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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.

Other Project Examples

Volunteers of America Southeast Louisiana's Stepping Stones Program

funded by the Health Resources Services Administration

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.

ASPIN's Certified Recovery Specialist Program

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 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.

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)

funded by the Federal Office of Rural Health Policy

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.

Medical Home Plus

funded by the Federal Office of Rural Health Policy

Updated/reviewed February 2020

  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.

University of Mississippi Medical Center's Center for Telehealth

funded by the Health Resources Services Administration

Updated/reviewed January 2020

  • Need: Rural areas in Mississippi often lack adequate access to specialty healthcare services such as emergency medicine, stroke neurology, pediatric specialists and psychiatrists.
  • Intervention: The University of Mississippi Medical Center created the Center for Telehealth to deliver quality specialty services through telehealth video conferencing and remote monitoring tools to the underserved areas of Mississippi.
  • Results: The program has been successfully implemented throughout many of the state's rural hospitals and has reduced transfers and geographic barriers for patients.

Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management

funded by the Federal Office of Rural Health Policy

Updated/reviewed December 2019

  • Need: Decrease hospital readmissions and emergency room visits for patients in rural Tidewater, Virginia.
  • Intervention: After inpatient admission or ER visit, identify at-risk patients to offer enrollment in remote monitoring and disease self-management education and coaching, with a special focus on behavioral health wellness.
  • Results: Decreased readmissions and ER visits paired with high patient satisfaction scores.

COPD Inpatient Navigator Program

Updated/reviewed December 2019

  • Need: Improve readmission rates for rural patients with Chronic Obstructive Pulmonary Disease (COPD).
  • Intervention: COPD Inpatient Navigator program implementation in a rural hospital in Oregon.
  • Results: With navigator assistance, COPD-associated readmission rate has decreased by almost 50%, with a continued improvement trend.

COPD Readmission Prevention Program

Updated/reviewed December 2019

  • Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
  • Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
  • Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.

Last Updated: 2/16/2023