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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

funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed November 2018
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: The Healthy Outcomes Integration Team 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: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.
funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed November 2018
  • 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 October 2018
  • Need: To reduce barriers to accessing healthcare for immigrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce barriers to accessing healthcare on an individual level. The program offers targeted technical assistance to address systemic barriers at health access points in areas with high numbers of immigrant farmworkers.
  • Results: Some barriers to accessing healthcare have been reduced or removed for immigrant farmworkers in certain counties in Vermont.
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.