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Rural Project Examples: Care coordination

Promising Examples

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.

Other Project Examples

Heartland OK
Updated/reviewed November 2020
  • Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
  • Intervention: Heartland OK, which began in 5 rural counties, is a care coordination model.
  • Results: Using a team-based care model increases patients' ability to reduce their blood pressure or achieve blood pressure control.
Super-Utilizer Pilot Project
Updated/reviewed November 2020
  • Need: To address patients' complex physical, behavioral, and social health needs with the goal to reduce unnecessary visits to the emergency department and reduce inpatient admissions.
  • Intervention: A registered nurse and community health worker used technology to address patients with high risk and high costs in their home setting through a 90-day intensive intervention.
  • Results: The healthcare team in Kalispell saved more than $1.8 million in hospital costs with the project's first 36 patients.
Beacon Health Accountable Care Organization
Updated/reviewed October 2020
  • 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, improving patient engagement and healthcare quality, and lowering the overall cost of care.
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.
funded by the Health Resources Services Administration MORE Care
Updated/reviewed July 2020
  • Need: To improve rural residents' oral healthcare.
  • Intervention: MORE Care creates interprofessional oral health networks to 1) better integrate oral health into primary healthcare and 2) coordinate oral health between primary and dental healthcare.
  • Results: MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.
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.