Rural Project Examples: Service delivery models
Effective Examples
Meadows Diabetes Education Program
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
Updated/reviewed September 2023
- 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.
- Results: Patients successfully learned self-management skills to lower their blood sugar, cholesterol, and blood pressure.
Perinatal Health Partnership Southeast Georgia
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
Updated/reviewed February 2023
- Need: In 12 rural southeast Georgia counties, high-risk pregnant individuals potentially face adverse birth outcomes, including maternal or infant mortality, low birthweight, very low birthweight, or other medical or developmental problems.
- Intervention: An in-home nursing case management program for high-risk pregnant individuals in order to maximize pregnancy outcomes for mothers and their newborns.
- Results: Mothers carry their babies longer and the babies are larger when born, leading to improved health outcomes.
New Mexico Mobile Screening Program for Miners
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
![funded by the Health Resources Services Administration](/assets/4669-20781/hrsa-badge-125.png)
Updated/reviewed December 2022
- Need: To increase access to medical screening for miners in New Mexico.
- Intervention: A mobile screening clinic with telemedicine capability screens miners for respiratory and other conditions.
- Results: In a survey, 92% of miners reported their care as very good, while the other 8% reported it as good. The program has expanded to three other states.
Vivir Mejor! (Live Better!) System of Diabetes Prevention and Care
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
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.
NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
![funded by the Health Resources Services Administration](/assets/4669-20781/hrsa-badge-125.png)
Updated/reviewed November 2020
- Need: Provision of medical care access and follow-up for rural North Carolina HIV patients with mental health, substance abuse, and unstable housing/homelessness challenges.
- Intervention: Medical home staff model expanded to a care coordination program with a core Network Navigator and Continuum of Care Coordinator assisting with medical, behavioral health, and basic life needs.
- Results: To date, the program has advanced three aspects of medical home patient care for this target population: provided further understanding of the spectrum of homelessness, including "hidden" homelessness; implemented outreach with creation of new community partnerships and a community housing coalition; and integrated medical care and behavioral health care for HIV.
Vermont Hub-and-Spoke Model of Care for Opioid Use Disorder
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.
Community Health Worker-based Chronic Care Management Program
Added May 2020
- Need: Improve healthcare access and decrease chronic disease disparities in rural Appalachia.
- Intervention: A community health worker-based Chronic Care Management program demonstrated such a level of success in a single West Virginia county that it was further scaled for implementation in a multi-center, 3-state area of Appalachia.
- Results: When analysis of the disseminated program's results also demonstrated improved health outcomes and decreased healthcare costs, sustainability became possible due to innovative financial reimbursement models.
Livingston County Help For Seniors
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
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.
Promising Examples
The Health-able Communities Program
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
Updated/reviewed July 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.
Cross-Walk: Integrating Behavioral Health and Primary Care
![funded by the Federal Office of Rural Health Policy](/assets/4668-20779/forhp-badge-125.png)
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.
For examples from other sources, see: