Rural Health
Resources by Topic: Care coordination
Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain
A guide to help primary care providers, practices, and healthcare systems manage patients who are on long-term opioid therapy. Provides an evidence-based prescribing guideline, quality improvement measures, and practice-level care coordination strategies. Appendix F provides examples of comprehensive management approaches, including discussion of telehealth approaches that could be used in rural communities.
Date: 2018
Sponsoring organization: Centers for Disease Control and Prevention
view details
A guide to help primary care providers, practices, and healthcare systems manage patients who are on long-term opioid therapy. Provides an evidence-based prescribing guideline, quality improvement measures, and practice-level care coordination strategies. Appendix F provides examples of comprehensive management approaches, including discussion of telehealth approaches that could be used in rural communities.
Date: 2018
Sponsoring organization: Centers for Disease Control and Prevention
view details
Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Sponsoring organization: American Hospital Association Rural Health Services
view details
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Sponsoring organization: American Hospital Association Rural Health Services
view details
Kalispell Regional Healthcare: Managing the Needs of Medically and Socially Complex Patients or Superutilizers
Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. Initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Sponsoring organization: American Hospital Association Rural Health Services
view details
Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. Initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Sponsoring organization: American Hospital Association Rural Health Services
view details
Behavioral Health Trends in Ohio
Covers publications focusing on behavioral health research in Ohio. Includes research briefs on a variety of topics, such as housing retention, care coordination, employment, social connectedness, and others, as they relate to behavioral health.
Date: 10/2017
Sponsoring organization: Ohio Department of Mental Health and Addiction Services
view details
Covers publications focusing on behavioral health research in Ohio. Includes research briefs on a variety of topics, such as housing retention, care coordination, employment, social connectedness, and others, as they relate to behavioral health.
Date: 10/2017
Sponsoring organization: Ohio Department of Mental Health and Addiction Services
view details
Evaluation of the Minnesota Accountable Health Model
Describes the final results of Minnesota's State Innovation Model (SIM) initiative evaluation sponsored by the Centers for Medicare and Medicaid (CMS). Includes information on SIM investments in rural counties, considerations to strengthen and support infrastructure to advance integrated health partnerships in rural areas, and engagement strategies to include rural clinics and providers in Health Care Homes care coordination cost study.
Author(s): Donna Spencer, Christina Worrall, Emily Zylla, et al.
Date: 09/2017
Sponsoring organization: State Health Access Data Assistance Center
view details
Describes the final results of Minnesota's State Innovation Model (SIM) initiative evaluation sponsored by the Centers for Medicare and Medicaid (CMS). Includes information on SIM investments in rural counties, considerations to strengthen and support infrastructure to advance integrated health partnerships in rural areas, and engagement strategies to include rural clinics and providers in Health Care Homes care coordination cost study.
Author(s): Donna Spencer, Christina Worrall, Emily Zylla, et al.
Date: 09/2017
Sponsoring organization: State Health Access Data Assistance Center
view details
Barriers and Facilitators to Implementation of VA Home-based Primary Care on American Indian Reservations: A Qualitative Multi-case Study
Highlights a study on the efficacy of the Veterans Health Affairs (VA) home-based primary care program at providing non-institutional long-term care for rural American Indian veterans living on reservations. Bases findings on a qualitative analysis of interviews conducted with staff, clinicians, and managers who oversaw the program's implementation. Discusses the challenges, barriers, and facilitators related the program's expansion into Indian Country.
Author(s): B. Josea Kramer, Sarah D. Cote, Diane I. Lee, Beth Creekmur, Debra Saliba
Citation: Implementation Science, 12, 109
Date: 09/2017
view details
Highlights a study on the efficacy of the Veterans Health Affairs (VA) home-based primary care program at providing non-institutional long-term care for rural American Indian veterans living on reservations. Bases findings on a qualitative analysis of interviews conducted with staff, clinicians, and managers who oversaw the program's implementation. Discusses the challenges, barriers, and facilitators related the program's expansion into Indian Country.
