Care Coordination Models

Care coordinators connect individuals to health and human service programs. 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 Online Library lists hundreds of resources relevant to rural care coordination programs.

Services Provided by Care Coordinators

Appointment scheduling and follow-up
Health education
Patient navigation
Care management
Medication management
Care transition support
Referrals
Self-management support
Linguistically appropriate care
Translation services
Transportation assistance
Community outreach
Program eligibility and enrollment assistance
Linkages to other community-based or social services

Types of Care Coordinators

There are several types of care coordinators, and they are defined by the coordination services they provide. Types of care coordinators may include:

Patient navigators – Provide support and guidance to patients as they navigate the healthcare system.
Care managers – Help to coordinate care, make appointments, and empower patients to reach self-management goals.
Recovery specialists – Lay health workers trained in substance use disorder treatment and recovery. Recovery specialists include peer specialists, who have also had personal experience with substance use.

Several types of roles can involve care coordination responsibilities. For example, community health workers, social workers, and public health nurses might all provide some form of care coordination services within their scope of work.

Community Action Agencies (CAAs) are critical providers of care coordination services in rural communities. CAAs are private and public nonprofit organizations that 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 Rural Alaska Community Action Program, Inc. (RurAL CAP) serves people experiencing homelessness through the Adult Supportive Housing and Unhoused Services program. RurAL CAP 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.
Community Care of North Carolina is a public-private partnership sponsored by the North Carolina Department of Health and Human Services and the North Carolina Division of Medical Assistance. Comprised of 14 regional networks of physicians, nurses, pharmacists, hospitals, health departments, social service agencies and other community organizations, professionals provide care coordination services to individuals with complex health needs through the medical home model.
The Rural Health Models and Innovations sections offers additional rural care coordination project examples.

Types of Care Coordination Program Models

Care coordination programs are designed to meet the unique needs of different people 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.

Accountable Care Organizations (ACOs) Model – Integrates people, information, and resources for patient care activities and creates financial incentives for care coordination.
Community Health Worker Model – Uses CHWs who can liaise between the target group and a variety of health, human, and social services organizations.
Community HUB Model – Creates a central registry of at-risk individuals for a network of care coordination agencies.
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.
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.
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.
Patient-Centered Medical Home Model – Uses a provider-based model for care coordination that can be implemented within a primary care practice.
Supportive Housing Model – Designed to coordinate a range of services for individuals experiencing homelessness.
Wraparound Model – Helps coordinate services for children with significant or complex needs and their families.

Implementation Considerations

It is important for care coordinators to receive training that is specific to the care coordination program being implemented. It is also important for healthcare professionals who work with care coordinators to receive training. These trainings can increase their familiarity of the care coordination program, the role of the care coordinator, and acceptance of care coordinators by the medical team. The Rural Community Health Workers Toolkit offers additional information about training materials.

Training topics for care coordinators may include:

Collaborating with community organizations and partners
Patient navigation
Health literacy
Communication and motivational interviewing
Community resources and referrals
Health education and chronic disease management
HIPAA and confidentiality of patient information
Data systems, evaluation forms, and methods for documentation
Use of social media, if applicable to the program
Home visiting and safety

One of the care coordinator's roles may be to connect patients and families to resources. To do so, it is important for care coordinators to have knowledge of available community resources. Training to familiarize care coordinators with the resources available in the community may include dedicated time for "resource finding" in the community, in which the care coordinators spend time identifying resources. Programs or community organizations may maintain the resources in a central resource directory.

Safety training provides care coordinators with the knowledge necessary to safely and effectively complete their jobs. Safety training is important for care coordinators conducting home visits to protect them from potentially unsafe environments. For example, care coordinators may be required to travel in pairs when conducting home visits in frontier, high-risk, or high-crime areas. Safety trainings for rural care coordination programs may utilize police officers, rather than clinicians or administrators, to convey information to home visiting staff.

Resources to Learn More

Care Coordination: A Self-Assessment for Rural Health Providers and Organizations
Document
Guides rural providers and organizations through the process of assessing the function of care coordination and the role of care coordinators within their organization.
Organization(s): Rural Policy Research Institute, Stratis Health
Date: 2020

Care Coordination Canvas Guide
Website
Assists rural communities in developing a care coordination program. Discusses the importance of care coordination in the new system of paying for value. Includes a guide, tool, case studies, and worksheets.
Organization(s): National Rural Health Resource Center

Small Rural Hospital Transition (SRHT) Project Guide: A Rural Hospital Guide to Improving Care Management: 2019 Update
Document
Describes care management best practices for rural hospitals and competencies a healthcare organization could incorporate to assist in transition from fee-for-service reimbursement to value-based reimbursement.
Organization(s): Stroudwater, National Rural Health Resource Center
Date: 2019