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Rural Health
Resources by Topic: Care coordination

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
Type: Document
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
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Rural Promising Practice Issue Brief: VA Coordinated Transitional Care (C-TraC) Program
Highlights a promising practice in providing coordinated transitional care for rural veterans. Details the Coordinated Transitional Care (C-TraC) Program and discusses implementation and results from the pilot program at a VA medical center in Madison, WI.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Rural Promising Practice Issue Brief: Osteoporosis Risk Assessment Using Osteoporosis Self-Assessment Tool (OST) and Other Interventions at Rural Facilities
Outlines the Osteoporosis Self-Assessment Tool (OST) as a promising practice for assessing osteoporosis risk in rural veteran populations. Features examples in three Veterans Affairs (VA) medical facilities.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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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
Type: Document
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
Type: Document
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
Type: Document
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
Type: Document
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
Type: Document
Sponsoring organizations: Maryland Community Health Resources Commission, Maryland Rural Health Association
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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
Type: Document
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