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Care Coordination Model

Care coordinators connect individuals to health and human service programs. The care coordinator may make referrals, develop an individualized care plan, and manage the exchange of information between providers and other human services organizations. Successful care coordination takes into consideration the continuum of health services, education, early child care and early intervention services, nutrition, housing, transportation, and other human services needed to improve the quality of life for people. The Rural Care Coordination Toolkit offers resources and best practices to communities that are seeking to identify and implement a care coordination program.

Community Action Agencies (CAAs) are critical providers of care coordination services in rural communities. CAAs are private and public nonprofit organizations that carry out the work of Community Action Programs, which were authorized by the Economic Opportunity Act of 1964 to promote self-sufficiency among individuals living in poverty. CAAs often offer direct services to community members and employ case managers or case coordinators to connect clients to the appropriate programs.

Examples of Rural Care Coordination Programs

  • The Butte Community Diabetes Network (BCDN), led by the St. James Healthcare Foundation in rural Montana, integrates resources for community members with diabetes through case management services. BCDN established a hotline that serves as a network referral system for healthcare professionals and consumers. The hotline operator provides callers with information about the network’s diabetes classes and support groups, makes appointments for patients, helps patients obtain needed prescriptions, refers patients to community partners for services and resources, conducts health screenings, and communicates with physicians.
  • The Rural Alaska Community Action Program, Inc. serves homeless individuals through the Housing First program. The Housing First Case Manager links participants to a range of health and human services, including rental assistance, medical and behavioral health treatment, employment services, and community support groups.
  • Rural Resources Community Action, which serves counties in rural North and Eastern Washington State, offers case management services to older adults. Case managers work with clients to develop individual care plans and connect them to meal programs and transportation services, among other programs.
  • The U.S. Department of Veterans Affairs offers homeless Veterans and Veterans at risk of homelessness a variety of resources, all available via 1-877-4AID-VET. Services include: the Homeless Providers Grant and Per Diem Program, HUD-VA Supportive Housing (VASH) Program, the Acquired Property Sales for Homeless Providers Program, and the Supportive Services for Veteran Families (SSVF) Program.

Types of Care Coordination Program Models

Care coordination programs are designed to meet the unique needs of different populations and communities. This module identifies seven types of care coordination models that can be used to integrate health and human services. Links to descriptions of each type of care coordination model are below.

  • The Program of All-Inclusive Care for the Elderly (PACE) Model: Designed to integrate care for frail older adults who are eligible for both Medicaid and Medicare.
  • Wraparound Model: Helps coordinate services for children with significant or complex needs and their families.
  • Community HUB Model: Creates a central registry of at-risk individuals for a network of care coordination agencies.
  • Community Health Worker Model: Uses CHWs who can liaise between the target population and a variety of health, human, and social services organizations.
  • Nurse-Family Partnership Model: Pairs first-time mothers with low incomes with maternal and child health nurses in order to promote healthy pregnancies, child development, and economic self-sufficiency.
  • Health Homes Model: Designed to coordinate healthcare and social services for Medicaid and Medicare-Medicaid dual eligible individuals with chronic conditions and mental or behavioral health problems.
  • Mobile Unit Model: Travels to rural communities to increase access to health and human services.
  • Supportive Housing Model: Designed to coordinate a range of services for individuals experiencing homelessness.

Resources to Learn More

Care Coordination
Provides a variety of resources on care coordination including a webinar entitled, Care Coordination in Rural Communities: Preliminary Findings on Strategies Used at 3 SNMHI Sites. This webinar describes key characteristics of three rural clinics and specific roles related to care coordination, as well as some specific examples of care coordination strategies.
Organization(s): Safety Net Medical Home Initiative

Integrated Care Management in Rural Communities
This paper highlights promising strategies for implementing integrated care in rural communities and describes implementation challenges related to relationship building, workforce, and infrastructure.
Author(s): Griffin, E., & Coburn, A.
Organization(s): University of Southern Maine
Date: 5/2014

Jackson Medical Center Improves Case Management Processes
An interview with the Chief Administrative Officer of the Jackson Medical Center in Jackson, AL about creating a case management system to improve patient care.
Organization(s): National Rural Heath Research Center