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Rural Health Information Hub

Care Coordination Models for Chronic Disease Management

Care coordination models seek to streamline care strategies and coordinate communication among providers to minimize disease progression and improve quality of life. Successful care coordination requires effective collaboration among care team members and between the care team and the patient. The Rural Care Coordination Toolkit provides detailed information about implementing care coordination models in rural communities.

The Patient-Centered Medical Home (PCMH) is an example of a care coordination model that centers the patient and their family at the core of the care team. The PCMH model shows promise in improving outcomes for rural patients with chronic diseases by improving adherence to follow-up care, increasing compliance with medication and disease management plans, and reducing rates of hospitalization.

Examples of Rural Care Coordination Programs

  • Public Health Solutions District Health Department worked in partnership with six Critical Access Hospitals across rural Nebraska, to implement a patient navigation and case management program to reduce local use of the emergency department. The Healthy Pathways program connected people with chronic diseases, who needed additional help managing their illness, with preventive services and connected them with a medical home. Case managers through the program provided health education and helped navigate barriers to care, including a lack of transportation.
  • The Genesis HealthCare System COPD Readmissions Prevention Program combines care coordination, patient education, and coordination with community services to reduce hospital readmissions among COPD patients.
  • St. Luke's Miners Memorial Hospital, in partnership with the Tamaqua Area Community Partnership and Lehigh Carbon Community College, created the My Health, My Community Program to provide community outreach and case management to community members in rural Appalachian Pennsylvania. This program uses nurse practitioners, nurse educators, and dietitians to provide self-management education and outreach about diabetes and obesity in the clinic and community.
  • Oswego Health Care Management focuses on individuals with complex medical and behavioral health comorbidities, including people with cardiovascular disease or diabetes and low incomes. The goal of the program is to implement and demonstrate the effectiveness of a sustainable clinical care management and care coordination system for individuals in the population of focus.
  • The Adventist Health System Quality Improvement Project, based in rural Butte County, California, is a patient navigator program incorporating treatment planning and COPD education to reduce avoidable hospital readmissions. Respiratory therapists provide COPD patients with treatment planning, case management, and one-on-one education before discharge. The respiratory therapists review patients' personalized COPD action plans to enhance self-management. The project was modeled on the evidence-based Reversible Obstructive Airway Disease (ROAD) program from the University of California Davis Medical Center.
  • Montana Health Network's Regional Care Coordination program brings together healthcare providers, like primary care providers and specialists, and community resources, like housing and transportation services, to support adult patients with managing chronic conditions.

Implementation Considerations

People with chronic diseases often have more than one chronic condition. For example, most chronic obstructive pulmonary disease patients have at least one other chronic condition, like cardiovascular disease. Patients with multiple chronic illnesses and comorbidities may receive care from several providers. They may also require support from a variety of social services, peer groups, or other healthcare specialists.

Coordination of chronic disease management requires communication among healthcare providers, care coordinators, patients, and their families. Rural communities can use health information technology (HIT) to facilitate communication through patient portals, electronic health records, health information exchange, and telehealth. Establishing and using HIT systems requires resources and expertise that may be limited in small provider practices in rural areas. The Telehealth and Health Information Technology in Rural Healthcare topic guide has more information on HIT and resources to support rural implementation.

Healthcare professionals can be reimbursed for coordinating care between appointments for Medicare beneficiaries with two or more chronic conditions. Recognized as Chronic Care Management by the Centers for Medicare & Medicaid Services (CMS), services can include communicating with other providers and coordinating home- and community-based services. See Chronic Care Management for more information on reimbursement.

To learn more about care coordination implementation considerations, see Implementation Considerations for Care Coordination Programs.

Program Clearinghouse Examples

Resources to Learn More

Pathways Community HUB Manual: A Guide to Identify and Address Risk Factors, Reduce Costs, and Improve Outcomes
Helps health professionals and organizations implement the Pathways Community HUB model, a community-based care coordination program that identifies and addresses health risk factors of underserved and vulnerable populations. Discusses the implementation of proven interventions, monitoring performance of workers and evaluating organizational performance.
Organization(s): Agency for Healthcare Research and Quality
Date: 1/2016