Rural Health
Resources by Topic: Care coordination
A Summary of State Innovation Models (SIM) Evaluation Results Across 17 States (2013-2020)
Summarizes evaluation results of the State Innovation Models (SIM), which examined the ability of 17 state governments to implement and test innovative value-based payment (VBP) healthcare models across multiple payers between 2013 and 2020. Presents findings regarding the implementation and impact of 29 delivery and payment models, including patient-centered medical homes, accountable care organizations, behavioral health integration, and more. Covers state contracting and consensus building, practice transformation, pediatric care, behavioral healthcare, beneficiary and provider perspectives, and more. Includes a section on payment model designs tailored to unique state needs, including rural populations, as well as rural references throughout.
Additional links: A Summary of State Innovation Models (SIM): Focus on State-Led Transformation - Findings at a Glance, Executive Summary, Findings at a Glance
Date: 01/2025
Sponsoring organization: Centers for Medicare and Medicaid Services
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Summarizes evaluation results of the State Innovation Models (SIM), which examined the ability of 17 state governments to implement and test innovative value-based payment (VBP) healthcare models across multiple payers between 2013 and 2020. Presents findings regarding the implementation and impact of 29 delivery and payment models, including patient-centered medical homes, accountable care organizations, behavioral health integration, and more. Covers state contracting and consensus building, practice transformation, pediatric care, behavioral healthcare, beneficiary and provider perspectives, and more. Includes a section on payment model designs tailored to unique state needs, including rural populations, as well as rural references throughout.
Additional links: A Summary of State Innovation Models (SIM): Focus on State-Led Transformation - Findings at a Glance, Executive Summary, Findings at a Glance
Date: 01/2025
Sponsoring organization: Centers for Medicare and Medicaid Services
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Health Information Technology Adoption and Utilization in Behavioral Health Settings
Explores the adoption and use of health information technology (HIT) among behavioral health providers. Presents findings from a literature review and focus group interviews regarding digital strategies that support integrated care models between physical health and behavioral health. Discusses how a lagging adoption and interoperability of HIT may affect community-based behavioral health providers working with underserved populations. Identifies policy considerations to increase interoperable HIT use among behavioral health providers. Includes rural references throughout.
Author(s): Michelle Dougherty, Rebecca McGavin, Meagan Pilar, Marc Horvath, Stephen Brown
Date: 12/2024
Sponsoring organizations: HHS Office of the Assistant Secretary for Planning and Evaluation, RTI International
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Explores the adoption and use of health information technology (HIT) among behavioral health providers. Presents findings from a literature review and focus group interviews regarding digital strategies that support integrated care models between physical health and behavioral health. Discusses how a lagging adoption and interoperability of HIT may affect community-based behavioral health providers working with underserved populations. Identifies policy considerations to increase interoperable HIT use among behavioral health providers. Includes rural references throughout.
Author(s): Michelle Dougherty, Rebecca McGavin, Meagan Pilar, Marc Horvath, Stephen Brown
Date: 12/2024
Sponsoring organizations: HHS Office of the Assistant Secretary for Planning and Evaluation, RTI International
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Building a Rural Cancer Care Network: Federal Funding Supports Collaboration of Urban, Regional, and Local Organizations
Features a rural cancer care network in Georgia funded by a federal care coordination grant that brings together an urban nonprofit organization, a regional healthcare system with rural locations, and a local rural physician's office. Highlights the network's work related to patient navigation and clinical cancer trial enrollment.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 11/2024
Sponsoring organization: Rural Health Information Hub
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Features a rural cancer care network in Georgia funded by a federal care coordination grant that brings together an urban nonprofit organization, a regional healthcare system with rural locations, and a local rural physician's office. Highlights the network's work related to patient navigation and clinical cancer trial enrollment.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 11/2024
Sponsoring organization: Rural Health Information Hub
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Tele-Collaborative Outreach to Rural Patients with Chronic Pain: Pragmatic Effectiveness Trial Protocol for the CORPs Study
Presents a trial protocol to examine the effectiveness of the Tele-Collaborative Outreach to Rural Patients (CORPs), a remote collaborative care intervention to improve pain interference among rural veterans with high-impact chronic pain. The intervention will be delivered through Veterans Health Administration (VA) system and will include pain education, care coordination, and navigation support provided by a nurse care manager (NCM). Discusses program implementation, evaluation, and cost-effectiveness.
Author(s): Benjamin J Morasco, Natassja Pal, Sarah S Ono, et al.
Citation: Pain Medicine, 25, S91-S98
Date: 11/2024
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Presents a trial protocol to examine the effectiveness of the Tele-Collaborative Outreach to Rural Patients (CORPs), a remote collaborative care intervention to improve pain interference among rural veterans with high-impact chronic pain. The intervention will be delivered through Veterans Health Administration (VA) system and will include pain education, care coordination, and navigation support provided by a nurse care manager (NCM). Discusses program implementation, evaluation, and cost-effectiveness.
Author(s): Benjamin J Morasco, Natassja Pal, Sarah S Ono, et al.
Citation: Pain Medicine, 25, S91-S98
Date: 11/2024
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The Rural Emergency Hospital Model: Year Two Progress Report
Provides an overview of the Rural Emergency Hospital (REH) payment designation, including the growth in REHs through September 1, 2024, factors that contribute to a hospital seeking REH conversion, and the impacts of REH conversion. Outlines concerns identified by REH leaders, facilities considering converting to REH status, and other rural stakeholders related to the REH designation, as well as policy recommendations to address these concerns.
