Other Case Studies and Collections of Program Examples: Care coordination
In addition to RHIhub's Rural Health Models and Innovations rural program examples, you may also want to browse other case studies, databases, and websites with collections of health programs.
Each resource listed below uses its own criteria for selecting program examples, which may range from programs known to be effective based on research to anecdotal accounts. In each resource, you may want to review information on the level of evidence required for a program's inclusion.
May include non-rural programs that could be applicable to rural health delivery.
Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Technical Assistance Helps Community #SilencetheShameTN
Features behavioral and mental health programming offered by Henry County Medical Center and the community of Paris, Tennessee. Describes technical assistance and resources provided by the Delta Region Community Health Systems Development program to support this effort.
Author(s): Tami Lichtenberg
Citation: Rural Monitor
Date: 11/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features behavioral and mental health programming offered by Henry County Medical Center and the community of Paris, Tennessee. Describes technical assistance and resources provided by the Delta Region Community Health Systems Development program to support this effort.
Author(s): Tami Lichtenberg
Citation: Rural Monitor
Date: 11/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Making a Difference for Generations to Come: School-Based Oral Healthcare in Louisiana
Features a Louisiana Federally Qualified Health Center that offers primary care oral health assessment and fluoride varnishes in school-based health centers. Discusses the impact that access to childhood oral health services may have into adulthood.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2020
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features a Louisiana Federally Qualified Health Center that offers primary care oral health assessment and fluoride varnishes in school-based health centers. Discusses the impact that access to childhood oral health services may have into adulthood.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2020
Type: Document
Sponsoring organization: Rural Health Information Hub
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Mobile Telehealth Units and Care Coordinators Improve Emergency Care Services for Rural Arizona Patients
Features an Arizona program focused on lowering ER readmissions through care coordination and EMS telehealth services. Explains how the telehealth services are provided via mobile telehealth units. Describes how care coordination helps meet the behavioral health needs of patients with chronic diseases.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 08/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features an Arizona program focused on lowering ER readmissions through care coordination and EMS telehealth services. Explains how the telehealth services are provided via mobile telehealth units. Describes how care coordination helps meet the behavioral health needs of patients with chronic diseases.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 08/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Rural Patients with Chronic Disease: A Nonprofit Organization and a Health Department Leverage Federal Funding to Provide Health Education and Care Coordination
Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Rural Health Opioid Program Funds Care Coordination Efforts for Recovery
Highlights programs funded by the Federal Office of Rural Health Policy that provide opioid treatment and recovery care coordination. An Ohio program uses care coordination in an existing syringe exchange program and county family drug court, a Kentucky program focuses on helping prisoners, and a Montana program reaches new and expectant mothers.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 09/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Highlights programs funded by the Federal Office of Rural Health Policy that provide opioid treatment and recovery care coordination. An Ohio program uses care coordination in an existing syringe exchange program and county family drug court, a Kentucky program focuses on helping prisoners, and a Montana program reaches new and expectant mothers.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 09/2018
Type: Document
Sponsoring organization: Rural Health Information Hub
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Case Studies From the 2017 Care Coordination Comparative Study
Provides an overview of four care coordination approaches being used in rural areas: care coach, clinical, community health worker, and school-based. Includes individual case studies of rural care coordination programs, with detailed information on target populations, technology used, partners, care team composition, and more.
Date: 05/2018
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Rural Health Innovations
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Provides an overview of four care coordination approaches being used in rural areas: care coach, clinical, community health worker, and school-based. Includes individual case studies of rural care coordination programs, with detailed information on target populations, technology used, partners, care team composition, and more.
Date: 05/2018
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Rural Health Innovations
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OSF HealthCare – Peoria, IL: Connecting Health Systems and Community-Based Organizations to Improve Outcomes
Features a faith-based, 13-hospital health care system serving Illinois and Michigan's Upper Peninsula. Describes OSF Center for Health - Streator, which will feature the first rural freestanding emergency department in Illinois. Discusses how OSF HealthCare is using a case management platform and working with community-based organizations to meet a wide range of patient needs.
Date: 05/2018
Type: Document
Sponsoring organization: American Hospital Association
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Features a faith-based, 13-hospital health care system serving Illinois and Michigan's Upper Peninsula. Describes OSF Center for Health - Streator, which will feature the first rural freestanding emergency department in Illinois. Discusses how OSF HealthCare is using a case management platform and working with community-based organizations to meet a wide range of patient needs.
Date: 05/2018
Type: Document
Sponsoring organization: American Hospital Association
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Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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Kalispell Regional Healthcare: Managing the Needs of Medically and Socially Complex Patients or Superutilizers
Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. Initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. Initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
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