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Rural Care Coordination

Care coordination is an important activity in providing efficient, quality healthcare. Unfortunately, care coordination activities have not traditionally been reimbursed by payers, so have not been a priority for the American healthcare system. However, in recent years, policymakers and payers have been more supportive of care coordination as a way to improve quality of care while reducing costs.

In rural communities, care coordination can help to address challenges in access to care as well as health disparities. Accountable Care Organizations (ACO) and Patient-Centered Medical Homes (PCMH) are two models being implemented in rural areas that incorporate care coordination.

The Promise of Care Coordination: Transforming Health Care Delivery defines care coordination as:

“a mechanism through which teams of health care professionals work together to ensure that their patients’ health needs are being met and that the right care is being delivered in the right place, at the right time, and by the right person.”

The complexities of the current healthcare system can make coordinating the care a patient receives from different providers and facilities a challenge. According to Care Across Settings: Challenges, Success, and Opportunities, there are four key points where a breakdown in care is most likely to happen:

  • Patient handoffs
  • Follow-up care
  • Ongoing care for those with chronic conditions
  • Care when something goes wrong

A primary focus of care coordination activities is reducing the likelihood of breakdowns in care by increasing communication and information exchange, and monitoring the care given more closely. Through fostering communication among providers, facilitating appropriate care, and reducing duplication, care coordination efforts aim to improve health outcomes and reduce costs.

Frequently Asked Questions


What barriers to care coordination exist in rural areas?

Both rural and urban settings face challenges that can make implementation of a successful care coordination program difficult. According to Care Across Settings: Challenges, Successes, and Opportunities, these challenges include a lack of appropriate reimbursement mechanisms for care coordination under current fee-for-service models, which means that providers have few financial incentives to take ownership of the patient’s care transitions. In addition, a lack of interoperable computer and medical records systems across the care settings inhibits the flow of information between providers

Barriers to Care Coordination in Rural Areas identifies additional challenges to implementing a successful care coordination program that may exist for rural areas, including:

  • Insufficient health insurance coverage
  • Distance as a barrier to accessing healthcare services
  • Low health literacy rates among the patient population
  • Limited access to public health programs

The National Advisory Committee on Rural Health and Human Services’ Options for Rural Health Care System Reform and Redesign identifies concern over the need to meet short-term fiscal goals while regulatory and reimbursement frameworks are being restructured and redesigned.


What are Accountable Care Organizations and how are they coordinating care in rural communities?

The Accountable Care Organization (ACO) is a care coordination model advanced in the Affordable Care Act, which established the Medicare Shared Savings Program. According to the Centers for Medicare and Medicaid Services (CMS):

“Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

The model provides financial incentive for all involved to align and coordinate care. Although not required, some ACOs employ care coordinators to provide support services to patients, helping them navigate the range of services they may be receiving. Care coordinators also work to address barriers to efficient treatment, including cultural, language, or transportation barriers.

Many healthcare organizations across the country have established or joined an ACO, including rural healthcare providers. In Development Strategies and Challenges of Rural Accountable Care Organizations, the RUPRI Center for Rural Health Policy Analysis shared insights from rural ACOs. They found that common care management techniques included:

  • identifying high-utilizing patients
  • providing care coordinators
  • directing patients to the most appropriate services, providers, and resources

What is the Patient-Centered Medical Home model and how can it help rural communities?

According to U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Primary Care Collaborative, the patient-centered medical home (PCMH) is a comprehensive, high quality, well-coordinated method of care provision that is focused around the needs of the patient. The PCMH is a provider-based model that is used in primary care settings and often includes care coordination as a central component.

The Patient-Centered Primary Care Collaborative describes the PCMH model as including the following characteristics:

  • Strong relationships between patients and primary care physicians
  • Robust coordination between primary care physicians and clinician teams
  • Strong coordination across healthcare setting
  • Implementation and use of health information technology (HIT)

The National Committee for Quality Assurance (NCQA) is the nation’s largest PCMH certification program. NCQA PCMH accreditation requires components of care coordination and care transitions, as outlined in their PCMH 2014 Standards and Guidelines. Some states have their own PCMH quality recognition in addition to NCQA recognition.

