Rural Health
Resources by Topic: Care coordination
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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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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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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Rural Promising Practice Issue Brief: Caring for Older Adults and Caregivers at Home (COACH)
Describes the efforts of the Durham Department of Veterans Affairs Medical Center (VAMC) to provide home-based care for veterans with moderate to severe dementia and their caregivers, through its COACH program. Helps VA providers to improve access for rural veterans and can be used as a model for other VAMCs.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Describes the efforts of the Durham Department of Veterans Affairs Medical Center (VAMC) to provide home-based care for veterans with moderate to severe dementia and their caregivers, through its COACH program. Helps VA providers to improve access for rural veterans and can be used as a model for other VAMCs.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Rural Promising Practice Issue Brief: Telehealth Collaborative Care for Rural Veterans with HIV Infection
Features a report on promising practices in providing access to care for rural veterans with HIV via telehealth enabled collaborative care. Details an organizational model and implementation information.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Features a report on promising practices in providing access to care for rural veterans with HIV via telehealth enabled collaborative care. Details an organizational model and implementation information.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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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
Type: Document
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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
Type: Document
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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 Coburn
Date: 10/2016
Type: Document
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 Coburn
Date: 10/2016
Type: Document
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
Using CMS 2014 and 2015 Medicare Accountable Care Organization (ACO) data, this brief examines the differences in ACO performance on 4 domains of quality measures: Patient/Caregiver Experience (PCE), Care Coordination/Patient Safety (CCP), Preventive Health (PH), and At-Risk Population (AtR) in rural and urban areas, and discusses the overall quality score of Medicare Shared Savings ACOs by geographic category.
Author(s): Xi Zhu, Keith Mueller, Thomas Vaughn, Fred Ullrich, A. Clinton MacKinney
Date: 09/2016
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Using CMS 2014 and 2015 Medicare Accountable Care Organization (ACO) data, this brief examines the differences in ACO performance on 4 domains of quality measures: Patient/Caregiver Experience (PCE), Care Coordination/Patient Safety (CCP), Preventive Health (PH), and At-Risk Population (AtR) in rural and urban areas, and discusses the overall quality score of Medicare Shared Savings ACOs by geographic category.
Author(s): Xi Zhu, Keith Mueller, Thomas Vaughn, Fred Ullrich, A. Clinton MacKinney
Date: 09/2016
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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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
Type: Document
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
Type: Document
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
Type: Document
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
Type: Document
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
Type: Document
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
Type: Document
Sponsoring organization: Agency for Healthcare Research and Quality
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