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Rural Health Information Hub

Rural Project Examples: Care coordination

Other Project Examples

Fostering Futures in Menominee Nation

Updated/reviewed August 2022

  • Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
  • Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
  • Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 94% since 2008.

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.

West Virginia's Partners In Health Network Regional Collaborative Services

funded by the Health Resources Services Administration

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.

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.