Cross-Cutting Implementation Considerations
For an overview of common implementation tasks for rural health programs, see Implementation Considerations
in the Rural Community Health Toolkit. Specific considerations for rural care coordination programs are
described in this section.
Community needs assessment. To identify program priorities, rural communities should conduct a
community needs assessment. Programs obtain
input from community members, partners and consortia leaders, and patients throughout the service area using
structured surveys or interviews. Nonprofit hospitals are required to conduct these needs assessments and in
some rural areas hospitals
can work with local health departments to collaborate to complete needs assessments. For an overview of
how to conduct a needs assessment, see RHIhub's Rural
Community Health Toolkit.
Tracking system. A tracking system helps to manage patient transitions, hospitalizations, and
community agency referrals across organizations. The ability to share information between multiple organizations
is an important element of any rural care coordination program and critical for success. When implementing any
type of data system it is important to consider resource and technology needs. This includes both financial
resources to implement the system as well as staffing resources for training and use of the system. HIT systems
can facilitate data sharing and tracking, and care coordination models may rely on this information sharing to
provide care. The use of HIT systems can also introduce implementation challenges for programs, since these
systems may not have available fields for inputting care-coordination specific information into the system. For
more information about implementation considerations related to HIT systems see the Health Information Technology Model in Module 2.
Adapting program models. Rural care coordination programs often blend several different program
models to achieve their goals. Program models that are successful in one community or with one patient
population may not work in all situations. In particular, rural programs should consider the services and
resources available to support implementation. Care coordination programs may be adapted to meet the unique
needs of the community and patients being served, to ensure that they are structured in a way that is most
effective for the setting. For example, in some programs care coordinators are integrated into the care team and
work directly with providers on a daily basis, while other programs may choose to have care coordinators less
directly involved with providers.
Perspectives on care coordination. Care coordination programs should address one or several perspectives
on care coordination, including the patient/family, healthcare professional, and healthcare system. Care
coordination programs focus on person/patient-centered care where the services provided aim to address a diverse
set of patient needs. When implementing a care coordination program, considering both clinical and non-clinical
perspectives is important to addressing these patient needs.
Care coordination programs may also be designed to focus on the healthcare professional perspective. These
programs tend to involve helping patients navigate through the healthcare system. This could involve
coordinating the care of patients who need to visit multiple specialists or assisting with care needed at an
outside healthcare facility. In addition to the healthcare professional perspective, some programs may focus on
coordinating care from the perspective of the healthcare system. Often these programs involve coordinating care
across systems with an emphasis on improving the financial success of the healthcare system.
Resources to Learn More
An overview of care coordination concepts and resources, including implementation guides and webinars.
Organization(s): Safety Net Medical Home Initiative
Coordination: A Self-Assessment for Rural Health Providers and Organizations
This tool is intended for use by rural organizations to guide discussion of important factors for developing
care coordination efforts.
Organization(s): Rural Policy Research Institute and Stratis Health
Coordination in Rural Communities: Supporting the High Performance Rural Health System
A report describing the elements and purpose of care coordination, key characteristics for rural care
coordination programs, financing considerations, and policy recommendations.
Organization(s): Rural Policy Research Institute (RUPRI)
Realizing Rural Care
Coordination: Considerations and Action Steps for State Policy-Makers
This issue brief describes the importance of care coordination, provides design and implementation
considerations for rural care coordination programs, and describes the strategies and experiences of six
Organization(s): Robert Wood Johnson Foundation