Rural Health
Resources by Topic: Care coordination
Medicaid: Efforts to Identify, Predict, or Manage High-Expenditure Beneficiaries
Describes strategies used in 7 states to manage beneficiaries' healthcare costs while ensuring quality care, and lists resources the Centers for Medicare and Medicaid Services provides to help states identify, predict, and manage high-expenditure beneficiaries. Discusses effects of social determinants of health and staff shortages in rural areas. Includes statistics for Medicaid expenditures among beneficiaries enrolled only in Medicaid, for fiscal years 2009-2011.
Additional links: Full Report
Date: 08/2019
Type: Document
Sponsoring organization: Government Accountability Office
view details
Describes strategies used in 7 states to manage beneficiaries' healthcare costs while ensuring quality care, and lists resources the Centers for Medicare and Medicaid Services provides to help states identify, predict, and manage high-expenditure beneficiaries. Discusses effects of social determinants of health and staff shortages in rural areas. Includes statistics for Medicaid expenditures among beneficiaries enrolled only in Medicaid, for fiscal years 2009-2011.
Additional links: Full Report
Date: 08/2019
Type: Document
Sponsoring organization: Government Accountability Office
view details
Small Rural Hospital Transition (SRHT) Project Guide: A Rural Hospital Guide to Improving Care Management: 2019 Update
A guide for rural hospital leadership that identifies best practices in care management. Addresses care management roles and staffing needs and covers utilization review and discharge planning. Helps identify opportunities for process improvement. Also discusses competencies needed to transition to a value-based reimbursement environment focused on population health.
Date: 08/2019
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Stroudwater Associates
view details
A guide for rural hospital leadership that identifies best practices in care management. Addresses care management roles and staffing needs and covers utilization review and discharge planning. Helps identify opportunities for process improvement. Also discusses competencies needed to transition to a value-based reimbursement environment focused on population health.
Date: 08/2019
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Stroudwater Associates
view details
Rural Care Coordination and Population Health Management Summit: Summit Findings
Provides guidance to rural hospitals, clinics, and healthcare networks on incorporating community care coordination planning to prepare for population health management. Identifies tools and resources to support the transition to value-based payment models. Summarizes findings from a series of summits with national experts.
Author(s): Rebecca Jolley
Date: 08/2019
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Rural Health Association of Tennessee
view details
Provides guidance to rural hospitals, clinics, and healthcare networks on incorporating community care coordination planning to prepare for population health management. Identifies tools and resources to support the transition to value-based payment models. Summarizes findings from a series of summits with national experts.
Author(s): Rebecca Jolley
Date: 08/2019
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Rural Health Association of Tennessee
view details
Rural Hospital Care Coordination and Population Health Management Summit Report
Materials related to the 2019 Rural Care Coordination and Population Health Management Summit, which focused on the role community care coordination plays in helping healthcare leaders prepare for population health management. Includes a short video of panelist interviews as well as a findings report from the summit and a care management best practices guide.
Date: 08/2019
Type: Website
Sponsoring organization: National Rural Health Resource Center
view details
Materials related to the 2019 Rural Care Coordination and Population Health Management Summit, which focused on the role community care coordination plays in helping healthcare leaders prepare for population health management. Includes a short video of panelist interviews as well as a findings report from the summit and a care management best practices guide.
Date: 08/2019
Type: Website
Sponsoring organization: National Rural Health Resource Center
view details
Supportive Services and Caregiving for Older Rural Adults: Policy Brief and Recommendations to the Secretary
Provides an overview of current supportive services and caregiving policies for rural seniors, in terms of availability, accessibility, and acceptability of services. Explores topics including long-term services and supports, telehealth, care coordination, transportation, stigma, and unpaid caregivers, and describes federal programs for older adults. Offers policy recommendations and considerations.
Date: 08/2019
Type: Document
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
view details
Provides an overview of current supportive services and caregiving policies for rural seniors, in terms of availability, accessibility, and acceptability of services. Explores topics including long-term services and supports, telehealth, care coordination, transportation, stigma, and unpaid caregivers, and describes federal programs for older adults. Offers policy recommendations and considerations.
Date: 08/2019
Type: Document
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
view details
Patient Experience and Function, Fall 2018 Cycle: CDP Report
Evaluates 5 new measures related to patient function and experience of care and supports using them for quality improvement efforts and public reporting. Measures focus on care coordination, particularly following discharge in order to reduce hospital readmissions. Includes Critical Access Hospitals under acute care hospitals, with exclusions for swing bed stays.
Date: 08/2019
Type: Document
Sponsoring organization: National Quality Forum
view details
Evaluates 5 new measures related to patient function and experience of care and supports using them for quality improvement efforts and public reporting. Measures focus on care coordination, particularly following discharge in order to reduce hospital readmissions. Includes Critical Access Hospitals under acute care hospitals, with exclusions for swing bed stays.
Date: 08/2019
Type: Document
Sponsoring organization: National Quality Forum
view details
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
view details
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
view details
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
Author(s): Amy Kandilov, Vincent Keyes, Noëlle Siegfried, et al.
Date: 07/2019
Type: Document
Sponsoring organization: HHS Office of the Assistant Secretary for Planning and Evaluation
view details
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
Author(s): Amy Kandilov, Vincent Keyes, Noëlle Siegfried, et al.
Date: 07/2019
Type: Document
Sponsoring organization: HHS Office of the Assistant Secretary for Planning and Evaluation
view details
Operationalizing an Implementation Framework to Disseminate a Care Coordination Program for Rural Veterans
Features a study on a framework for assessment prior to the implementation of a care coordination program in Veterans Affairs (VA) facilities. Details a nurse-led care coordination program and highlights the methods for assessing the local context of the program before implementation.
Author(s): Chelsea Leonard, Heather Gilmartin, Marina McCreight, et al.
Citation: Journal of General Internal Medicine, 34, 58-66
Date: 05/2019
Type: Document
view details
Features a study on a framework for assessment prior to the implementation of a care coordination program in Veterans Affairs (VA) facilities. Details a nurse-led care coordination program and highlights the methods for assessing the local context of the program before implementation.
Author(s): Chelsea Leonard, Heather Gilmartin, Marina McCreight, et al.
Citation: Journal of General Internal Medicine, 34, 58-66
Date: 05/2019
Type: Document
view details
Practical Use of Process Mapping to Guide Implementation of a Care Coordination Program for Rural Veterans
Details a study on the use of process mapping in the implementation of a care coordination program in Veterans Affairs (VA) facilities. Discusses a nurse-led care coordination program and outlines its implementation process.
Author(s): Marina S. McCreight, Heather M. Gilmartin, PhD, Chelsea A. Leonard, et al.
Citation: Journal of General Internal Medicine, 34, 67-74
Date: 05/2019
Type: Document
view details
Details a study on the use of process mapping in the implementation of a care coordination program in Veterans Affairs (VA) facilities. Discusses a nurse-led care coordination program and outlines its implementation process.
Author(s): Marina S. McCreight, Heather M. Gilmartin, PhD, Chelsea A. Leonard, et al.
Citation: Journal of General Internal Medicine, 34, 67-74
Date: 05/2019
Type: Document
view details