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Rural Health Information Hub

Rural Health
Resources by Topic: Care coordination

Care Coordination Canvas Guide
A framework and resources for developing effective care coordination programs. Includes worksheets, guides, and case studies describing different care coordination approaches: care coach, clinical, community health worker, and school-based. Based on a survey of rural health networks engaged in implementing care coordination initiatives.
Type: Website
Sponsoring organizations: National Rural Health Resource Center, Rural Health Innovations
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Care Management Medicare Reimbursement Strategies for Rural Providers
Information for rural healthcare providers on Medicare billing codes for services to keep beneficiaries healthy and better coordinate services to support beneficiaries at home. Addresses Annual Wellness Visits, Chronic Care Management, Transitional Care Management, and Principal Care Management.
Type: Website
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, Rural Health Information Hub
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Rural Care Coordination Toolkit
Provides supporting resources and best practices designed to help identify and implement a rural care coordination program. Consists of several modules each concentrating on different aspects of care coordination programs.
Type: Website
Sponsoring organization: Rural Health Information Hub
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Co-Managed Care Toolkit
Designed to address knowledge and communication gaps existing between VA healthcare teams and non-VA teams in cases where veterans utilize both types of providers. Designed to help create a care network for rural veterans.
Type: Website
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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AHA Community Connections
Provides access to case studies spotlighting hospitals and health systems (some are in rural areas) that have successfully collaborated with local community organizations to promote care coordination, wellness, and prevention. Website also includes tools and resources to help healthcare facilities be accountable and transparent to their communities and deliver quality care.
Type: Website
Sponsoring organization: American Hospital Association
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Integrated Care Resource Center
Helps states learn about best practices for delivering coordinated healthcare to high-need, high-cost Medicaid beneficiaries. The resource center is a joint technical assistance project of the Centers for Medicare & Medicaid Services (CMS) Medicare-Medicaid Coordination Office and the Center for Medicaid, CHIP, and Survey & Certification (CMCS).
Type: Website
Sponsoring organization: Centers for Medicare and Medicaid Services
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