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

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

Pacific AIDS Education and Training Center-Nevada

Updated/reviewed February 2024

• 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 2023, PAETC-NV trained more than 1,600 healthcare providers across Nevada to increase clinical capacity in the care, screening, and prevention of HIV, other sexually transmitted diseases, and hepatitis C.

Positively Living & Choice Health Network

Updated/reviewed February 2024

• 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.

University of Virginia Diabetes Tele-Education Program

Updated/reviewed January 2024

• 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.

Rapid HCV Testing as an HIV Testing Strategy in Rural Areas

Updated/reviewed December 2023

• Need: To provide HIV testing in rural areas while navigating around HIV stigma.
• Intervention: A pilot study to provide HCV (Hepatitis C Virus) rapid tests and then offer an HIV rapid test as well.
• Results: An increase in the number of people tested for HCV and HIV.

HIV Telehealth Collaborative Care (HIV TCC) Program

Updated/reviewed September 2023

• 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.

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.

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.

Heartland OK

Updated/reviewed November 2022

• Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
• Intervention: Heartland OK, which began in 5 rural counties, was a care coordination model.
• Results: Using a team-based care model increased patients' ability to reduce their blood pressure or achieve blood pressure control.

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