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Rural Health
Resources by Topic: Care coordination

Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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Kalispell Regional Healthcare: Managing the Needs of Medically and Socially Complex Patients or Superutilizers
Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. The initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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Improving Healthcare Value in Rural America
Identifies and explains the challenges facing rural communities as they work to improve healthcare value. Discusses the distinct differences between urban and rural value initiatives, highlights promising strategies for achieving rural value, and makes the case for using customized approaches rather than one-size-fits-all models.
Date: 10/2017
Type: Document
Sponsoring organization: Healthcare Value Hub
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Behavioral Health Trends in Ohio
Covers publications focusing on behavioral health research in Ohio. Includes research briefs on a variety of topics, such as housing retention, care coordination, employment, social connectedness, and others, as they relate to behavioral health.
Date: 10/2017
Type: Document
Sponsoring organization: Ohio Department of Mental Health and Addiction Services
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Coordinated Whole-Person Care that Addresses Social Determinants of Health
Presents approaches used and lessons learned from five projects funded by Data Across Sectors for Health (DASH) - an initiative to align various health-related sectors and promote the collection, sharing, and effective use of data. Each DASH project is working to develop the infrastructure necessary to support cross-sector data sharing, enhance care coordination, and address social determinants of health. One of the five projects is based on the White Earth Indian Reservation in rural northwest Minnesota.
Date: 09/2017
Type: Document
Sponsoring organization: Data Across Sectors for Health
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Barriers and Facilitators to Implementation of VA Home-based Primary Care on American Indian Reservations: A Qualitative Multi-case Study
Highlights a study on the efficacy of the Veterans Health Affairs (VA) home-based primary care program at providing non-institutional long-term care for rural American Indian veterans living on reservations. Bases findings on a qualitative analysis of interviews conducted with staff, clinicians, and managers who oversaw the program's implementation. Discusses the challenges, barriers, and facilitators related the program's expansion into Indian Country.
Author(s): B. Josea Kramer, Sarah D. Cote, Diane I. Lee, Beth Creekmur, Debra Saliba
Location: Implementation Science, 12, 109
Date: 09/2017
Type: Document
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Providing Patient-Centered Enhanced Discharge Planning and Rural Transition Support: Building a Rural Transitions Network Between Regional Referral and Critical Access Hospitals
Manual describing procedures used in Western Montana to develop a model improving likelihood of a good recovery for patients and decreasing chances of re-hospitalization. Includes a guide to ethical considerations in discharge and rural transition planning.
Author(s): Tom Seekins, Heidi Boehm, Jennifer Wong, Linda Yearous, AnnaJean Smith
Date: 08/2017
Type: Document
Sponsoring organization: Rural Institute for Inclusive Communities
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Research Highlight: The Virtual Specialty Care QUERI Program - Improving Access to High-Quality Specialty Care for Rural Veterans
Highlights the Virtual Specialty Care (VSC) QUERI Program, a measure to support operational partners, such as the Office of Rural Health, Office of Connected Care, and Mental Health Services, as virtual care technologies are implemented to increase access to specialty care for rural veterans. Discusses the challenges of evaluating rapidly evolving technologies without stifling their development.
Author(s): John Fortney, Greg Reger, Alexis Beatty
Date: 08/2017
Type: Document
Sponsoring organization: VA Health Services Research & Development Service
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Transitions in Care among Rural Residents with Congestive Heart Failure, Acute Myocardial Infarction, and Pneumonia
Findings brief examining continuum of care of Medicare patients as they are transferred from a hospital to another facility. Features statistics including patient residence and condition, admitting facility type, proportion of hospitalizations with a transfer, transfer patterns, and discharge status following transferred admission, with breakdowns by urban and rural locations.
Author(s): Kevin J. Bennett, Jarrod Bullard, Yu-Hsiu Lin, Janice C. Probst
Date: 08/2017
Type: Document
Sponsoring organization: South Carolina Rural Health Research Center
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Medical Home Plus
Video featuring the Medical Home Plus project, which works to reduce diabetes, depression, and stroke risk in rural Idaho via a collaborative care model and a medical home model.
Date: 08/2017
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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