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Rural Health Information Hub
Rural Health Information Hub

Chronic Disease in Rural America – Models and Innovations

These stories feature model programs and successful rural projects that can serve as a source of ideas and provide lessons others have learned. Some of the projects or programs may no longer be active. Read about the criteria and evidence-base for programs included.

Effective Examples

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.
funded by the Federal Office of Rural Health Policy

Updated/reviewed September 2023

  • Need: A cost-effective approach to help rural patients with hypertension learn to manage their condition.
  • Intervention: Community volunteers trained as health coaches provided an 8-session hypertension management training program to hypertension patients older than 60, with an optional supplemental 8 sessions focused on nutrition and physical activity.
  • Results: Just 16 weeks after the program, participants had improved systolic blood pressure, weight, and fasting glucose, greater knowledge of hypertension, and improved self-reported behaviors.

Promising Examples

funded by the Federal Office of Rural Health Policy funded by the Health Resources Services Administration

Updated/reviewed January 2025

  • Need: To improve the health of communities in the south central region of New Mexico.
  • Intervention: A program was developed to address diabetes prevention and control, behavioral healthcare, and immunization in Luna County.
  • Results: During the program, 1,500 immunizations were distributed, baseline measurements of participants improved, and 935 new patients were seen for behavioral health issues.
funded by the Federal Office of Rural Health Policy

Updated/reviewed March 2024

  • Need: To prevent or slow the progression of diabetes for at-risk residents in Rural Northeast Louisiana.
  • Intervention: The North Louisiana Regional Alliance developed a program that offered screenings, education, and an intense course for participants throughout the Northeast Louisiana region to lower the risk of diabetes.
  • Results: The program saw an overall decrease in blood sugar levels in residents who participated in their initiatives.

Updated/reviewed March 2024

  • 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.
funded by the Federal Office of Rural Health Policy

Updated/reviewed May 2020

  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.

Other Project Examples

funded by the Federal Office of Rural Health Policy

Updated/reviewed March 2025

  • Need: To educate people in rural Virginia who either have diabetes or are considered at high risk for developing it.
  • Intervention: Teleconferencing technology is used to offer diabetes education programs to people with diabetes or those at high risk for developing it. Health professionals are also indirectly trained in diabetes care and management.
  • Results: Participants reported better prevention practices and/or self-management of diabetes after being thoroughly educated about this condition.

Updated/reviewed November 2024

  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK was a care coordination model in 20 counties.
  • Results: Using a team-based care model increased patients' ability to reduce their blood pressure or achieve blood pressure control.

Updated/reviewed October 2024

  • Need: To increase access to specialty care for rural veterans living with HIV.
  • Intervention: The HIV Telehealth Collaborative Care (TCC) study connects these patients with HIV specialists via clinical video telehealth or VA video connect and works to create shared care relationships with primary care teams in rural areas.
  • Results: The HIV TCC program provides HIV specialty care access to rural veterans in a sustainable manner with infrastructure, mentorship, and capacity building.
funded by the Health Resources Services Administration

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.
Last Updated: 3/31/2025