Examples of Care Coordinator Programs
Examples of rural programs that utilize care coordinators are provided below. Additional examples are available in Module 7: Program Clearinghouse.
- Community Access Program: A program in West Virginia that focuses on improving healthcare services for people with chronic diseases through case management services; used as a model for other rural care coordination programs because of its success in reducing hospitalizations and emergency visits.
- Community Health Access Project: Uses community health workers (CHWs) to provide evidence-based care in Mansfield, Ohio. This project has been adapted by rural care coordination programs because of its emphasis on working across organizational silos and connecting at-risk individuals to health and social services that can improve health outcomes.
- Lincoln E.D. Connections Program: Utilizes case managers to help chronically ill patients who utilize the emergency department identify a medical home and other needed community resources in Lincoln, Nebraska.
- Tri-County Rural Health Network: A non-profit community development organization that works with low-income individuals in the Mississippi Delta. Outreach workers called “community connectors” identify Medicaid-eligible residents with unmet healthcare needs that put them at high risk of nursing home placement. Community connectors arrange for these individuals to receive home and community-based care.
- Richland Health Network: Joins a hospital, health department, and agency on aging to form a partnership that conducts case management services using a nurse and a social worker in Montana.