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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.

Rural Mental Health Network: Expanding and Strengthening Care Coordination
Highlights the Rural Mental Health Network in Missouri through an interview with its director. Addresses the network's focus on care coordination for social determinants of health needs, challenges, accomplishments, the role of Community Health Workers (CHWs), lessons learned, and more.
Date: 03/2019
Type: Document
Sponsoring organization: National Rural Health Resource Center
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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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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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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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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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Medical Center Barbour Reduces Readmission Rates
Highlights the accomplishments of Medical Center Barbour (MCB), a prospective payment system (PPS) hospital located in Eufaula, Alabama, as it progressed through a Small Rural Hospital Transition (SRHT) quality of care and transition of care project. MCB's top accomplishments include reducing readmissions, improving communication among staff and patients, and enhancing the discharge process.
Additional links: One-Page Summary
Date: 06/2017
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Innovations in Rural Health System Development: Service Delivery Advances in Care Coordination, Emergency Care, and Telehealth
Offers examples of emergency services, telehealth technology, and care coordination initiatives with a focus on Maine, and how they impact rural service delivery and safeguard rural access to critical health services.
Author(s): Amanda Burgess, Andrew Coburn
Date: 10/2016
Type: Document
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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Project ECHO's Complex Care Initiative: Building Capacity to Help "Superutilizers" in Underserved Communities
Describes a case study from the University of New Mexico's Project ECHO (Extension for Community Health Outcomes) program, which uses telehealth to support primary care clinicians in underserved areas. Focuses on a project targeting Medicaid beneficiaries with substance abuse and mental health issues, with details on two primary care teams being supported, including one in a rural New Mexico community.
Author(s): Martha Hostetter, Sarah Klein, Douglas McCarthy
Date: 08/2016
Type: Document
Sponsoring organization: Commonwealth Fund
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Integrated Care in a Frontier Community
Examines the Southeast Health Group (SHG) in La Junta, Colorado, which coordinates physical and behavioral health using patient-centered, wellness-based care coordination to empower patients and promote self-directed care. Focuses on hiring providers who share SHG's philosophy of care, using community resources, and engaging peer support specialists.
Date: 07/2016
Type: Document
Sponsoring organization: Rural Health Value
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Investing in Population Health
Profile of a pilot project in rural New Mexico focused on population health for Medicaid recipients. Offers communities three levels of patient services and payment. Uses community health workers to address the social determinants of health.
Date: 08/2015
Type: Document
Sponsoring organization: Rural Health Value
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Rural Accountable Care Organization Care Coordination
Profile of the MaineHealth Accountable Care Organization (MHACO), which uses regional teams to provide care coordination to patients with complex medical profiles.
Date: 2015
Type: Document
Sponsoring organization: Rural Health Value
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Olympic Physicians Case Study: Rural Health IT: Clinic in Washington State Uses EHR System to Improve Care Coordination
Describes how physicians in Olympic, WA developed an EHR system to improve patient care coordination within the rural health IT setting's local referral network.
Date: 2011
Type: Document
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AHA Community Connections
Provides access to case studies spotlighting hospitals and health systems (some are in rural areas) that have successfully collaborated with local community organizations to promote care coordination, wellness, and prevention. Website also includes tools and resources to help healthcare facilities be accountable and transparent to their communities and deliver quality care.
Type: Website
Sponsoring organization: American Hospital Association
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