Rural Project Examples Addressing Care coordination

Perinatal Health Partners Southeast Georgia
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.

Kitsap Mental Health Services: Race to Health!
Updated/reviewed November 2022

Need: To improve the physical health of individuals seeking mental healthcare.
Intervention: Race to Health! in Washington integrated mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
Results: Race to Health! helped reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).

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
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.

Reducing Hospitalizations in Medicare Beneficiaries
Updated/reviewed May 2022

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 increased, while emergency department visits decreased.

Prevention through Care Navigation Outreach Program
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.

Outer Cape Health Services Community Resource Navigator Program
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.

Rural Project Examples: Care coordination