Rural Health
Resources by Topic: Care coordination
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
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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
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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
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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
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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
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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
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Integrating Community Health Workers into Complex Care Teams: Key Considerations
Examines effective strategies for integrating community health workers (CHWs) into complex care teams. Discusses factors to consider, such as recruiting and hiring, training and career progression, team integration, support and retention, and more. Includes a brief description of characteristics that are particularly important for CHWs working in rural areas.
Author(s): Jim Lloyd, Caitlin Thomas-Henkel
Date: 05/2017
Sponsoring organization: Center for Health Care Strategies
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Examines effective strategies for integrating community health workers (CHWs) into complex care teams. Discusses factors to consider, such as recruiting and hiring, training and career progression, team integration, support and retention, and more. Includes a brief description of characteristics that are particularly important for CHWs working in rural areas.
Author(s): Jim Lloyd, Caitlin Thomas-Henkel
Date: 05/2017
Sponsoring organization: Center for Health Care Strategies
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Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring: Third Annual Report
Third annual evaluations of 24 Health Care Innovation Awards Round One projects focused on enhancing care coordination and healthcare access through the use of health information technology, care coordination/patient navigation, and health promotion and prevention services. Discusses awardees' progress and impact over the 3-year funding period from 2012 to 2015. Includes profiles of rural-focused projects, as well as projects serving rural and urban areas.
Additional links: Addendum, August 2017
Date: 03/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Third annual evaluations of 24 Health Care Innovation Awards Round One projects focused on enhancing care coordination and healthcare access through the use of health information technology, care coordination/patient navigation, and health promotion and prevention services. Discusses awardees' progress and impact over the 3-year funding period from 2012 to 2015. Includes profiles of rural-focused projects, as well as projects serving rural and urban areas.
Additional links: Addendum, August 2017
Date: 03/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Third Annual Report: HCIA Disease-Specific Evaluation
Findings from the third year for 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Provides information on program effectiveness based on Medicare and Medicaid claims data and awardee-collected data. Includes projects that serve a variety of rural areas and address conditions such as diabetes, cancer, cardiovascular disease, and chronic pain. Approaches discussed include care coordination, education, and telehealth.
Additional links: Addendum, June 2017
Date: 02/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Findings from the third year for 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Provides information on program effectiveness based on Medicare and Medicaid claims data and awardee-collected data. Includes projects that serve a variety of rural areas and address conditions such as diabetes, cancer, cardiovascular disease, and chronic pain. Approaches discussed include care coordination, education, and telehealth.
Additional links: Addendum, June 2017
Date: 02/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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HCIA Complex/High-Risk Patient Targeting: Third Annual Report
Third annual evaluations of Health Care Innovation Awards Round One projects focused on patients with medically complex conditions at high risk for hospitalization, re-hospitalization, emergency department visits, or nursing home stays. Presents program effectiveness findings based on Medicare and Medicaid claims data, surveys, site visits, and interviews. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches.
Additional links: Addendum, April 2017
Date: 02/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Third annual evaluations of Health Care Innovation Awards Round One projects focused on patients with medically complex conditions at high risk for hospitalization, re-hospitalization, emergency department visits, or nursing home stays. Presents program effectiveness findings based on Medicare and Medicaid claims data, surveys, site visits, and interviews. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches.
Additional links: Addendum, April 2017
Date: 02/2017
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Native Americans with Diabetes: Better Diabetes Care Can Decrease Kidney Disease
Provides an overview of diabetes and related kidney disease among American Indians and Alaska Natives. Describes an Indian Health Service (IHS) approach using population health and team-based approaches to diabetes and kidney care.
Additional links: Podcast
Date: 01/2017
Sponsoring organization: Centers for Disease Control and Prevention
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Provides an overview of diabetes and related kidney disease among American Indians and Alaska Natives. Describes an Indian Health Service (IHS) approach using population health and team-based approaches to diabetes and kidney care.
Additional links: Podcast
Date: 01/2017
Sponsoring organization: Centers for Disease Control and Prevention
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Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives — United States, 1996–2013
Reports on diabetes-related end-stage renal disease by race/ethnicity from 1996-2013. Discusses clinical, public health, and population management approaches used by Indian Health Service that may have positively impacted incidence rates among American Indians and Alaska Natives.
Author(s): Ann Bullock, Nilka Ríos Burrows, Andrew S. Narva, et al.
Citation: MMWR (Morbidity and Mortality Weekly Report), 66(1), 26-32
Date: 01/2017
Sponsoring organization: Centers for Disease Control and Prevention
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Reports on diabetes-related end-stage renal disease by race/ethnicity from 1996-2013. Discusses clinical, public health, and population management approaches used by Indian Health Service that may have positively impacted incidence rates among American Indians and Alaska Natives.
Author(s): Ann Bullock, Nilka Ríos Burrows, Andrew S. Narva, et al.
Citation: MMWR (Morbidity and Mortality Weekly Report), 66(1), 26-32
Date: 01/2017
Sponsoring organization: Centers for Disease Control and Prevention
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Social Determinants of Health and Vulnerable Populations in Rural Maryland
White paper discussing how social determinants of health impact those who face barriers to health and are susceptible to poor health due to circumstances such as environmental conditions, housing concerns, lack of transportation, and poverty. Includes strategies and examples of programs that have worked in rural communities to address topics such as substance use disorder and care coordination.
Date: 12/2016
Sponsoring organizations: Maryland Community Health Resources Commission, Maryland Rural Health Association
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White paper discussing how social determinants of health impact those who face barriers to health and are susceptible to poor health due to circumstances such as environmental conditions, housing concerns, lack of transportation, and poverty. Includes strategies and examples of programs that have worked in rural communities to address topics such as substance use disorder and care coordination.
Date: 12/2016
Sponsoring organizations: Maryland Community Health Resources Commission, Maryland Rural Health Association
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