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Rural Health
Resources by Topic: Care coordination

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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Care Coordination Comparative Matrix
Identifies rural health networks that are developing or implementing value-based models and recaps brief interviews with the network leaders that are implementing or developing care coordination initiatives. The matrix allows rural health networks to share features and lessons learned through the process of implementing the care coordination programs with one another.
Date: 08/2014
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Realizing Rural Care Coordination: Considerations and Action Steps for State Policy-Makers
Identifies action steps and policy considerations for coordinating care in rural areas based on the experiences of six states: Colorado, Alabama, New Mexico, Montana, Vermont, and North Carolina.
Author(s): Michael Stanek, Carrie Hanlon, Tess Shiras
Date: 03/2014
Type: Document
Sponsoring organization: Robert Wood Johnson Foundation
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Care Management for Medicaid Enrollees Through Community Health Teams
Presents data from a 2011-2012 review of state Medicaid medical home programs in 8 states. Identifies community health team programs that provide services such as care coordination and self-management coaching. Includes information on small or rural practices.
Author(s): Mary Takach, Jason Buxbaum
Date: 05/2013
Type: Document
Sponsoring organization: Commonwealth Fund
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Creating a Patient Navigation Model to Address Cervical Cancer Disparities in a Rural Hispanic Farmworker Community
Details a program to address cervical cancer disparities in rural Hispanic agricultural workers. Addresses specific barriers to preventive screenings, including awareness and knowledge of screening, cultural beliefs, cost, lack of health insurance, transportation, and child care.
Author(s): Kristen J. Wells, Maria I. Rivera, Sister Sara K. Proctor, et al.
Citation: Journal of Health Care for the Poor and Underserved, 23(4), 1712-1718
Date: 11/2012
Type: Document
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Palliative Care Rural Initiative Dissemination Model and Implementation Guide
Includes tools, best practices, and lessons learned associated with implementing care coordination models to help rural community hospice organizations meet the needs of veterans. Created within a collaboration of the National Rural Health Resource Center and the Veterans Integrated Service Network (VISN) 23 and designed to be replicated by other VISNs.
Date: 11/2012
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Exploring Opportunities to Strengthen the Rural Health Network Development Planning Grant Program
Reports on the efforts of Office of Rural Health Policy (ORHP) Networking Planning grantees and provides recommendations for future rural health networks, including on the topics of network planning and sustainability. Focus areas included care coordination, health information technology, behavioral and mental health services, and services for vulnerable populations.
Author(s): Walter Gregg, Adam Hofer, Ira Moscovice
Date: 02/2012
Type: Document
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
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