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Rural Health
Resources by Topic: Care coordination

Accountable Care Communities in Rural: Laying the Groundwork in Humboldt County, California
Describes how Accountable Care Communities (ACCs) employ a unified approach to improving the health of a population and reducing costs, by emphasizing preventive health and wellness efforts, as well as promoting collaboration among community-based organizations, social services, and the local health care system. Examines the ways in which the ACC model may help rural communities face challenges associated with poorer health outcomes, transportation difficulties, and shortages of healthcare providers.
Author(s): Paula Weigel, Chance Finegan, Jocelyn Richgels, et al.
Date: 03/2015
Type: Document
Sponsoring organization: Rural Policy Research Institute Rural Health Panel
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Colorado Critical Access Hospitals and Clinics: Improving Communication and Readmission (iCARE) White Paper
Details how the Colorado Rural Health Center's Improving Communication and Readmission (iCARE) program is improving the patient experience at Critical Access Hospitals and Rural Health Clinics in Colorado by enhancing care coordination and lowering readmission rates.
Date: 03/2015
Type: Document
Sponsoring organization: Colorado Rural Health Center
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CPC Practice Spotlights
A collection of short features on primary care practices that participated in the CMS Comprehensive Primary Care (CPC) initiative, a multi-payer initiative that offered population-based care management fees and shared savings opportunities to participating practices. Includes examples of practices serving rural areas.
Date: 01/2015
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Grantee Directory: Rural Health Care Coordination Network Partnership Grant Program, 2015-2018
Provides contact information and brief overviews of the 8 initiatives funded under the Rural Health Care Coordination Network Partnership Grant Program in the 2015-2018 funding cycle. The initiatives focus on care coordination activities for diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD).
Date: 2015
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Rural Accountable Care Organization Care Coordination
Profile of the MaineHealth Accountable Care Organization (MHACO), which uses regional teams to provide care coordination to patients with complex medical profiles.
Date: 2015
Type: Document
Sponsoring organization: Rural Health Value
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Access to Behavioral Health Care for Geographically Remote Service Members and Dependents in the U.S.
Offers a geospatial analysis using TRICARE and other data to determine access to and utilization of mental and behavioral healthcare services for veterans who reside in remote locations. Recommends two pathways for improving access to care: telehealth service and collaborative care between primary care and specialty behavioral care.
Author(s): Ryan Andrew Brown, Grant N. Marshall, Joshua Breslau, et al.
Date: 2015
Type: Document
Sponsoring organization: RAND Corporation
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Annual Report 1: HCIA Disease-Specific Evaluation
Evaluations of 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Includes projects that serve a variety of rural areas and address conditions such as diabetes, cancer, and cardiovascular disease. Approaches discussed include care coordination, education, and telehealth.
Date: 11/2014
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: First Annual Report
Evaluations of 23 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. Identifies several projects serving rural areas, including programs that use telehealth, in-home care, and various care coordination approaches.
Date: 11/2014
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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How 3 Rural Safety Net Clinics Integrate Care for Patients: A Qualitative Case Study
Case study of two Rural Health Clinics and one rural Federally Qualified Health Center that were part of the Commonwealth Fund's Safety Net Medical Home Initiative (SNMHI), a project to implement and evaluate the patient-centered medical home (PCMH). Reports on challenges encountered related to a transition to team-based care and practical approaches for rural care coordination.
Author(s): Sarah Derrett, Kathryn E. Gunter, Robert S. Nocon, et al.
Citation: Medical Care, 52(11), S39-S47
Date: 11/2014
Type: Document
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Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring: Annual Report
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. Includes information on 5 rural-focused projects, as well as projects that serve both rural and urban areas.
Author(s): RTI International
Date: 10/2014
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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