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Rural Health
Resources by Topic: Care coordination

Reducing Cancer Among Native Populations: Models for Research, Prevention, and Treatment
Highlights the work of a cancer researcher, a foundation director, and healthcare provider who are engaging American Indians and Alaska Natives in cancer research, prevention, and treatment.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 05/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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VA and Indian Health Service: Actions Needed to Strengthen Oversight and Coordination of Health Care for American Indian and Alaska Native Veterans
Report discusses the relationship between the Department of Veterans Affairs (VA) and the Indian Health Service (IHS) with regard to providing care to American Indian and Alaska Native veterans. Details the cooperative agreement between the two entities and the ways their efforts could be improved.
Additional links: Full Report
Date: 03/2019
Type: Document
Sponsoring organization: Government Accountability Office
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Implementation and Early Results of the Flex Program's Innovative Models Program Area: Final Evaluation Report
Reports on the implementation of the Flex Program and the integration of the Innovative Health Care Models (Innovative Projects) program area in 7 states focused on telehealth, care coordination, and quality improvement. Highlights lessons learned, program discussion, and the evaluation methods for each of the projects. Builds on a 2018 briefing paper, An Interim Evaluation Report of the Innovative Projects Portfolio of the Medicare Flex Grant Program.
Author(s): John A. Gale, Sara Kahn-Troster, Andrew Coburn
Date: 03/2019
Type: Document
Sponsoring organization: Flex Monitoring Team
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Rural Mental Health Network: Expanding and Strengthening Care Coordination
Highlights the Rural Mental Health Network in Missouri through an interview with its director. Addresses the network's focus on care coordination for social determinants of health needs, challenges, accomplishments, the role of Community Health Workers (CHWs), lessons learned, and more.
Date: 03/2019
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Rural Patients with Chronic Disease: A Nonprofit Organization and a Health Department Leverage Federal Funding to Provide Health Education and Care Coordination
Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Critical Access Hospital Network (CAHN): Eastern Washington Critical Access Hospital Network’s Rural Health Care Coordination Network Partnership Program, Washington
Brief overview of a care coordination program that used Washington State’s Health Home Program, an intensive care coordination program for high risk Medicare-Medicaid patients, as a guide. Discusses the program's sustainability efforts, as well as key takeaways about the program. The program was funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018 and received additional philanthropic funding through a public-private partnership.
Date: 2019
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Williamson Health and Wellness Center (WHWC): Community Health Worker Care Coordination Program, West Virginia
Brief overview of a care coordination program using a team of community health workers, a registered nurse, and a nurse practitioner. Discusses the program's sustainability efforts, as well as key takeaways about the program. The program was funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018 and received additional philanthropic funding through a public-private partnership.
Date: 2019
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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State Innovation Models (SIM) Round 2: Model Test Annual Report Three
Third annual report on the Round 2 State Innovation Models (SIM) program across eleven participating states - Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Ohio, Rhode Island, Tennessee, and Washington. Addresses the adoption of delivery models and payment reforms related to value-based payment (VBP) and alternative payment models (APMs). Offers an update and lessons learned on strategies to support healthcare delivery transformation related to behavioral health integration, data for improving health care quality and performance, health information technology, care coordination, and workforce development. Describes states' population health activities. Includes discussion of rural issues throughout the report.
Additional links: Findings at a Glance
Date: 2019
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Sourcebook: Rural Health Care Coordination Network Partnership Grant Recipients, 2015-2018
Detailed descriptions of the eight initiatives funded under the Rural Health Care Coordination Network Partnership Grant Program for the 2015-2018 period. The programs focused on care coordination activities for type 2 diabetes, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Includes information on the organizations involved, community characteristics, program services, outcomes, and more.
Date: 12/2018
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Frequently Asked Questions
Provides general information about care management services, specific program requirements, detailed descriptions of billing, claims processing, and payment rules, and requirements for people who are considered part of a care management team.
Date: 12/2018
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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