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
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 (RurAL CAP). serves homeless
individuals through the Homeless
Outreach program. RurAL CAP
link 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)
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.
Health Worker Model: Uses CHWs who can liaise between the target population and a variety of health,
human, and social services organizations.
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
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
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