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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

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.
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.
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%).
funded by the Federal Office of Rural Health Policy The Adolescent Pre-Diabetes Prevention Program
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 Updated: 2/27/2020