Rural Health
Resources by Topic: Care coordination
The Rural Health Care Coordination Network Partnership Program: Critical Access Hospital Network of Eastern Washington
Describes and examines the impact of a care coordination program developed by the Critical Access Hospital Network (CAHN) of Eastern Washington. Provides care coordination services to Medicaid patients with at least two chronic conditions or one chronic condition and the risk of developing another. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional funding from the Empire Health Foundation.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by the Critical Access Hospital Network (CAHN) of Eastern Washington. Provides care coordination services to Medicaid patients with at least two chronic conditions or one chronic condition and the risk of developing another. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional funding from the Empire Health Foundation.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Avera St. Mary's Completing the Circle Project
Describes and examines the impact of a care coordination program developed by Avera St. Mary's located in Pierre, South Dakota. Used a Patient Centered Medical Home (PCMH) model, providing services to patients with type 2 diabetes. The program's care team connected patients to resources and coordinated the patient's primary care providers, medications, specialists, other health care services, and a variety of social services. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by Avera St. Mary's located in Pierre, South Dakota. Used a Patient Centered Medical Home (PCMH) model, providing services to patients with type 2 diabetes. The program's care team connected patients to resources and coordinated the patient's primary care providers, medications, specialists, other health care services, and a variety of social services. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Chautauqua County Health Hospital Network
Describes and examines the impact of a care coordination program developed by the Chautauqua County Health Network in New York. Offers well-coordinated preventive health services and links to community-based services to patients with diabetes, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) who need regular support but are not medically frail. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by the Chautauqua County Health Network in New York. Offers well-coordinated preventive health services and links to community-based services to patients with diabetes, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) who need regular support but are not medically frail. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: South East Rural Physicians Alliance
Describes and examines the impact of a care coordination program developed by the South East Rural Physicians Alliance-Independent Physician Association located in Nebraska. Program focuses on clinic-based care coordination for high-risk patients with diagnosed diabetes or congestive heart failure. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by the South East Rural Physicians Alliance-Independent Physician Association located in Nebraska. Program focuses on clinic-based care coordination for high-risk patients with diagnosed diabetes or congestive heart failure. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Worcester County Health Department
Describes and examines the impact of a care coordination program developed by the Worcester County Health Department located on the Eastern Shore of Maryland. Describes the program's care team of a registered nurse, masters-level social worker, and community health worker (CHW), working in collaboration with primary care providers. Serves patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), with a home visit and services tailored to the patient's unique needs. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by the Worcester County Health Department located on the Eastern Shore of Maryland. Describes the program's care team of a registered nurse, masters-level social worker, and community health worker (CHW), working in collaboration with primary care providers. Serves patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), with a home visit and services tailored to the patient's unique needs. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Williamson Health and Wellness Center
Describes and examines the impact of a care coordination program developed by the Williamson Health and Wellness Center based in Williamson, West Virginia. Describes the program's use of care teams of community health workers, a registered nurse, and a nurse practitioner providing care coordination to patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional private funding from a network of local philanthropies.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Describes and examines the impact of a care coordination program developed by the Williamson Health and Wellness Center based in Williamson, West Virginia. Describes the program's use of care teams of community health workers, a registered nurse, and a nurse practitioner providing care coordination to patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional private funding from a network of local philanthropies.
Date: 2020
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Care Coordination: A Self-Assessment for Rural Health Providers and Organizations
Developed to provide a preliminary review of important factors for rural organizations interested in developing, expanding, or enhancing care coordination activities.
Date: 2020
Sponsoring organization: Rural Health Value
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Developed to provide a preliminary review of important factors for rural organizations interested in developing, expanding, or enhancing care coordination activities.
Date: 2020
Sponsoring organization: Rural Health Value
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Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Frequently Asked Questions
Provides general information about chronic care management services, specific program requirements, detailed descriptions of billing, claims processing, and payment rules, and requirements for people who are considered part of a care management team for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Date: 12/2019
Sponsoring organization: Centers for Medicare and Medicaid Services
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Provides general information about chronic care management services, specific program requirements, detailed descriptions of billing, claims processing, and payment rules, and requirements for people who are considered part of a care management team for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
Date: 12/2019
Sponsoring organization: Centers for Medicare and Medicaid Services
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Financial Alignment Initiative South Carolina Healthy Connections Prime: First Evaluation Report
Evaluation of the first year of the South Carolina Healthy Connections Prime demonstration to integrate care for the state's Medicare-Medicaid beneficiaries. Discusses access and other challenges for rural enrollees and how the program has worked to address rural needs.
Date: 09/2019
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Evaluation of the first year of the South Carolina Healthy Connections Prime demonstration to integrate care for the state's Medicare-Medicaid beneficiaries. Discusses access and other challenges for rural enrollees and how the program has worked to address rural needs.
Date: 09/2019
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Russell County Hospital Listens to their Community to Improve Transitions of Care
Highlights quality improvement activities underway at a 25-bed Critical Access Hospital (CAH) in rural Kentucky. Discusses community collaboration efforts, expansion of specialty services, renovations, a focus on staff satisfaction, and care coordination activities.
Date: 09/2019
Sponsoring organization: National Rural Health Resource Center
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Highlights quality improvement activities underway at a 25-bed Critical Access Hospital (CAH) in rural Kentucky. Discusses community collaboration efforts, expansion of specialty services, renovations, a focus on staff satisfaction, and care coordination activities.
Date: 09/2019
Sponsoring organization: National Rural Health Resource Center
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