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Rural Health
Resources by Topic: Care coordination

Practice Perspectives on Care Coordination in Rural Settings
Analyzes perspectives on care coordination models in rural areas that integrate social services with healthcare. Examines interview feedback from 16 healthcare informants in rural Missouri regarding integration of social determinant of health (SDOH) services into their practices, such as transportation, mental health, housing, food access, and dental care.
Author(s): Julie M. Kapp, Beau Underwood, Kristi Ressel, Kathleen Quinn
Citation: Professional Case Management, 29(1), 4-12
Date: 08/2023
Type: Document
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Assisting Rural Consumers: Webinar Slides
Provides an overview of the Centers for Medicare & Medicaid's (CMS) frameworks for health equity and advancing health equity in rural, tribal, and geographically isolated communities. Outlines barriers for healthcare consumers living in rural areas, and offers tactics for healthcare assisters and navigators who help rural populations make healthcare decisions.
Date: 07/2023
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Sourcebook: Rural Health Network Development Program, 2020-2023
Provides brief program descriptions and overviews of the sustained impact of the 44 rural health networks funded during the 2020-2023 grant period. Programs used integrated rural healthcare networks to address health needs including behavioral/mental health, care coordination, chronic disease, social determinants of health, and telehealth. Grantee profiles include a network overview, program outcomes, partners involved, and program sustainability.
Date: 07/2023
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Transforming Tribal Health: Addressing American Indians and Alaska Natives Health Disparities
Recording of a June 8, 2023, conference session on addressing tribal health disparities as part of the Centers for Medicare & Medicaid Services (CMS) Health Equity Conference. Includes presentations from the Arizona Health Care Cost Containment System on the use of care coordination and care management strategies and the National Indian Health Board on rethinking how CMS approaches health equity for American Indians and Alaska Natives. Transcript available by clicking the dots above the video description, then selecting Show transcript.
Additional links: Carrie Field, National Indian Health Board - Presentation Slides, Leslie Short, Arizona Health Care Cost Containment System - Presentation Slides
Date: 06/2023
Type: Video/Multimedia
Sponsoring organization: Centers for Medicare and Medicaid Services
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2023 National Survey on MIH-CP Programs
Results of a February 2023 survey of approximately 400 emergency medical services (EMS) agencies nationwide that have launched mobile integrated healthcare and community paramedicine (MIH-CP) programs. Features statistics on nontraditional services offered, and programs by demographic region served, with breakdowns by 3 levels of population density.
Date: 05/2023
Type: Document
Sponsoring organization: National Association of Emergency Medical Technicians
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Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Marshall Browning Spotlight Video
Profiles Marshall Browning Hospital, a participant in the 2019 cohort of the Delta Region Community Health Systems Development Program (DRCHSD). Describes how shifting the Marshall Browning Hospital mission statement led to improvements to care coordination and transitional care services.
Date: 05/2023
Type: Video/Multimedia
Sponsoring organization: National Rural Health Resource Center
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Evaluation of the Maternal Opioid Misuse (MOM) Model Second Annual Report (Implementation Year 1)
Provides an overview of the Maternal Opioid Misuse Model, which provides evidence-based integrated care and care coordination for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). Describes activities MOM Model awardees undertook during the MOM Model's first implementation year, July 1, 2021–June 30, 2022. Discusses barriers pregnant and postpartum people with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 04/2023
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?
Describes a care model utilizing CHWs to engage patients by screening for diseases, and offering education and information to help them manage their chronic conditions in an accessible, non-traditional setting such as a food bank distribution center, county fair, livestock auction, and educational events in rural Idaho. Discusses the value of CHWs, along with a primary care team, in improving outcomes for populations at risk, and the absence of payment models to support this model.
Author(s): Kelly McGrath
Citation: Journal of General Internal Medicine, 38 (Suppl 1), 16-17
Date: 03/2023
Type: Document
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Achieving Whole Health: A New Approach for Veterans and the Nation
Report offers guidance for providers both inside and outside of the VA for filling gaps in veterans healthcare. Discusses a team-based interprofessional care structure for preventing disease and promoting well-being. Highlights some considerations for providing a whole health approach for rural veterans as well.
Additional links: Read Online
Author(s): Board on Health Care Services
Date: 02/2023
Type: Document
Sponsoring organization: Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
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