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Rural Project Examples: Care coordination

Effective Examples

funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed March 2018
  • 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.
Patient Care Connect
Updated/reviewed December 2017
  • 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 lay 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.

Promising Examples

Kitsap Mental Health Services: Race to Health!
Updated/reviewed August 2018
  • 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 2018
  • 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
Updated/reviewed June 2018
  • 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.
Maryland Faith Health Network
Updated/reviewed May 2018
  • Need: To coordinate formal and informal community-based caregivers for optimal patient experience.
  • Intervention: The Maryland Faith Health Network unites places of worship and healthcare systems in Maryland. This program aims to decrease the amount of potentially avoidable hospitalizations, improve a patient's overall wellness, and cut down on the cost of medical services.
  • Results: This model is currently running in 3 hospitals that serve both rural and urban residents in central Maryland. So far, 1,300 congregants from 70 congregations representing Christian, Jewish, and Muslim faiths have enrolled in the Network.
funded by the Federal Office of Rural Health Policy MI-Connect Community Health Worker Program
Updated/reviewed March 2018
  • 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 March 2018
  • Need: Keeping older adults living safely and independently in their own homes.
  • Intervention: Northland PACE plans and coordinates a wide range of healthcare, in-home, and day center services to promote independence at home, hoping to avoid or delay nursing home admission.
  • 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 High Plains Community Health Center Care Teams
Updated/reviewed January 2018
  • Need: Meeting health care demands in a region with a limited number of physicians, where recruiting additional providers is considered impractical.
  • Intervention: Using the additional support of health coaches, implementation of care teams consisting of 3 medical assistants to support each provider.
  • Results: More patients seen per provider hour, with improved patient outcomes and clinic cost savings.
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Updated/reviewed January 2018
  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers were utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: Over 1700 people were screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol levels and blood pressure after engaging with a Community Health Worker.