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.

Other Project Examples

ASPIN's Certified Recovery Specialist Program

Updated/reviewed September 2022

• Need: Improved approach in addressing the behavioral health and primary care disparities of Indiana's underserved rural counties.
• Intervention: A network was established that trained community health workers (CHWs) to be certified health insurance enrollment navigators and provide mental health services.
• Results: This year, ASPIN trained 230 CHWs, cross-trained 70 behavioral health case managers as CHWs, and 35 individuals in the Indiana Navigator Pre-certification Education.

Boone County Health Center Pulmonary Rehabilitation Program

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.

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.

University of Mississippi Medical Center's Center for Telehealth

Updated/reviewed January 2020

• Need: Rural areas in Mississippi often lack adequate access to specialty healthcare services such as emergency medicine, stroke neurology, pediatric specialists and psychiatrists.
• Intervention: The University of Mississippi Medical Center created the Center for Telehealth to deliver quality specialty services through telehealth video conferencing and remote monitoring tools to the underserved areas of Mississippi.
• Results: The program has been successfully implemented throughout many of the state's rural hospitals and has reduced transfers and geographic barriers for patients.

Bridges to Care Transitions-Remote Home Monitoring and Chronic Disease Self-Management

Updated/reviewed December 2019

• Need: Decrease hospital readmissions and emergency room visits for patients in rural Tidewater, Virginia.
• Intervention: After inpatient admission or ER visit, identify at-risk patients to offer enrollment in remote monitoring and disease self-management education and coaching, with a special focus on behavioral health wellness.
• Results: Decreased readmissions and ER visits paired with high patient satisfaction scores.

COPD Inpatient Navigator Program

Updated/reviewed December 2019

• Need: Improve readmission rates for rural patients with Chronic Obstructive Pulmonary Disease (COPD).
• Intervention: COPD Inpatient Navigator program implementation in a rural hospital in Oregon.
• Results: With navigator assistance, COPD-associated readmission rate has decreased by almost 50%, with a continued improvement trend.

COPD Readmission Prevention Program

Updated/reviewed December 2019

• Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
• Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
• Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.

The Adolescent Pre-Diabetes Prevention Program

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.

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