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Rural Health Information Hub

Rural Health
Resources by Topic: Care coordination

The 2010 Report to the Secretary: Rural Health and Human Services Issues
Report to the Secretary of the U.S. Department of Health and Human Services on issues related to rural America. Topics include home and community based care for rural seniors, rural primary care workforce, and rural health care provider integration.
Date: 05/2010
Sponsoring organization: National Advisory Committee on Rural Health and Human Services
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Expanding Rural Elder Care Options: Models That Work
Proceedings from the 2008 Rural Long Term Care Access and Options Workshop, which discussed model options for home, community, and facility-based care by care coordination systems that enhance autonomy and quality of life for rural elders.
Author(s): Peter Fitzgerald, Andy Coburn, Sharon K. Dwyer
Date: 06/2009
Sponsoring organization: Rural Long Term Care Workgroup
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MedPAC Report to the Congress: Increasing the Value of Medicare
Examines issues affecting the Medicare program and makes recommendations to the Congress. Topics covered include care coordination, pricing accuracy in the hospice and physician payment systems, quality measures in home health, gathering data on outpatient therapy, Medicare Advantage, the Part D prescription drug program, and cost-effectiveness analysis.
Date: 06/2006
Sponsoring organization: Medicare Payment Advisory Commission
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Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States
Discusses state programs that provide enhanced benefits to Medicaid beneficiaries such as enhanced primary care case management (PCCM). Includes examples from three states: Florida, North Carolina, and Oklahoma.
Additional links: Findings Brief, March 2003: Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States
Author(s): Pam Silberman, Stephanie Poley, Rebecca Slifkin
Date: 01/2003
Sponsoring organization: North Carolina Rural Health Research Program
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Transforming Episode Accountability Model (TEAM)
Provides information on the Centers for Medicare & Medicaid Services (CMS) Innovation Center's Transforming Episode Accountability Model (TEAM), an episode-based alternative payment method in which selected acute care hospitals will coordinate care for patients who undergo certain surgeries. Aims to improve the coordination and transition of care between providers for patients.
Sponsoring organization: Centers for Medicare and Medicaid Services
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Medicare Learning Network: Chronic Care Management Services
Provides general information about payable chronic care management service elements, practitioners able to bill for CCM services, patient eligibility, service codes, concurrent billing, and Medicare Physician Fee Schedule (PFS) billing requirements. Includes information on Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for CCM services.
Sponsoring organization: Centers for Medicare and Medicaid Services
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Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model
Provides information on the Centers for Medicare & Medicaid Services (CMS) Innovation Center's Achieving Healthcare Efficiency through Accountable Design (AHEAD) Model, a voluntary state total cost of care model that will test state accountability for controlling overall growth in health expenditures while increasing investment in primary care and improving population health outcomes.
Sponsoring organization: Centers for Medicare and Medicaid Services
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Making Care Primary (MCP) Model
Provides information on the Centers for Medicare & Medicaid Services (CMS) Innovation Center's Making Care Primary (MCP) Model, which offers a pathway for primary care clinicians in eight states to gradually adopt prospective, population-based payments while building infrastructure to improve behavioral health and specialty care integration and enhance equitable access to care.
Sponsoring organization: Centers for Medicare and Medicaid Services
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Rural Healthcare Payment and Reimbursement Topic Guide
Resources and information on how rural healthcare providers are reimbursed by different payers and payment systems and the impact of payment policies on rural healthcare.
Sponsoring organization: Rural Health Information Hub
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The Virtual Patient-Centered Medical Home (PCMH): A Model for Idaho's Rural and Underserved Communities
Describes the virtual Patient-Centered Medical Home (PCMH), including benefits such as reduced cost of care and increased access to and quality of care. Discusses how telehealth and community health emergency medical services (CHEMS) will be used in the PCMH model. Includes contact information for Public Health District Small Rural Hospital Improvement (SHIP) Grant Project Managers.
Sponsoring organization: Idaho Department of Health and Welfare
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