Author(s): B. Josea Kramer, Sarah D. Cote, Diane I. Lee, Beth Creekmur, Debra Saliba
Citation: Implementation Science, 12, 109
Date: 09/2017
view details
Providing Patient-Centered Enhanced Discharge Planning and Rural Transition Support: Building a Rural Transitions Network Between Regional Referral and Critical Access Hospitals
Details manual procedures used in Western Montana to develop a model to improve the likelihood of a good recovery for patients and decreasing chances of re-hospitalization. Includes a guide to ethical considerations in discharge and rural transition planning.
Author(s): Tom Seekins, Heidi Boehm, Jennifer Wong, Linda Yearous, AnnaJean Smith
Date: 08/2017
Sponsoring organization: University of Montana: Rural Institute for Inclusive Communities
view details
Details manual procedures used in Western Montana to develop a model to improve the likelihood of a good recovery for patients and decreasing chances of re-hospitalization. Includes a guide to ethical considerations in discharge and rural transition planning.
Author(s): Tom Seekins, Heidi Boehm, Jennifer Wong, Linda Yearous, AnnaJean Smith
Date: 08/2017
Sponsoring organization: University of Montana: Rural Institute for Inclusive Communities
view details
Care Coordination for Community Transitions for Individuals Post-Stroke Returning to Low-Resource Rural Communities
Assesses the Kentucky Care Coordination for Community Transitions (KC3T) program of employing a specially trained community health worker (CHW) as a navigator to aid in the transition of individuals who have had a stroke from acute in-patient care to their rural community. The goal of the study was to determine the community navigation and resources required by people who have had a stroke in order to transition back to rural communities with few resources and to facilitate positive health outcomes.
Author(s): Patrick Kitzman, Keisha Hudson, Violet Sylvia, Johnnie Lovins
Citation: Journal of Community Health, 42(3), 565-572
Date: 06/2017
view details
Assesses the Kentucky Care Coordination for Community Transitions (KC3T) program of employing a specially trained community health worker (CHW) as a navigator to aid in the transition of individuals who have had a stroke from acute in-patient care to their rural community. The goal of the study was to determine the community navigation and resources required by people who have had a stroke in order to transition back to rural communities with few resources and to facilitate positive health outcomes.
Author(s): Patrick Kitzman, Keisha Hudson, Violet Sylvia, Johnnie Lovins
Citation: Journal of Community Health, 42(3), 565-572
Date: 06/2017
view details
Medical Center Barbour Reduces Readmission Rates
Highlights the accomplishments of Medical Center Barbour (MCB), a prospective payment system (PPS) hospital located in Eufaula, Alabama, as it progressed through a Small Rural Hospital Transition (SRHT) quality of care and transition of care project. MCB's top accomplishments include reducing readmissions, improving communication among staff and patients, and enhancing the discharge process.
Additional links: One-Page Summary
Date: 06/2017
Sponsoring organization: National Rural Health Resource Center
view details
Highlights the accomplishments of Medical Center Barbour (MCB), a prospective payment system (PPS) hospital located in Eufaula, Alabama, as it progressed through a Small Rural Hospital Transition (SRHT) quality of care and transition of care project. MCB's top accomplishments include reducing readmissions, improving communication among staff and patients, and enhancing the discharge process.
Additional links: One-Page Summary
Date: 06/2017
Sponsoring organization: National Rural Health Resource Center
view details
Rural Health Philanthropy Partnership: Leveraging Public-Private Funds to Improve Health
Highlights the work of two grantees funded through the Rural Health Care Coordination Network Partnership Program, a combined effort of the Federal Office of Rural Health Policy and philanthropy organizations. Discusses how the coordinated efforts of the grantees and their philanthropy partners benefit patients.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 05/2017
Sponsoring organization: Rural Health Information Hub
view details
Highlights the work of two grantees funded through the Rural Health Care Coordination Network Partnership Program, a combined effort of the Federal Office of Rural Health Policy and philanthropy organizations. Discusses how the coordinated efforts of the grantees and their philanthropy partners benefit patients.
Author(s): Kay Miller Temple
Citation: Rural Monitor
Date: 05/2017
Sponsoring organization: Rural Health Information Hub
view details