Rural Project Examples Addressing Home and community-based services

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.

Updated/reviewed March 2024

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 April 2024

Need: To prevent hospital readmissions and improve the recovery process for older adults in rural southern Ohio.
Intervention: Hospital2Home identifies individuals who have an elevated risk of hospital readmission and provides vouchers for services like personal care and home-delivered meals.
Results: In each of the seven years the program has been in operation, over 85% of participants have avoided readmission in the first two months after hospital discharge.

Updated/reviewed January 2024

Need: To connect underserved and isolated older adults in rural Minnesota, Montana, North Dakota, and South Dakota to services and supports so they can age in place.
Intervention: The Rural Aging Action Network is a collaborative of organizations that offer different services like caregiver support, behavioral health, financial counseling, and assistance with chores and household maintenance.
Results: Since 2015, the collaborative has reached over 4,000 older adults and caregivers in over 100 rural communities.

Updated/reviewed August 2023

Need: To educate rural community members about Alzheimer's disease and other dementias and to support older adults in need.
Intervention: A community group formed in Winnemucca, Nevada, to discuss topics like health, housing, social events, community improvement, education, and transportation for older adults. The group also provides outreach to older adults, caregiver support, and a variety of of educational activities and events.
Results: The group's efforts have led to many changes for community welfare and safety as well as opportunities for education and activities.

Updated/reviewed July 2023

Need: To help older adults age in place.
Intervention: For five months, CAPABLE participants receive home visits from a registered nurse, occupational therapist, and home repair services.
Results: There are currently over 35 CAPABLE sites across the country, 11 of which are located in rural communities.

Updated/reviewed August 2022

Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 94% since 2008.

Updated/reviewed April 2021

Need: Ending a local Vermont population's homelessness experience.
Intervention: In 2010, Pathways Vermont implemented a first-of-its-kind, rural-focused Housing First program in order to provide housing and support services to those with mental health and substance use conditions experiencing homelessness.
Results: Since its initial start-up, Pathways Vermont has assisted over 560 Vermonters — about 70% from rural areas — experiencing homelessness using the Housing First model. The organization has collaborated with the state mental health department, corrections department, local healthcare systems and providers, and other organizations to end homelessness. In addition, programmatic work has expanded to reach other local populations, including veterans and at-risk families.

Rural Project Examples: Home and community-based services