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Rural Health
Resources by Topic: Care coordination

Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Evaluation of the Maternal Opioid Misuse (MOM) Model Second Annual Report (Implementation Year 1)
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 first implementation year, July 1, 2021–June 30, 2022. 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: 04/2023
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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Care Coordination Between Rural Primary Care and Telemedicine to Expand Medication Treatment for Opioid Use Disorder: Results from a Single-Arm, Multisite Feasibility Study
Examines the feasibility of expanding access to medication treatment for opioid use disorder (MOUD) in rural areas through the use of telemedicine. Analyzes 6 rural primary care sites and their care coordination model. Includes data on patients referred to telemedicine and total number of patient-days on MOUD.
Author(s): Yih-Ing Hser, Larissa J. Mooney, Laura-Mae Baldwin, et al.
Citation: The Journal of Rural Health
Date: 04/2023
Type: Document
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Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?
Describes a care model utilizing CHWs to engage patients by screening for diseases, and offering education and information to help them manage their chronic conditions in an accessible, non-traditional setting such as a food bank distribution center, county fair, livestock auction, and educational events in rural Idaho. Discusses the value of CHWs, along with a primary care team, in improving outcomes for populations at risk, and the absence of payment models to support this model.
Author(s): Kelly McGrath
Citation: Journal of General Internal Medicine, 38 (Suppl 1), 16-17
Date: 03/2023
Type: Document
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Achieving Whole Health: A New Approach for Veterans and the Nation
Report offers guidance for providers both inside and outside of the VA for filling gaps in veterans healthcare. Discusses a team-based interprofessional care structure for preventing disease and promoting well-being. Highlights some considerations for providing a whole health approach for rural veterans as well.
Additional links: Read Online
Author(s): Board on Health Care Services
Date: 02/2023
Type: Document
Sponsoring organization: Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
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Filling Behavioral Health Gaps in Rural Communities: A Unique Partnership in Washington State
Discusses a collaboration between a Critical Access Hospital (CAH) in Washington and state hospitals to accept patient transfers by utilizing swing beds to care for patients with complex behavioral health and social needs, such as substance use disorder, mental health, homelessness, and more. Includes data on swing bed admissions and information on incorporating behavioral health services into primary care.
Author(s): Sarah Klein, Martha Hostetter
Date: 02/2023
Type: Document
Sponsoring organization: The Commonwealth Fund
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Critical Access Hospital Telehealth Guide
Provides practical guidance on implementing and sustaining telehealth in Critical Access Hospitals, to optimize healthcare delivery, expand access, enhance care coordination, and address health inequity. Focuses on Medicare outpatient telehealth services, but also includes information on Medicaid coverage and remote services that may not strictly be considered telehealth.
Date: 01/2023
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Northwest Regional Telehealth Resource Center
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Care Coordination and Community Partnerships for Cancer Care in Critical Access Hospitals
Presents findings from a survey of 135 Critical Access Hospitals (CAHs) regarding care coordination practices for patients with cancer. Describes the types of care coordination services provided by CAHs and the staff that provide these services. Discusses partnerships between CAHs and community organizations regarding cancer initiatives.
Author(s): Megan Lahr, Xiomara Santana, Nathan Bean, Helen Parsons, Ira Moscovice
Date: 01/2023
Type: Document
Sponsoring organization: Flex Monitoring Team
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Engaging Rural Communities to Incorporate Social Determinants in Developing Strategies to Improve Access to Health Care in the Missouri Bootheel Counties
Presents a study on how social determinants of health affect healthcare access in several rural counties in Missouri. Discusses the perceived barriers to care in the rural "Bootheel" counties, such as economic issues, lack of health insurance coverage, and lack of coordinated care, among others.
Author(s): Ashish Shrestha, Katherine Stamatakis, Janice Ballard
Citation: Rural and Remote Health, 23, 7678
Date: 01/2023
Type: Document
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Rural Health Network Development Planning Program: 2022 Grantee Directory
Detailed descriptions of 23 Rural Health Network Development Planning Program grant projects funded in fiscal year 2022. Lists grantees by organization type and focus area, including topics such as network organization and infrastructure development, health system efficiencies, integrated service delivery, and behavioral health. Includes grantee profiles describing their programs and network structures, geographic areas served, network partners, and contacts for each network.
Date: 12/2022
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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