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Rural Health Information Hub

Rural Project Examples: Care coordination

Effective Examples

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).
funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed February 2021
  • Need: In the 11 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

funded by the Federal Office of Rural Health Policy 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.
SASH® (Support and Services at Home)
Updated/reviewed March 2022
  • 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 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 2020
  • 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 Bridges to Health
Updated/reviewed October 2020
  • 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.
funded by the Federal Office of Rural Health Policy 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.
funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed December 2019
  • 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.

Other Project Examples

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.