Rural Health
Resources by Topic: Care coordination
State Medicaid & CHIP Toolkit for Children's Behavioral Health Services and the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Requirements
Toolkit designed to support state Medicaid and CHIP agencies in ensuring that children and youth experiencing behavioral health conditions get the care they need under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. Offers state examples within each strategy and sub-strategy presented. Includes rural considerations throughout.
Date: 02/2026
Sponsoring organization: Centers for Medicare and Medicaid Services
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Toolkit designed to support state Medicaid and CHIP agencies in ensuring that children and youth experiencing behavioral health conditions get the care they need under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements. Offers state examples within each strategy and sub-strategy presented. Includes rural considerations throughout.
Date: 02/2026
Sponsoring organization: Centers for Medicare and Medicaid Services
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Evaluation of the Making Care Primary Model
Provides an overview of the Centers for Medicare & Medicaid Services (CMS) Innovation Center's Making Care Primary (MCP) Model. Explores model participation, participants' early implementation experiences, and the model's chances for meeting model expansion criteria related to cost and quality.
Additional links: Findings at a Glance
Date: 02/2026
Sponsoring organization: Centers for Medicare and Medicaid Services
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Provides an overview of the Centers for Medicare & Medicaid Services (CMS) Innovation Center's Making Care Primary (MCP) Model. Explores model participation, participants' early implementation experiences, and the model's chances for meeting model expansion criteria related to cost and quality.
Additional links: Findings at a Glance
Date: 02/2026
Sponsoring organization: Centers for Medicare and Medicaid Services
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Medicare Care Management Opportunities - What's New in 2026?
Recording of a December 17, 2025, webinar on care management practices in Rural Health Clinics, associated Medicare care management codes, and changes over time in billing requirements and implementation. Part of the Rural Health Clinic Technical Assistance Series.
Additional links: 2026 Care Management Codes and Reimbursement, Presentation Slides
Date: 12/2025
Sponsoring organization: National Association of Rural Health Clinics
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Recording of a December 17, 2025, webinar on care management practices in Rural Health Clinics, associated Medicare care management codes, and changes over time in billing requirements and implementation. Part of the Rural Health Clinic Technical Assistance Series.
Additional links: 2026 Care Management Codes and Reimbursement, Presentation Slides
Date: 12/2025
Sponsoring organization: National Association of Rural Health Clinics
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Nurse-Directed Coordination of Cancer Survivorship Care in a Tribal Primary Care Clinic
Examines the feasibility of a nurse cancer care coordinator intervention focused on improving cancer care at a tribally-operated primary care clinic in the Choctaw Nation of Oklahoma. Provides data on survivorship care plans, cancer-related distress, time spent on coordination activities, and other aspects of program implementation via a trial utilizing data of 23 American Indian intervention participants.
Author(s): Amber S. Anderson-Buettner, Kathleen A. Dwyer, Zsolt J. Nagykaldi, et al.
Citation: BMC Primary Care, 26, 334
Date: 10/2025
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Examines the feasibility of a nurse cancer care coordinator intervention focused on improving cancer care at a tribally-operated primary care clinic in the Choctaw Nation of Oklahoma. Provides data on survivorship care plans, cancer-related distress, time spent on coordination activities, and other aspects of program implementation via a trial utilizing data of 23 American Indian intervention participants.
Author(s): Amber S. Anderson-Buettner, Kathleen A. Dwyer, Zsolt J. Nagykaldi, et al.
Citation: BMC Primary Care, 26, 334
Date: 10/2025
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Best Practices for Implementing the Continuum of Crisis Services Under Medicaid and CHIP
Provides guidance for states to maintain a continuum of behavioral health crisis care for patients covered by Medicaid and CHIP. Details core elements of the continuum of crisis care and how Medicaid and CHIP function within that framework. Highlights considerations for rural communities.
