Rural Health
Resources by Topic: Care coordination
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 & 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 & Medicaid Services, NORC at the University of Chicago
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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 & 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 & 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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Rural Health Networks and Care Coordination: Health Care Innovation in Frontier Communities to Improve Patient Outcomes and Reduce Health Care Costs
Discusses the findings of a single-case, community-based participatory design study in a frontier community in northern Minnesota to determine the effectiveness of developing a community care team focused on collaboration and care coordination to improve patient outcomes and reduce emergency room use.
Author(s): Pat Conway, Heidi Favet, Laurie Hall, Jenny Uhrich, Jeanette Palcher, et al.
Citation: Journal of Health Care for the Poor and Underserved, 27(4A), 91–115
Date: 11/2016
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Discusses the findings of a single-case, community-based participatory design study in a frontier community in northern Minnesota to determine the effectiveness of developing a community care team focused on collaboration and care coordination to improve patient outcomes and reduce emergency room use.
Author(s): Pat Conway, Heidi Favet, Laurie Hall, Jenny Uhrich, Jeanette Palcher, et al.
Citation: Journal of Health Care for the Poor and Underserved, 27(4A), 91–115
Date: 11/2016
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Innovations in Rural Health System Development: Service Delivery Advances in Care Coordination, Emergency Care, and Telehealth
Offers examples of emergency services, telehealth technology, and care coordination initiatives with a focus on Maine, and how they impact rural service delivery and safeguard rural access to critical health services.
Author(s): Amanda Burgess, Andrew F. Coburn
Date: 11/2016
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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Offers examples of emergency services, telehealth technology, and care coordination initiatives with a focus on Maine, and how they impact rural service delivery and safeguard rural access to critical health services.
Author(s): Amanda Burgess, Andrew F. Coburn
Date: 11/2016
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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"How Can We Talk about Patient-centered Care without Patients at the Table?" Lessons Learned from Patient Advisory Councils
Reports on a survey of patient advisory council (PAC) members associated with 8 primary care clinics and Federally Qualified Health Clinics (FQHCs), both rural and urban, in Northern California. Focuses on how PACs are developed, challenges faced, and the benefits of effective PACs.
Author(s): Anjana E. Sharma, Rachel Willard-Grace, Andrew Willis, et al.
Citation: Journal of the American Board of Family Medicine, 29(6), 775-784
Date: 11/2016
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Reports on a survey of patient advisory council (PAC) members associated with 8 primary care clinics and Federally Qualified Health Clinics (FQHCs), both rural and urban, in Northern California. Focuses on how PACs are developed, challenges faced, and the benefits of effective PACs.
Author(s): Anjana E. Sharma, Rachel Willard-Grace, Andrew Willis, et al.
Citation: Journal of the American Board of Family Medicine, 29(6), 775-784
Date: 11/2016
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Project ECHO's Complex Care Initiative: Building Capacity to Help "Superutilizers" in Underserved Communities
Describes a case study from the University of New Mexico's Project ECHO (Extension for Community Health Outcomes) program, which uses telehealth to support primary care clinicians in underserved areas. Focuses on a project targeting Medicaid beneficiaries with substance abuse and mental health issues, with details on two primary care teams being supported, including one in a rural New Mexico community.
Author(s): Martha Hostetter, Sarah Klein, Douglas McCarthy
Date: 08/2016
Sponsoring organization: Commonwealth Fund
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Describes a case study from the University of New Mexico's Project ECHO (Extension for Community Health Outcomes) program, which uses telehealth to support primary care clinicians in underserved areas. Focuses on a project targeting Medicaid beneficiaries with substance abuse and mental health issues, with details on two primary care teams being supported, including one in a rural New Mexico community.
Author(s): Martha Hostetter, Sarah Klein, Douglas McCarthy
Date: 08/2016
Sponsoring organization: Commonwealth Fund
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Integrated Care in a Frontier Community
Examines the Southeast Health Group (SHG) in La Junta, Colorado, which coordinates physical and behavioral health using patient-centered, wellness-based care coordination to empower patients and promote self-directed care. Focuses on hiring providers who share SHG's philosophy of care, using community resources, and engaging peer support specialists.
Date: 07/2016
Sponsoring organization: Rural Health Value
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Examines the Southeast Health Group (SHG) in La Junta, Colorado, which coordinates physical and behavioral health using patient-centered, wellness-based care coordination to empower patients and promote self-directed care. Focuses on hiring providers who share SHG's philosophy of care, using community resources, and engaging peer support specialists.
Date: 07/2016
Sponsoring organization: Rural Health Value
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National Healthcare Quality and Disparities Chartbook on Care Coordination
A summary of trends in Care Coordination from the National Healthcare Quality and Disparities Report (QDR) for 2015. Includes data and statistics by metropolitan statistical area with a focus on groups with disparities in care coordination regarding hospital and emergency department visits, discharge, readmission, use of ED for chronic healthcare, and potentially avoidable hospitalizations. Also highlights the use of electronic health records and electronic exchange and how that affects care coordination and quality.
Date: 06/2016
Sponsoring organization: Agency for Healthcare Research and Quality
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A summary of trends in Care Coordination from the National Healthcare Quality and Disparities Report (QDR) for 2015. Includes data and statistics by metropolitan statistical area with a focus on groups with disparities in care coordination regarding hospital and emergency department visits, discharge, readmission, use of ED for chronic healthcare, and potentially avoidable hospitalizations. Also highlights the use of electronic health records and electronic exchange and how that affects care coordination and quality.
Date: 06/2016
Sponsoring organization: Agency for Healthcare Research and Quality
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