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Rural Health
Resources by Topic: Care coordination

Financial Incentives to Improve Community Health
Slides presented at the 2019 National Organization of State Offices of Rural Health (NOSORH) Annual Meeting discussing several federal initiatives as a result of the Affordable Care Act (ACA), including the Medicare Shared Savings Program and Accountable Care Organizations (ACOs), resulting in controlled costs, improved quality of care, and offering financial incentives. Identifies how State Offices of Rural Health can support health organizations to participate successfully in these initiatives.
Author(s): Keith Mueller
Date: 10/2019
Type: Presentation Slides
Sponsoring organization: National Organization of State Offices of Rural Health
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Financial Alignment Initiative South Carolina Healthy Connections Prime: First Evaluation Report
Evaluation of the first year of the South Carolina Healthy Connections Prime demonstration to integrate care for the state's Medicare-Medicaid beneficiaries. Discusses access and other challenges for rural enrollees and how the program has worked to address rural needs.
Date: 09/2019
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Russell County Hospital Listens to their Community to Improve Transitions of Care
Highlights quality improvement activities underway at a 25-bed Critical Access Hospital (CAH) in rural Kentucky. Discusses community collaboration efforts, expansion of specialty services, renovations, a focus on staff satisfaction, and care coordination activities.
Date: 09/2019
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Advancing Primary Care Innovation in Medicaid Managed Care: A Toolkit for States
Designed to help states leverage their Medicaid managed care contracts and request for proposals (RFPs) supporting primary care innovation (PCI). Provides examples of state approaches, with rural considerations, for identifying and addressing social determinants of health, integrating behavioral healthcare, developing team-based care, and implementing technology to improve access.
Date: 08/2019
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Improving the Health and Well-Being of Rural Communities Through Collaboration
Webinar recording discusses the Federal Office of Rural Health Policy's report on care coordination between hospitals, health centers, and public health agencies. Features presentations from representative from the Health Care Collaborative of Rural Missouri and the Sakakawea Medical Center.
Additional links: Audio Recording, PowerPoint Handout, Webinar Transcript
Date: 08/2019
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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Medicaid: Efforts to Identify, Predict, or Manage High-Expenditure Beneficiaries
Describes strategies used in 7 states to manage beneficiaries' healthcare costs while ensuring quality care, and lists resources the Centers for Medicare and Medicaid Services provides to help states identify, predict, and manage high-expenditure beneficiaries. Discusses effects of social determinants of health and staff shortages in rural areas. Includes statistics for Medicaid expenditures among beneficiaries enrolled only in Medicaid, for fiscal years 2009-2011.
Additional links: Full Report
Date: 08/2019
Type: Document
Sponsoring organization: Government Accountability Office
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Small Rural Hospital Transition (SRHT) Project Guide: A Rural Hospital Guide to Improving Care Management: 2019 Update
A guide for rural hospital leadership that identifies best practices in care management. Addresses care management roles and staffing needs and covers utilization review and discharge planning. Helps identify opportunities for process improvement. Also discusses competencies needed to transition to a value-based reimbursement environment focused on population health.
Author(s): Stroudwater
Date: 08/2019
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Rural Care Coordination and Population Health Management Summit: Summit Findings
Provides guidance to rural hospitals, clinics, and healthcare networks on incorporating community care coordination planning to prepare for population health management. Identifies tools and resources to support the transition to value-based payment models. Summarizes findings from a series of summits with national experts.
Author(s): Rebecca Jolley
Date: 08/2019
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Rural Health Association of Tennessee
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Rural Hospital Care Coordination and Population Health Management Summit Report
Materials related to the 2019 Rural Care Coordination and Population Health Management Summit, which focused on the role community care coordination plays in helping healthcare leaders prepare for population health management. Includes a short video of panelist interviews as well as a findings report from the summit and a care management best practices guide.
Date: 08/2019
Type: Website
Sponsoring organization: National Rural Health Resource Center
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Supportive Services and Caregiving for Older Rural Adults: Policy Brief and Recommendations to the Secretary
Provides an overview of current supportive services and caregiving policies for rural seniors, in terms of availability, accessibility, and acceptability of services. Explores topics including long-term services and supports, telehealth, care coordination, transportation, stigma, and unpaid caregivers, and describes federal programs for older adults. Offers policy recommendations and considerations.
Date: 08/2019
Type: Document
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
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