Date: 09/2025
Sponsoring organizations: Centers for Medicare and Medicaid Services, Substance Abuse and Mental Health Services Administration
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Provides guidance for states to maintain a continuum of behavioral health crisis care for patients covered by Medicaid and CHIP. Details core elements of the continuum of crisis care and how Medicaid and CHIP function within that framework. Highlights considerations for rural communities.
Date: 09/2025
Sponsoring organizations: Centers for Medicare and Medicaid Services, Substance Abuse and Mental Health Services Administration
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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.
Date: 09/2025
Sponsoring organizations: Federal Office of Rural Health Policy, Maternal and Child Health Bureau
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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.
Date: 09/2025
Sponsoring organizations: Federal Office of Rural Health Policy, Maternal and Child Health Bureau
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Evaluation of the Maternal Opioid Misuse (MOM) Model: Fourth Annual Report (Implementation Year 3)
Provides an overview of the Maternal Opioid Misuse Model, which provides evidence-based integrated care and care coordination for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). Describes activities MOM Model awardees undertook during the MOM Model's second implementation year, July 1, 2023–June 30, 2024, and summarizes qualitative and beneficiary-level process data findings by state awardee. Discusses barriers pregnant and postpartum women with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 06/2025
Sponsoring organizations: Centers for Medicare and Medicaid Services, Westat
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Provides an overview of the Maternal Opioid Misuse Model, which provides evidence-based integrated care and care coordination for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). Describes activities MOM Model awardees undertook during the MOM Model's second implementation year, July 1, 2023–June 30, 2024, and summarizes qualitative and beneficiary-level process data findings by state awardee. Discusses barriers pregnant and postpartum women with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 06/2025
Sponsoring organizations: Centers for Medicare and Medicaid Services, Westat
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Medicare Care Management Billing Strategies
Webinar recording featuring speakers from Eide Bailly and the NORC Walsh Center for Rural Health Analysis discussing new 2025 Medicare care management billing codes and how they can be used to support care coordination to improve care quality for Medicare beneficiaries
Additional links: Audio Recording, Webinar Slides
Date: 05/2025
Sponsoring organization: Rural Health Information Hub
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Webinar recording featuring speakers from Eide Bailly and the NORC Walsh Center for Rural Health Analysis discussing new 2025 Medicare care management billing codes and how they can be used to support care coordination to improve care quality for Medicare beneficiaries
Additional links: Audio Recording, Webinar Slides
Date: 05/2025
Sponsoring organization: Rural Health Information Hub
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Bringing Virtual Behavioral Health Care Access to Rural Youth in West Virginia
Podcast episode that discusses a virtual collaborative behavioral healthcare model for children in rural West Virginia. Focuses on early behavioral health interventions, access, and improved health outcomes.
Author(s): Tom Haederle, Adrienne Coopey, Jordan Steiger
Date: 05/2025
Sponsoring organization: American Hospital Association
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Podcast episode that discusses a virtual collaborative behavioral healthcare model for children in rural West Virginia. Focuses on early behavioral health interventions, access, and improved health outcomes.
Author(s): Tom Haederle, Adrienne Coopey, Jordan Steiger
Date: 05/2025
Sponsoring organization: American Hospital Association
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Barriers and Facilitators to Implementing a Technology-Enhanced Psychiatric Collaborative Care Model among Rural Primary Care Sites: A Mixed-Methods Implementation Case Study
Examines the process of implementing a telehealth psychiatric collaborative care management (CoCM) model in rural South Carolina clinics. Utilizes mixed-methods data to examine workflow development, telehealth platform configuration, provider teams, implementation assessment, and more.
Author(s): Ryan Kruis, Emily Johnson, Constance Guille, et al.
Citation: BMC Primary Care, 26, 177
Date: 05/2025
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Examines the process of implementing a telehealth psychiatric collaborative care management (CoCM) model in rural South Carolina clinics. Utilizes mixed-methods data to examine workflow development, telehealth platform configuration, provider teams, implementation assessment, and more.
Author(s): Ryan Kruis, Emily Johnson, Constance Guille, et al.
Citation: BMC Primary Care, 26, 177
Date: 05/2025
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