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Rural Health Information Hub

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

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

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