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Rural Health Information Hub

Formerly the
Rural Assistance Center

Rural Project Examples: Care coordination

Effective Examples

funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed February 2017
  • Need: In the 11 rural southeast Georgia counties, high-risk pregnant women 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 women 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.

Promising Examples

funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed October 2017
  • Need: To properly address and treat patients who have concurrent substance abuse and chronic healthcare issues.
  • Intervention: A referral system was created that utilizes Community Health Workers (CHWs) in a drug and alcohol treatment setting.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.
funded by the Federal Office of Rural Health Policy Bridges to Health
Updated/reviewed September 2017
  • Need: To reduce barriers to accessing healthcare for migrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce the barriers to accessing healthcare and provides services and education.
  • Results: Some barriers to accessing healthcare have been reduced or removed for migrant farmworkers in certain counties in Vermont.
Kitsap Mental Health Services: Race to Health!
Added August 2017
  • Need: To improve the physical health of individuals seeking mental healthcare.
  • Intervention: Race to Health! in Washington integrates mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
  • Results: Race to Health! helps reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).
Proactive Palliative Care and Palliative Radiation Model: Making MyCourse Better
Updated/reviewed July 2017
  • Need: To provide palliative care to patients with stage 4 cancer.
  • Intervention: The Emily Couric Clinical Cancer Center in Charlottesville, Virginia, has implemented a three-part program to help these patients manage their symptoms.
  • Results: The Proactive Palliative Care and Palliative Radiation Model enrolled 646 patients during its three-year funding period of 2012-2015.
Reducing Hospitalizations in Medicare Beneficiaries
Added June 2017
  • Need: To reduce hospital readmissions for Medicare patients in rural Kentucky and Tennessee.
  • Intervention: Two quality improvement tools called IMPACT and INTERACT helped older patients transition from Vanderbilt University Medical Center to a skilled nursing facility.
  • Results: Practitioner follow-up visits have increased, while emergency department visits have decreased.
funded by the Federal Office of Rural Health Policy MI-Connect Community Health Worker Program
Updated/reviewed March 2017
  • Need: To improve healthcare access for rural Michigan residents managing chronic diseases.
  • Intervention: Community health workers (CHWs) were used to link chronically ill patients with the healthcare services in the Michigan counties of Alcona, Iosco, Arenac, Ogemaw, and Oscoda.
  • Results: This program has provided assistance to more than 400 individuals in the 5-county service area.
Northland PACE (Program of All-Inclusive Care for the Elderly)
Updated/reviewed January 2017
  • Need: Older adults who are nursing home eligible need assistance in order to remain living safely and independently in their own homes.
  • Intervention: Northland PACE (Program of All-Inclusive Care for the Elderly) offers, plans, and coordinates a wide range of healthcare, in-home, and day center services to promote independence at home.
  • Results: Older adults remain safely in their homes for a longer period of time with this support. The PACE program sites in North Dakota work to preserve, enhance, and, in many cases, restore the independence, health, and well-being of their participants.
funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed November 2016
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: This program was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Thus far, 84 clients have received integrated health and mental health services.
Patient Care Connect
Added September 2016
  • Need: Cancer patients living in the Deep South encounter multiple barriers in accessing regular cancer treatment.
  • Intervention: The University of Alabama at Birmingham Comprehensive Cancer Center developed a program that uses patient navigators to support and direct patients to appropriate resources to overcome barriers to accessing care.
  • Results: The program has become a model for improving cancer care quality, decreasing unnecessary utilization (ER visits and hospitalizations), removing barriers to care, and enhancing patient satisfaction.