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.

Promising Examples

TelePrEP
Updated/reviewed January 2023
  • 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 Health without Borders
Updated/reviewed December 2022
  • 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.
funded by the Federal Office of Rural Health Policy Northeast Louisiana Regional Pre-Diabetes Prevention Program
Updated/reviewed October 2021
  • 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 The Health Wagon
Updated/reviewed January 2021
  • Need: Healthcare access in Central Appalachia for the medically underserved challenged by social and economic determinants of health, including transportation barriers, food insecurity, poverty, and lack of health insurance.
  • Intervention: Three mobile clinics and 2 stationary clinics provide free health care for people in 16 counties in Virginia, Kentucky, and Tennessee.
  • Results: By leveraging technology and meeting patients where they are, Health Wagon provided comprehensive healthcare services — including specialty care — to 5,500 patients during 16,000 visit encounters in 2020.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
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

funded by the Federal Office of Rural Health Policy Facing Diabetes: Quality Improvement in Rural South Dakota Project
Updated/reviewed May 2023
  • Need: To help adults and children in rural South Dakota prevent or manage their diabetes.
  • Intervention: The Facing Diabetes Project offered medical visits for adults and provided prevention and education sessions for the local 4th and 5th graders.
  • Results: Many adults and children in the region felt better equipped to choose healthy foods, exercise regularly, and manage their stress: all factors that can help prevent diabetes or decrease its effects.
It's a Girl Thing: Making Proud Choices
Updated/reviewed February 2023
  • Need: Teen pregnancy and sexually transmitted diseases, including HIV, in young 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, and personal responsibility to teen girls.
  • Results: Teen pregnancy rates in Union Parish have dropped by 18%, exceeding the program's initial goal of 5%. Graduation rates have also increased the longer girls remain in the program.
funded by the Health Resources Services Administration Pacific AIDS Education and Training Center-Nevada
Updated/reviewed February 2023
  • 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 2022, PAETC-NV trained more than 1,400 healthcare providers across Nevada to increase clinical capacity in the care, screening, and prevention of HIV, other sexually transmitted diseases, COVID-19, and hepatitis C.
funded by the Health Resources Services Administration Volunteers of America Southeast Louisiana's Stepping Stones Program
Added February 2023
  • Need: Black women living with HIV in rural southeastern Louisiana face challenges in accessing care and other needed resources, often while dealing with other life stressors such as poverty, physical and mental health comorbidities, and a history of trauma.
  • Intervention: Implementing three evidence-informed interventions simultaneously ensures success in linking, treating, and retaining Black women in HIV care to improve health outcomes.
  • Results: As of February 2023, Stepping Stones has recruited 38 participants.
funded by the Federal Office of Rural Health Policy University of Virginia Diabetes Tele-Education Program
Updated/reviewed January 2023
  • 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.

Last Updated: 5/3/2023