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

Positively Living & Choice Health Network
Updated/reviewed December 2022

• Need: To provide healthcare and support to thousands of East Tennesseans living with HIV/AIDS, mental illness, substance use disorder, and homelessness and dealing with LGBT discrimination.
• Intervention: Positively Living & Choice Health Network provides services like a medical clinic and pharmacy, therapy, client services like housing aid and transportation, and a harm reduction program.
• Results: The program currently serves 5,000 individuals and families through its offices in Knoxville, Chattanooga, Memphis, and rural Cookeville and its mobile medical unit for rural communities.

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.

Rapid HCV Testing as an HIV Testing Strategy in Rural Areas
Updated/reviewed November 2022

• 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.

ASPIN's Certified Recovery Specialist Program
Updated/reviewed September 2022

• Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's underserved 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.

HIV Telehealth Collaborative Care
Updated/reviewed September 2022

• 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.

Kansas Asthma Initiative
Updated/reviewed September 2022

• Need: Many of Kansas's rural residents have low incomes and are medically underserved, putting them at a potential increased risk for uncontrolled asthma.
• Intervention: The Kansas Asthma Initiative was a partnership that provided education and professional development opportunities via telehealth for healthcare providers and caregivers of asthma patients.
• Results: The partnership developed a better methodology for working with physicians. Telehealth technology helped facilitate a positive collaboration among providers in Kansas in order to decrease the burden of asthma.

Boone County Health Center Pulmonary Rehabilitation Program
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.

Community Healthcare Integrated Paramedicine Program (CHIPP)
Updated/reviewed January 2022

• Need: To reduce 911 use and improve older adults' health in rural Santa Cruz County, Arizona.
• Intervention: Community paramedics made scheduled visits to patients and connected them to other community resources.
• Results: CHIPP assisted over 150 people, and 911 calls decreased.

Generation Patient
Updated/reviewed June 2021

• Need: To help young adults with chronic or rare conditions access health and educational resources and build a community of peers and advocates.
• Intervention: Generation Patient summits bring together young adults with chronic medical disabilities, including chronic and rare conditions. The nonprofit organization also facilitates programming such as the Crohn's and Colitis Young Adults Network.
• Results: Generation Patient facilitates about six virtual meetings per month in addition to programming around higher education, civic engagement, and more. The organization also facilitates a Virtual International Summit for young adults with chronic and rare conditions.

Catalina Island Telemedicine Center
Updated/reviewed August 2020

• Need: To access specialty medical services, residents of Santa Catalina Island have to travel 20 miles by boat to southern California. A telemedicine service was needed to connect island residents to the mainland's specialty services.
• Intervention: The Catalina Island Medical Center created a telemedicine center to give residents quick access to specialty medical care, including diabetic consultations and pain management.
• Results: An analysis of the telemedicine program found that patients had measurable improvements, and that 90% of patients were pleased with the program and will continue to use it.

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