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Rural Health Information Hub
Rural Health Information Hub

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.

Effective Examples

Meadows Diabetes Education Program

funded by the Federal Office of Rural Health Policy

Updated/reviewed September 2025

  • 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. The program is no longer active.
  • Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.

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

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration

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

funded by the Federal Office of Rural Health Policy

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

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.

University of Virginia Diabetes Tele-Education Program

funded by the Federal Office of Rural Health Policy

Updated/reviewed February 2026

  • Need: To educate people in rural Virginia who either have diabetes or are considered at high risk for developing it.
  • Intervention: Teleconferencing technology is used to offer diabetes education programs to people with diabetes or those at high risk for developing it. Health professionals are also indirectly trained in diabetes care and management.
  • Results: Participants reported better prevention practices and/or self-management of diabetes after being thoroughly educated about this condition.

COPD Readmission Prevention Program

Updated/reviewed August 2025

  • Need: Organized focus on COPD patients' medical needs to decrease hospital readmissions in a rural Ohio healthcare system.
  • Intervention: Creation of an integrated system model with nurse navigators central to evidence-based chronic disease care management approaches to COPD care.
  • Results: Since its creation in 2014, the model continues to mature its comprehensive approach to provide optimized acute and chronic care for the area's COPD patients.
Last Reviewed: 3/27/2026