers require trained frontline workers who can support care navigation, address social drivers of health, and expand access to prevention, intervention, and recovery services.
• Intervention: A statewide training and workforce development model that certifies Community Health Workers (CHWs) and dual CHW/PRSS (Peer Recovery Support Specialists) to serve in rural settings.
• Results: ASPIN has trained and certified 2,235 Community Health Workers, expanded PRSS training opportunities, and supported rural partners statewide through CHW training and workforce development programs.

Major Health Partners Kidney Care Options (KCO) Program

Added July 2026

• Need: To improve kidney care for patients in rural Indiana.
• Intervention: A nurse-led, interdisciplinary kidney care program redesigned clinical workflows to identify patients earlier, provide education, address barriers to treatment, and support informed decision-making.
• Results: From 2023 to 2025, 80% to 92% of patients received Kidney Care Options education before initiating kidney replacement therapy.

Positively Living & Choice Health Network

Updated/reviewed June 2026

• Need: To provide affirming, destigmatized healthcare and support to thousands of Tennesseans living with HIV/AIDS, mental illness, substance use disorder, and homelessness – and prevention services for individuals at risk of contracting HIV.
• Intervention: Positively Living & Choice Health Network provides services including a medical clinic, pharmacy, therapy, case management, client services like housing aid and transportation, HIV prevention, and a harm reduction program.
• Results: The program currently serves over 6,000 individuals and families through its offices in Knoxville, Chattanooga, Memphis, and Cookeville and its mobile medical unit for rural communities in Cocke and Claiborne counties.

HealthScreen at UF HealthStreet

Added May 2026

• Need: To provide chronic disease screening and follow-up services to people in rural North Central Florida.
• Intervention: A mobile health program that hosts screenings at community events.
• Results: The program has seen at least 225 people per quarter.

Promise Community Health Center Hypertension Control Program

Added February 2026

• Need: To improve hypertension in rural Iowa patients.
• Intervention: Promise Community Health Center offers team-based care to help patients manage hypertension.
• Results: The center increased its hypertension control rate from 73% in 2022 to 84% in 2024.

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