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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.

Other Project Examples

Updated/reviewed October 2024

  • Need: To increase access to specialty care for rural veterans living with HIV.
  • Intervention: The HIV Telehealth Collaborative Care (TCC) study connects these patients with HIV specialists via clinical video telehealth or VA video connect and works to create shared care relationships with primary care teams in rural areas.
  • Results: The HIV TCC program provides HIV specialty care access to rural veterans in a sustainable manner with infrastructure, mentorship, and capacity building.
funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration

Updated/reviewed September 2022

  • Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's rural counties.
  • Intervention: A network was established that trained community health workers (CHWs) to be certified health insurance enrollment navigators and provide mental health services.
  • Results: This year, ASPIN trained 230 CHWs, cross-trained 70 behavioral health case managers as CHWs, and 35 individuals in the Indiana Navigator Pre-certification Education.

Updated/reviewed June 2022

  • Need: Evidenced-based intervention to improve function and quality of life for patients with chronic obstructive pulmonary disease and other chronic lower respiratory conditions.
  • Intervention: Pulmonary rehabilitation program implementation in 1989.
  • Results: Compared to a national average of only about 3% of referred Medicare beneficiaries actually enrolling in pulmonary rehabilitation, 60% of the program's referred patients enroll. Averaging around 15 patients/year completing the program, a large combined cardiac and pulmonary rehabilitation maintenance population averages 8,000 visits/year.
funded by the Federal Office of Rural Health Policy

Added October 2018

  • Need: Prevention of type 2 diabetes in adolescents living in rural parts of Louisiana.
  • Intervention: Through screenings, the Adolescent Pre-Diabetes Prevention Program detects the onset of prediabetes. Through nutrition and physical activity education, the program teaches high school students and staff how to adopt healthy lifestyles.
  • Results: The program has seen an increase in enrollment and continues to see decreases in body weight, body mass index, and A1C levels among participants.
Last Reviewed: 5/20/2022