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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

funded by the Federal Office of Rural Health Policy 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.
funded by the Federal Office of Rural Health Policy Medical Home Plus
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.
funded by the Health Resources Services Administration University of Mississippi Medical Center's Center for Telehealth
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.
AmeriCorps Community Health Workers Program
Updated/reviewed December 2019
  • Need: Chronic diseases, diabetes, and opioid misuse has caused significant health disparities in Ohio and West Virginia.
  • Intervention: A program recruiting AmeriCorps members to serve as community health workers helps bring health services and education to local residents.
  • Results: As a result of the program, community members have reported weight loss, increased physical activity, reduction in medication, and improvements in self-management of chronic diseases.
funded by the Federal Office of Rural Health Policy Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management
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.
funded by the Health Resources Services Administration National Jewish Health Rural Miners Outreach Clinics
Added December 2019
  • Need: Early detection of health risks associated with mining in the Western region of the United States.
  • Intervention: The National Jewish Health Miners Clinic of Colorado developed two rural outreach programs that partner with local healthcare facilities to offer free medical screening for active and retired miners and historic uranium industry workers.
  • Results: Since beginning in 2003, these programs have served over 2,000 miners and historic uranium industry workers. Dust disease of the lungs have been detected on chest X-ray screenings in 16% of patients, abnormal breathing tests have been found in 24%, and other chronic conditions have been detected.
It's a Girl Thing: Making Proud Choices
Updated/reviewed November 2019
  • 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.
Foundations Family Medicine's HIV, HCV, Opioid and Substance Use Disorder Services
Added November 2018
  • Need: Due to the opioid crisis, Austin, Indiana has seen the largest concentrated outbreak of HIV in rural America's recent history. Since 2015, over 200 residents have been diagnosed with the virus.
  • Intervention: Foundations Family Medicine began offering testing and treatment services for HIV, hepatitis C, and opioid/substance use disorder. Education, care coordination and behavioral health services were also offered as an integrated part of their primary care clinic.
  • Results: Although the virus continues to spread throughout Scott County, the rate has significantly decreased, outdoing national suppression rates by a large margin (76% compared to national average of 49%).

Last Updated: 8/17/2020