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Rural Health
Resources by Topic: Care coordination

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
Type: Document
Sponsoring organization: North Carolina Rural Health Research Program
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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.
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model
Provides information on the Centers for Medicare & Medicaid Services (CMS) Innovation Center's States Advancing All-Payer Health Equity Approaches and Development (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.
Type: Website
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.
Type: Website
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.
Type: Website
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.
Type: Document
Sponsoring organization: Idaho Department of Health and Welfare
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Allied Health Workforce Projections, 2016-2030: Community Health Workers
Offers demand projections for community health workers (CHWs) from 2016-2030, using data from the Health Resources and Services Administration's Health Workforce Simulation Model. Includes projected statistics for various care coordination scenarios, including a rural healthcare scenario.
Type: Document
Sponsoring organization: Health Resources and Services Administration
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Maternal Opioid Misuse (MOM) Model
Overview of a CMS initiative focused on the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) through state-driven transformation of the delivery system. Supports coordination of clinical care and integration of other services critical for health, well-being, and recovery.
Type: Website
Sponsoring organization: Centers for Medicare and Medicaid Services
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Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)
Provides instructions for payment to Rural Health Clinics (RHCs) billing under the all-inclusive rate and Federally Qualified Health Centers (FQHCs) billing under the prospective payment system for care coordination services provided to Medicare beneficiaries on or after January 1, 2018.
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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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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