Rural Project Examples Addressing Service delivery models

Community Health Worker-based Chronic Care Management Program

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 comprehensive 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 December 2023

Need: To improve the health status and access for rural nursing home patients in need of mental health services.
Intervention: The University of Vermont Medical Center provides telepsychiatry care and education to nursing homes in communities that face shortages of mental health professionals.
Results: These telepsychiatry consultations have eased the burden on nursing home residents by saving travel time, distance, and money it takes to travel to the nearest tertiary facility.

Updated/reviewed August 2020

Need: Increase access to medication-assisted treatment for opioid use disorder in rural Vermont.
Intervention: Statewide hub-and-spoke treatment access system.
Results: Increased treatment capacity and care coordination.

Updated/reviewed May 2020

Need: Meeting the health needs of geriatric patients in rural Livingston County, New York.
Intervention: The Help for Seniors program was developed and using its 'vodcasts,' local EMTs were trained in geriatric screening methods and health needs treatment.
Results: In addition to developing a successful model for educating EMS personnel, the program screened over 1200 individuals and identified various risks among the geriatric population.

Updated/reviewed May 2025

Need: To prevent new cases of HIV in rural Iowa.
Intervention: TelePrEP provides preventive care via telehealth and prescription delivery.
Results: Between February 2017 and August 2020, TelePrEP received 456 referrals, with 403 patients completing an initial visit.

Updated/reviewed April 2025

Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, poses significant challenges for those who want to remain living independently at home.
Intervention: SASH® (Support and Services at Home), based in affordable housing and their surrounding communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
Results: Compared to their non-SASH peers, SASH participants have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and lower Medicare and Medicaid expenditures.

Updated/reviewed December 2024

Need: To properly address and treat patients who have concurrent substance use disorders and chronic healthcare issues.
Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.

Added July 2024

Need: Solutions for Medicare beneficiaries' post-acute care recovery gaps in Arkansas's southeast Delta Region.
Intervention: Supported by federal funding and their membership organization, seven hospitals implemented an evidence-supported Critical Access Hospital transitional care model.
Results: Participating hospitals found a significant increase in swing bed services revenue, an all-cause low readmission rate, high percentage of patients discharged to home or to an assisted living environment, and positive patient satisfaction surveys.

Updated/reviewed May 2024

Need: To address and treat substance use disorder (SUD) and depression in the Upper Great Lakes region.
Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.