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

Health Coaches for Hypertension Control

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.

Meadows Diabetes Education Program

Updated/reviewed September 2023

• 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.
• Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.

Strong African American Families-Teen Program

Updated/reviewed May 2023

• 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.

New Mexico Mobile Screening Program for Miners

Updated/reviewed December 2022

• Need: To increase access to medical screening for miners in New Mexico.
• Intervention: A mobile screening clinic with telemedicine capability screens miners for respiratory and other conditions.
• Results: In a survey, 92% of miners reported their care as very good, while the other 8% reported it as good. The program has expanded to three other states.

Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care

Updated/reviewed August 2022

• Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
• Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
• Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.

HoMBReS

Updated/reviewed February 2022

• Need: To reduce the risk of HIV/STDs among Latino men living in rural regions of the United States.
• Intervention: Soccer team leaders are elected and trained as lay health advisors to promote sexual health education among team members.
• Results: Program participants report an increase in HIV testing, an increase in condom use, and an increase in awareness of how to prevent the transmission of HIV.

NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless

Updated/reviewed November 2020

• 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.

Promising Examples

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.

TelePrEP

Updated/reviewed March 2024

• 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 2024

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

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