Author(s): Emma Sheffert, Julia Harris, Marilyn Werber Serafini
Date: 10/2024
Sponsoring organization: Bipartisan Policy Center
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Provides an overview of the Rural Emergency Hospital (REH) payment designation, including the growth in REHs through September 1, 2024, factors that contribute to a hospital seeking REH conversion, and the impacts of REH conversion. Outlines concerns identified by REH leaders, facilities considering converting to REH status, and other rural stakeholders related to the REH designation, as well as policy recommendations to address these concerns.
Author(s): Emma Sheffert, Julia Harris, Marilyn Werber Serafini
Date: 10/2024
Sponsoring organization: Bipartisan Policy Center
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Diagnostic Excellence in U.S. Rural Healthcare: A Call to Action
Issue brief exploring challenges to diagnostic quality in rural healthcare. Provides an overview of the topic of diagnostic errors in rural settings, and provides suggestions related to resource and workforce limitations, access to care, care coordination and other service delivery models, and social determinants of health.
Author(s): Kisha J. Ali, Nick J. Galvez, Sarah Craig, et al.
Date: 09/2024
Sponsoring organization: Agency for Healthcare Research and Quality
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Issue brief exploring challenges to diagnostic quality in rural healthcare. Provides an overview of the topic of diagnostic errors in rural settings, and provides suggestions related to resource and workforce limitations, access to care, care coordination and other service delivery models, and social determinants of health.
Author(s): Kisha J. Ali, Nick J. Galvez, Sarah Craig, et al.
Date: 09/2024
Sponsoring organization: Agency for Healthcare Research and Quality
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A Qualitative Study of Providers' Perspectives on Cross-Institutional Care Coordination for Pancreatic Cancer: Challenges and Opportunities
Examines pancreatic cancer (PC) care coordination by comparing perspectives of urban, high-volume center providers (HVCPs) and rural, community-based providers (CBPs). Utilizes semi-structured interview feedback to explore issues such as communication, electronic health records (EHRs), patient co-management, and more.
Author(s): Matthew J. DePuccio, Karen Shiu-Yee, Natasha A. Kurien, et al.
Citation: BMC Health Services Research, 24, 1041
Date: 09/2024
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Examines pancreatic cancer (PC) care coordination by comparing perspectives of urban, high-volume center providers (HVCPs) and rural, community-based providers (CBPs). Utilizes semi-structured interview feedback to explore issues such as communication, electronic health records (EHRs), patient co-management, and more.
Author(s): Matthew J. DePuccio, Karen Shiu-Yee, Natasha A. Kurien, et al.
Citation: BMC Health Services Research, 24, 1041
Date: 09/2024
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Community Health Centers' Progress and Challenges in Meeting Patients' Essential Primary Care Needs: Findings from the Commonwealth Fund 2024 National Survey of Federally Qualified Health Centers
Summarizes findings from the 2024 Commonwealth Fund National Survey of Federally Qualified Health Centers (FQHCs), which received responses from 737 FQHC leaders in fall 2023 and spring 2024. Explores the extent to which FQHCs achieve primary care accessibility, comprehensiveness, and coordination. Compares findings to data from the 2018 version of this survey to assess how care delivery changed over time. Describes barriers FQHCs face in offering high-quality care. Presents data by rural and urban location throughout.
Author(s): Celli Horstman, Corinne Lewis, Alexandra Bryan, Sara Federman
Date: 08/2024
Sponsoring organization: Commonwealth Fund
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Summarizes findings from the 2024 Commonwealth Fund National Survey of Federally Qualified Health Centers (FQHCs), which received responses from 737 FQHC leaders in fall 2023 and spring 2024. Explores the extent to which FQHCs achieve primary care accessibility, comprehensiveness, and coordination. Compares findings to data from the 2018 version of this survey to assess how care delivery changed over time. Describes barriers FQHCs face in offering high-quality care. Presents data by rural and urban location throughout.
Author(s): Celli Horstman, Corinne Lewis, Alexandra Bryan, Sara Federman
Date: 08/2024
Sponsoring organization: Commonwealth Fund
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Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2023
Provides an overview of the Certified Community Behavioral Health Clinic (CCBHC) demonstration. Describes changes in the quality of care during the first four years of the demonstration for states with available quality measures, as well as quality bonus payments states made to CCBHCs based on quality measure performance. Builds on findings on demonstration implementation, quality improvement, and costs outlined in previous evaluation reports, focusing on data collected since spring 2022.
Date: 07/2024
Sponsoring organizations: HHS Office of the Assistant Secretary for Planning and Evaluation, Mathematica, RAND Corporation
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Provides an overview of the Certified Community Behavioral Health Clinic (CCBHC) demonstration. Describes changes in the quality of care during the first four years of the demonstration for states with available quality measures, as well as quality bonus payments states made to CCBHCs based on quality measure performance. Builds on findings on demonstration implementation, quality improvement, and costs outlined in previous evaluation reports, focusing on data collected since spring 2022.
Date: 07/2024
Sponsoring organizations: HHS Office of the Assistant Secretary for Planning and Evaluation, Mathematica, RAND Corporation
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Evaluation of the Maternal Opioid Misuse (MOM) Model: Third Annual Report (Implementation Year 2)
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, 2022–June 30, 2023. Discusses barriers pregnant and postpartum people with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 05/2024
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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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, 2022–June 30, 2023. Discusses barriers pregnant and postpartum people with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 05/2024
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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