This website is being reviewed for updates. Some information is offline. We apologize for any inconvenience.
Skip to main content
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

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.
funded by the Federal Office of Rural Health Policy

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.

Promising Examples

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.
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.
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.
funded by the Federal Office of Rural Health Policy

Updated/reviewed May 2020

  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.

Other Project Examples

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.

Updated/reviewed June 2025

  • Need: Teen pregnancy, sexually transmitted diseases, and mental health challenges in adolescent girls were concerns for members of Union Parish, Louisiana.
  • Intervention: Union General Hospital, a Critical Access Hospital, created the program It's a Girl Thing: Making Proud Choices to teach prevention, self-confidence, personal responsibility, and mental well-being to teen girls.
  • Results: Teen pregnancy rates in Union Parish have dropped by more than 40% since the start of the program, significantly exceeding the program's initial goal of 5%. Graduation rates have also increased. The addition of Together We Can Be Bully Free as an integral part of It's a Girl Thing has further expanded mental health support for participants.

Updated/reviewed May 2025

  • 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 5,000 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.
funded by the Health Resources Services Administration

Updated/reviewed April 2025

  • Need: To improve and increase prevention and care services for HIV, STDs, hepatitis C, and other infectious diseases.
  • Intervention: PAETC-NV provides clinical and didactic trainings, conferences, technical assistance, capacity building, webinars, and other services to providers and healthcare organizations statewide.
  • Results: In 2024, PAETC-NV trained more than 1,800 healthcare providers across Nevada to increase clinical capacity in the care, screening, and prevention of HIV, other sexually transmitted diseases, and hepatitis C.
Last Reviewed: 5/20/2022