Rural Project Examples: Medical homes

Promising Examples

Atlantic General Hospital Patient Centered Medical Home

Updated/reviewed August 2022

• Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
• Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
• Results: From the program's care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.

Other Project Examples

Clinic for Special Children

Updated/reviewed July 2024

• Need: To provide healthcare for the genetically vulnerable children and adults of the rural, uninsured Amish and Mennonite communities in southern Pennsylvania.
• Intervention: A clinic that serves as a comprehensive medical practice for children and adults (primarily from the Amish and Mennonite communities) with rare, inherited, or complex disorders.
• Results: In 2023, about 1,700 active patients with more than 450 unique genetic mutations were treated at the Clinic for Special Children.

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.

Optimal Health Behavioral Health Home Models

Updated/reviewed December 2019

• Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
• Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
• Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.