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Rural Health
Resources by Topic: Care coordination

Post-Acute Care Trajectories for Rural Medicare Beneficiaries: Planned versus Actual Hospital Discharges to Skilled Nursing Facilities and Home Health Agencies
Examines care transitions among rural fee-for-service Medicare beneficiaries following discharge from an acute care hospital. Compares planned and actual discharges to home health agencies and skilled nursing facilities. Discusses implications of these findings on rural healthcare policy and practice.
Author(s): Tracy M. Mroz, Lisa A. Garberson, C. Holly A. Andrilla, et al.
Date: 03/2021
Type: Document
Sponsoring organization: WWAMI Rural Health Research Center
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2021 Rural Advocacy Agenda
Outlines the American Hospital Association's federal policy priorities for rural hospitals in 2021. Offers recommendations in the areas of payment and reimbursement, care coordination, maternal and obstetric care, behavioral health, regulations, health information technology, workforce, and prescription drug prices.
Date: 02/2021
Type: Document
Sponsoring organization: American Hospital Association
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Grantee Directory: Rural Health Network Development Planning Program, 2020
Detailed descriptions of 26 Rural Health Network Development Planning Program grant projects funded in fiscal year 2020. Lists grantees by state and focus area, including topics such as integrated service delivery, telehealth, care coordination, and chronic disease management. Includes grantee profiles describing their programs and network structures, geographic areas served, network partners, and contacts for each network.
Date: 01/2021
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Mental Health Systems Solutions Explorer
Interactive tool offering evidence-based solutions to increase mental healthcare utilization, increase access to care, and establish a continuum of care. Contains examples of each solution in practice. Solutions can be filtered to view those specifically of interest to rural communities.
Date: 01/2021
Type: Tool
Sponsoring organization: RAND Corporation
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How to Transform the U.S. Mental Health System: Evidence-based Recommendations
Discusses evidence-based strategies to promote mental healthcare utilization, improve access to care, and establish a continuum of care. Offers 15 recommendations to improve mental healthcare, including policies regarding reimbursement, workforce growth, and digital and telehealth services, among other topics. Includes rural references throughout.
Additional links: Full Report, Research Brief: Transforming Mental Health Care in the United States
Author(s): Ryan K. McBain, Nicole K. Eberhart, Joshua Breslau, et al.
Date: 01/2021
Type: Document
Sponsoring organization: RAND Corporation
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Grantee Directory: Rural Health Care Coordination Program, 2020
Provides contact information and brief overviews of the 10 rural healthcare coordination initiatives funded through the Rural Health Care Coordination Program in the 2020-2023 funding cycle. Each profile includes information on the focus areas to be addressed.
Date: 01/2021
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Chronic Care Management - Understanding the Value & How it can Transform your Quality of Care
Webinar presented by a representative of the Illinois Critical Access Hospital Network, identifying key components required to create a chronic care management (CCM) program in rural hospitals, listing quality measures and outcomes affected by the CCM process, and showing income opportunities CCM programs provide. Explains what data institutions should track in order to remain compliant with regulations, and shows ways that CMM programs can reduce negative patient outcomes. Transcript available by clicking the three dots above the Subscribe button.
Additional links: Slides
Author(s): Trudi Colby
Date: 12/2020
Type: Video/Multimedia
Sponsoring organizations: Association for Rural & Community Health Professional Coding, Illinois Critical Access Hospital Network
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Transitional Care Management - Simple Process with a Big Impact
Webinar presented by a representative of the Illinois Critical Access Hospital Network, showing how to identify and understand the different ways in which transitional care management (TCM) can work in healthcare facilities to improve healthcare quality. Lists the key components within TCM guidelines and identifies which types of providers can or cannot perform TCM services. Transcript available by clicking the three dots above the Subscribe button.
Additional links: Slides
Author(s): Trudi Colby
Date: 12/2020
Type: Video/Multimedia
Sponsoring organizations: Association for Rural & Community Health Professional Coding, Illinois Critical Access Hospital Network
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Rural Maternity and Obstetrics Management Strategies (RMOMS) Program
Describes a pilot grant program designed to improve maternal and neonatal health in rural communities by collecting data and supporting the development of financially sustainable and coordinated network models. Aims to make maternal and obstetrics care more accessible through increased use of telehealth and specialty care. Fact sheet provides information on the activities of 3 rural networks funded through the RMOMS program.
Additional links: Fact Sheet, October 2020
Date: 11/2020
Type: Website
Sponsoring organizations: Federal Office of Rural Health Policy, Maternal and Child Health Bureau
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Psychiatrist and Psychologist Experiences with Telehealth and Remote Collaborative Care in Primary Care: A Qualitative Study
Discusses delivery of mental health services to rural patients through telehealth referral and remote collaborative care based on focus group sessions with 10 telepsychiatrists and 4 telepsychologists working in primary care clinics in Washington, Michigan, and Arkansas. Summarizes participant experiences of challenges and successes with telehealth delivery models.
Author(s): Molly Howland, McKenna Tennant, Deborah J. Bowen, et al.
Citation: The Journal of Rural Health
Date: 10/2020
Type: Document
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