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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

Health Coaches for Hypertension Control

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.

Meadows Diabetes Education Program

funded by the Federal Office of Rural Health Policy

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.

Hidalgo Medical Services – Family Support Program

Updated/reviewed April 2023

  • Need: To reduce health disparities in two rural/frontier counties in southwest New Mexico.
  • Intervention: Community health workers worked with clients to help them better manage their health and promote awareness of healthy lifestyle options in the community.
  • Results: Better health outcomes for patients.

New Mexico Mobile Screening Program for Miners

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

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

funded by the Federal Office of Rural Health Policy

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

funded by the Health Resources Services Administration

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.

Medical Advocacy & Outreach's Telehealth Services

funded by the Health Resources Services Administration

Updated/reviewed November 2018

  • Need: Rural Alabama residents with HIV/AIDS face stigma, poverty, and transportation barriers, limiting their access to expert HIV/AIDS healthcare.
  • Intervention: Medical Advocacy & Outreach utilizes telemedicine to remove these barriers and offers cost-effective care to rural patients living with HIV/AIDS.
  • Results: This telehealth network has expanded to reach rural patients in 12 Alabama counties. Patients are staying engaged due to its convenience and cost-effective nature.

Promising Examples

Health without Borders

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

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.

Last Updated: 1/3/2024