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Rural Health Information Hub

Rural Project Examples: Care coordination

Effective Examples

Perinatal Health Partnership Southeast Georgia

funded by the Federal Office of Rural Health Policy

Updated/reviewed February 2023

  • Need: In 12 rural southeast Georgia counties, high-risk pregnant individuals 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 individuals 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

SASH® (Support and Services at Home)

Updated/reviewed March 2023

  • 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.

Maryland Faith Health Network

Updated/reviewed December 2022

  • 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.

Nurse Navigator and Recovery Specialist Outreach Program

funded by the Federal Office of Rural Health Policy

Updated/reviewed November 2022

  • Need: To properly address and treat patients who have concurrent substance use and chronic healthcare issues.
  • Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.

Prevention through Care Navigation Outreach Program

funded by the Federal Office of Rural Health Policy

Updated/reviewed May 2020

  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
  • Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.

Other Project Examples

Moms Do Care EMPOWER (MDC-E)

Added February 2024

  • Need: To support pregnant or new parents in rural Massachusetts affected by substance use or on medication for opioid use.
  • Intervention: This program offers a medical and behavioral health home, providing trauma-informed support before, during, and after childbirth.
  • Results: Six months after enrollment, there was a 20% increase in the number of participants who felt socially connected and a 5% increase in abstinence from all substances.

Queen Anne's County Mobile Integrated Community Health (MICH) Program

Updated/reviewed April 2023

  • Need: To connect patients to resources in order to reduce use of emergency services, emergency department visits, and hospital readmissions.
  • Intervention: Patients receive support (by in-person visit, phone call, or telehealth visit) from a paramedic, community health nurse, peer recovery specialist, and pharmacist.
  • Results: Between July 2016 and June 2019, the MICH program enrolled 233 patients and demonstrated a total savings of $3,393,908 in healthcare costs.

Outer Cape Health Services Community Resource Navigator Program

funded by the Health Resources Services Administration

Updated/reviewed March 2023

  • Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance use disorder services while reducing the burden and costs to town agencies and hospital emergency rooms.
  • Intervention: The Community Resource Navigator Program works with local social services, town agencies, faith-based institutions, hospitals, the criminal justice system, and others to identify and connect clients to needed services.
  • Results: Clients are gaining access to the care they were once lacking, as measured by improvements in self-sufficiency. The program also helps community partners and stakeholders work together to reduce the impact of risks associated with behavioral health symptoms, substance use disorder, and social determinants of health.

Heartland OK

Updated/reviewed November 2022

  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK, which began in 5 rural counties, was a care coordination model.
  • Results: Using a team-based care model increased patients' ability to reduce their blood pressure or achieve blood pressure control.

Beacon Health Accountable Care Organization

Updated/reviewed October 2022

  • Need: To implement coordinated healthcare to improve patient health and engagement and to reduce the overall cost of medical services in Maine.
  • Intervention: The Beacon Health network launched with a focus on patient-centered care to improve overall wellness and reduce ever-increasing healthcare costs.
  • Results: Through care coordination, Beacon Health is enhancing provider efficiency and a team approach to delivering care, leading to improved patient engagement and healthcare quality and lowering the overall cost of care.