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Rural Health
Resources by Topic: Care coordination

Mobile Telehealth Units and Care Coordinators Improve Emergency Care Services for Rural Arizona Patients
Features an Arizona program focused on lowering ER readmissions through care coordination and EMS telehealth services. Explains how the telehealth services are provided via mobile telehealth units. Describes how care coordination helps meet the behavioral health needs of patients with chronic diseases.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 08/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Support and Services at Home (SASH) Evaluation: SASH Evaluation Findings, 2010-2016
Evaluates the Support and Services at Home (SASH) program in Vermont, which provides support services and care coordination for older adults and people with disabilities in conjunction with affordable housing. Addresses Medicaid and Medicare expenditures, medication management, property management, challenges, and lessons learned. Identifies the percent of rural SASH host properties and differences for rural areas.
Additional links: Highlights
Date: 07/2019
Type: Document
Sponsoring organization: HHS Office of the Assistant Secretary for Planning and Evaluation
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The Impact of Rural Social Workers and Patient-Aligned Care Teams
Podcast explores the impact social workers have on rural veterans' healthcare outcomes. Discusses the role social workers have in coordinating care, providing referrals, and overseeing the well-being of rural veterans.
Date: 06/2019
Type: Audio
Sponsoring organization: U.S. Department of Veterans Affairs
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Leveraging Medicaid Financing and Coverage Benefits to Deliver PrEP Intervention Services
Shows how stakeholders in Medicaid agencies, Medicaid managed care organizations, and public health departments can identify barriers to pre-exposure prophylaxis (PrEP) medication and clinical services, in an effort to prevent HIV. Includes a section on provision of PrEP through Federally Qualified Health Centers and Rural Health Centers, and through telehealth.
Author(s): Naomi Seiler
Date: 05/2019
Type: Document
Sponsoring organization: AcademyHealth
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Reducing Cancer Among Native Populations: Models for Research, Prevention, and Treatment
Highlights the work of a cancer researcher, a foundation director, and healthcare provider who are engaging American Indians and Alaska Natives in cancer research, prevention, and treatment.
Author(s): Jenn Lukens
Citation: Rural Monitor
Date: 05/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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VA and Indian Health Service: Actions Needed to Strengthen Oversight and Coordination of Health Care for American Indian and Alaska Native Veterans
Report discusses the relationship between the Department of Veterans Affairs (VA) and the Indian Health Service (IHS) with regard to providing care to American Indian and Alaska Native veterans. Details the cooperative agreement between the two entities and the ways their efforts could be improved.
Additional links: Full Report
Date: 03/2019
Type: Document
Sponsoring organization: Government Accountability Office
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Implementation and Early Results of the Flex Program's Innovative Models Program Area: Final Evaluation Report
Reports on the implementation of the Flex Program and the integration of the Innovative Health Care Models (Innovative Projects) program area in 7 states focused on telehealth, care coordination, and quality improvement. Highlights lessons learned, program discussion, and the evaluation methods for each of the projects. Builds on a 2018 briefing paper, An Interim Evaluation Report of the Innovative Projects Portfolio of the Medicare Flex Grant Program.
Author(s): John A. Gale, Sara Kahn-Troster, Andrew Coburn
Date: 03/2019
Type: Document
Sponsoring organization: Flex Monitoring Team
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Rural Mental Health Network: Expanding and Strengthening Care Coordination
Highlights the Rural Mental Health Network in Missouri through an interview with its director. Addresses the network's focus on care coordination for social determinants of health needs, challenges, accomplishments, the role of Community Health Workers (CHWs), lessons learned, and more.
Date: 03/2019
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Rural Patients with Chronic Disease: A Nonprofit Organization and a Health Department Leverage Federal Funding to Provide Health Education and Care Coordination
Features rural Alabama and North Carolina organizations that are using Federal Office of Rural Health Policy grants to improve health outcomes for patients with chronic disease through remote patient monitoring, health education, and network development.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 02/2019
Type: Document
Sponsoring organization: Rural Health Information Hub
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Critical Access Hospital Network (CAHN): Eastern Washington Critical Access Hospital Network's Rural Health Care Coordination Network Partnership Program, Washington
Brief overview of a care coordination program that used Washington State's Health Home Program, an intensive care coordination program for high risk Medicare-Medicaid patients, as a guide. Discusses the program's sustainability efforts, as well as key takeaways about the program. The program was funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018 and received additional philanthropic funding through a public-private partnership.
Date: 2019
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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