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Rural Health Information Hub

Rural Project Examples: Care coordination

Other Project Examples

Queen Anne's County Mobile Integrated Community Health (MICH) Program
Updated/reviewed March 2022
  • 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.
Avita Health System Comprehensive Cardiology Program
Added April 2021
  • Need: Population health approach to decreasing area deaths from cardiovascular disease.
  • Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
  • Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.
funded by the Health Resources Services Administration West Virginia's Partners In Health Network Regional Collaborative Services
Updated/reviewed September 2020
  • Need: Coordinated approach to healthcare delivery in central and southern West Virginia.
  • Intervention: Creation of a nonprofit organization that focused on quality and collaboration.
  • Results: With an ability to provide services that meet the evolving needs of patients, providers, and communities, the organization provides unique services, such as a credentialing service and web-based data sharing care management tool.
COPD Readmission Prevention Program
Updated/reviewed December 2019
  • Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
  • Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
  • Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.
funded by the Health Resources Services Administration Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed December 2019
  • 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.
Scheffe Prescription Shop's Medication Synchronization Program
Updated/reviewed December 2019
  • Need: For adults with chronic conditions, skipping a dose or two is common, but can also be risky. Frequent medication in-adherence has accounted for emergency department visits, hospitalizations, and even death.
  • Intervention: The Scheffe Prescription Shop in Enid, Oklahoma started a medication synchronization program. Pharmacists serve as care coordinators for patients by prepackaging pills, scheduling recheck appointments, and providing pickup reminders and medication education over the phone.
  • Results: The program has reduced the number of trips patients have to take to the pharmacy to pick up their pills and has increased medication adherence rates over 4 years.
funded by the Federal Office of Rural Health Policy The Community Care Alliance
Updated/reviewed December 2018
  • Need: Rural healthcare networks in Colorado and Washington felt the urgency to help their communities improve population health with better care at lower cost.
  • Intervention: The Community Care Alliance was formed to serve rural patient populations by assisting their healthcare organizations in transforming their practices to succeed at value-based reimbursement.
  • Results: Member healthcare communities have seen an increased collaboration among independent providers, clinics, and local hospitals on community health initiatives, patient transfers, and appropriate access and education.
SAMA HealthCare Services's Patient-Centered Medical Home
Updated/reviewed February 2018
  • Need: The traditional model where providers work independently from one another in treating patients proved to lack care continuity at SAMA Healthcare Services in rural Arkansas.
  • Intervention: The family practice clinic shifted to a team-based model of care where the medical staff works together in pods in order to create a patient-centered medical home.
  • Results: SAMA doubled the amount of patients seen in 1 day and at least 90% of patients receive medical treatment from a provider within their pod.