Rural Project Examples Addressing Population health

Partners in Health and Wholeness

Updated/reviewed December 2022

Need: To lessen the impact of chronic disease and associated complications in North Carolina.
Intervention: Partners in Health and Wholeness, an initiative of the NC Council of Churches, is a faith-based program that integrates healthy living within congregations while offering financial support to launch or expand health initiatives. The program partners with faith communities in North Carolina to fund and support their health initiatives through collaborative partnerships.
Results: Since its founding in 2009, over 900 churches have become a part of the PHW, many in rural areas, and over 600 mini-grants have been awarded to congregations.

Updated/reviewed October 2022

Need: A community-wide collaborative process to identify and address specific quality-of-life challenges confronting the citizens of Beaufort County, South Carolina.
Intervention: Together for Beaufort County facilitates the coordination of local and regional coalitions that address economic, social, health, educational, and environmental factors through shared collective impact process.
Results: Out of 46 counties in South Carolina, Beaufort County has reached the top ranking in health outcomes.

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.

Added April 2021

Need: Population health approach to decreasing area deaths from cardiovascular disease.
Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.

Updated/reviewed November 2020

Need: Preventive and chronic medical condition care for farm families/agribusiness owners/employees with time and monetary constraints.
Intervention: Through a "Kitchen Wellness" program, a trained healthcare professional provides in-home or on-site complimentary preventive health screening, educational materials, and community referral information.
Results: Completion of hundreds of health screenings, tailored health education sessions and referral information.

Updated/reviewed July 2020

Need: Connect individuals to services that address health barriers.
Intervention: A pay-for-outcomes model utilizing Community Health Workers who help provide community members with tools to address needs associated with improving health.
Results: Trained Community Health Workers help patients navigate the healthcare and social service systems and provide education about community healthcare resources.

Updated/reviewed May 2020

Need: Agricultural producers and Pennsylvania's diverse farmworker population needed guidance on complying with Environmental Protection Agency regulations on the safe use of pesticides used in agricultural production.
Intervention: An outreach education program providing compliance and technical assistance for growers was developed which included culturally appropriate training materials targeted to workers.
Results: Pesticide use training and other farm safety information is now readily available to Pennsylvania's farmers and farmworkers.

Updated/reviewed March 2020

Need: Comprehensive cancer services for residents of an 8-county, 3-state area in Appalachia.
Intervention: Using a Cancer Patient Navigation Tool Kit, a Maryland acute care facility led a multidisciplinary collaboration that provided the area's patients with expanded cancer treatment services.
Results: In addition to several new cancer-related programs, expanded services are now available for cancer patients, families, and cancer survivors.

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.

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.