Rural Project Examples Addressing Chronic disease management

Chronic Disease Self-Management Program

Updated/reviewed September 2023

Need: To help people with chronic conditions learn how to manage their health.
Intervention: A small-group 6-week workshop for individuals with chronic conditions to learn skills and strategies to manage their health.
Results: Participants have better health and quality of life, including reduction in pain, fatigue, and depression.

Updated/reviewed October 2024

Need: Rural Appalachian Kentucky residents have deficits in health resources and health status, including high levels of cancer, heart disease, hypertension, asthma, and diabetes.
Intervention: Kentucky Homeplace was created as a community health worker initiative to provide health coaching, increased access to health screenings, and other services.
Results: From July 2001 to June 2024, over 196,801 rural residents were served. Preventive health strategies, screenings, educational services, and referrals are all offered at no charge to clients.

Updated/reviewed September 2024

Need: To provide diabetes care and education services to those in rural southeast Georgia.
Intervention: Diabetes outreach screening, education, and clinical care services were provided to participants in Toombs, Tattnall, and Montgomery counties. The program is no longer active.
Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.

Updated/reviewed August 2024

Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
Intervention: A unique community health worker-based chronic care management program, created with philanthropy support.
Results: After a decade of use in attending to population health needs, health outcomes, healthcare costs, in 2024, the medical condition-agnostic model has a 4-year track record of financial sustainability with recent scaling to include 31 rural counties in a 3-state area of Appalachia and recent implementation in urban areas.

Updated/reviewed August 2024

Need: Expand healthcare access for the more remote residents of 3 frontier counties in north central Idaho.
Intervention: With early federal grant-funding, a consortium of healthcare providers and community agencies used a hybrid Community Health Worker model to augment traditional healthcare delivery services in order to offer a diverse set of health-related interventions to frontier area residents.
Results: With additional private grant funding, success continued to build into the current model of an established and separate CHW division within the health system's population health department.

Updated/reviewed October 2023

Need: The U.S. Associated Pacific Islands (USAPI) needed an efficient, effective, integrated method to improve primary care services that addressed the increased rates of non-communicable disease (NCD), the regional-specific phrase designating chronic disease.
Intervention: Through specialized training, multidisciplinary teams from five of the region's health systems implemented the Chronic Care Model (CCM), an approach that targets healthcare system improvements, uses information technology, incorporates evidence-based disease management, and includes self-management support strengthened by community resources.
Results: Aimed at diabetes management, teams developed a regional, culturally-relevant Non-Communicable Disease Collaborative Initiative that addresses chronic disease management challenges and strengthens healthcare quality and outcomes.

Updated/reviewed August 2022

Need: To address high rates of diabetes in rural Hispanic/Latino populations near the U.S.-Mexico border.
Intervention: A comprehensive, culturally competent diabetes education program was implemented in Santa Cruz County, Arizona.
Results: Since 2012, this program has helped participants better manage their diabetes and increase healthy living behaviors.

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.

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.

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.