Rural Health
Resources by Topic: Care coordination
HEARTLAND Protocol: A Tiered Clinical Implementation Toolkit for Primary Care-Led Heart Failure Management in Rural and Resource-Limited Settings
Presents a study on the efficacy of the HEARTLAND (Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery) protocol at managing heart failure (HF) in rural and low-resourced healthcare settings. Highlights the protocol's structure and the process by which it evaluates patient HF risk, establishes monitoring, and ensures continuity of care.
Author(s): Vicky Muller Ferreira
Citation: Cureus, 18(3), e104817
Date: 03/2026
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Presents a study on the efficacy of the HEARTLAND (Heart failure Evidence-based Access in Rural Treatment, Linking Advanced Network Delivery) protocol at managing heart failure (HF) in rural and low-resourced healthcare settings. Highlights the protocol's structure and the process by which it evaluates patient HF risk, establishes monitoring, and ensures continuity of care.
Author(s): Vicky Muller Ferreira
Citation: Cureus, 18(3), e104817
Date: 03/2026
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Barriers to Implementing a Pharmacist-Led COPD CARE Bundle in Rural Settings: A Qualitative Evaluation
Examines barriers to implementing the COPD Coordinated Access to Reduce Exacerbations (COPD CARE) program, a care bundle focused on improving chronic obstructive pulmonary disease care coordination among pharmacists, nurse care managers, and other pharmacy clinicians in the Veterans Affairs system. Describes themes from clinician interviews, including discussion of staffing challenges, limited referral availability, fragmentation of care, technological limitations, and more.
Author(s): Edward Christopher Portillo, Martha Maurer, Steven Do, et al.
Citation: BMJ Open Respiratory Research, 13, e003178
Date: 03/2026
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Examines barriers to implementing the COPD Coordinated Access to Reduce Exacerbations (COPD CARE) program, a care bundle focused on improving chronic obstructive pulmonary disease care coordination among pharmacists, nurse care managers, and other pharmacy clinicians in the Veterans Affairs system. Describes themes from clinician interviews, including discussion of staffing challenges, limited referral availability, fragmentation of care, technological limitations, and more.
Author(s): Edward Christopher Portillo, Martha Maurer, Steven Do, et al.
Citation: BMJ Open Respiratory Research, 13, e003178
Date: 03/2026
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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 & 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 & 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 & 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 & 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 & 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 & 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 & 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 & 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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