Two examples of how the PCMH model can be implemented in rural areas are the Safety Net Medical Home Initiative (SNMHI) and the Primary Care Quality Improvement Collaborative. SNMHI provides technical assistance and helpful resources to safety net providers, including those located in rural areas, to assist in achieving PCMH accreditation. The Primary Care Quality Improvement Collaborative is a program that supports internships/practicums for healthcare management students that work with rural practices to achieve PCMH recognition and identify quality improvement activities.

Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results 2012 concludes that the PCMH model improves health outcomes, improves patient experience, and reduces expensive, unnecessary services — offering both short- and long-term savings for all stakeholders. This, in turn, addresses racial, socioeconomic, and geographic disparities.

For more information, see the Patient-Centered Medical Home Model in RHIhub's Rural Care Coordination Toolkit.


What is the role of health information technology in rural care coordination?

Health information technology (HIT) is integral to both quality and financial aims of rural healthcare coordination. HIT facilitates communication among the multi-disciplinary healthcare providers through the use of computers that store, protect, retrieve, and transfer information among a number of healthcare settings.

Some care coordination models, such as the Patient-Centered Medical Home, require electronic health record (EHR) implementation for advanced accreditation. HIT aims to accomplish the same informational exchange of care coordination, including:

  • Reducing medical errors and duplicative testing, especially across multiple providers
  • Coordinating information across providers, laboratories, pharmacies and patients
  • Transitioning smoothly between place and provider

HIT is especially important for rural healthcare coordination given the inherent challenges to healthcare access that exist in rural areas, including geographic distances.

HIT adoption by rural providers has grown significantly in recent years, making care coordination more accessible in rural settings, although interoperability challenges remain. To read more about the potential of an efficient HIT system, see the Health Information Technology in Rural Healthcare topic guide.


Where can I find information concerning implementing a care coordination program?

The Rural Health Information Hub’s Rural Care Coordination Toolkit is designed to help identify and implement a care coordination program, providing valuable resources and best practices.

The Integrated Care Resource Center was established to provide technical assistance and share best practices with states developing care coordination programs. The resource center is a joint technical assistance project of the Centers for Medicare & Medicaid Services (CMS) Medicare-Medicaid Coordination Office and the Center for Medicaid, CHIP, and Survey & Certification (CMCS).

Stratis Health has produced a Community-Based Care Coordination Toolkit which provides tools for use at different stages in the development of a program — including how to start a program. Tools focus on people, functions, policy, and processes to achieve success in the community-based care coordination environment.


What are other models that have been used for care coordination in rural communities?

One model for closing the gaps along the healthcare continuum in rural communities is the use of community health workers (CHWs) as care coordinators and patient navigators. CHWs serve as liaisons between a target population and a wide variety of health and human service providers. They are uniquely positioned to bridge the gap between the rural consumers and health services because they are typically members of the community they serve. They help patients by providing resources and information, coordinating transportation to and from medical appointments, and monitoring progress towards health goals. The report Community Health Worker Model for Care Coordination offers some examples of how CHWs are being used to coordinate care for health concerns in rural areas, including chronic disease management, immunizations, and maternal and child health.

For more information about CHWs in a care coordination role, see the Care Coordinator/Manager Model program model listed in RHIhub’s Community Health Workers Toolkit. For a broader discussion of community health workers, see RHIhub’s Community Health Workers in Rural Settings topic guide.

Community paramedicine is a similar model being implemented across rural America to better coordinate care. Community paramedics are trusted emergency medical technicians (EMTs) or paramedics who work in a primary care role in an outpatient setting, in addition to emergency response. For examples of community paramedicine programs in rural areas, information on how to fund and implement a program in your community, or more information in general, see RHIhub's Community Paramedicine topic guide.

For more information on care coordination and resources to help implement a rural care coordination program, see the Program Models section of the Rural Care Coordination Toolkit.


What are interprofessional teams and how are they used in care coordination?

Interprofessional, or interdisciplinary, healthcare teams consist of healthcare professionals from multiple disciplines who work closely together to improve outcomes. The use of interprofessional teams is a very important aspect of most care coordination models.

According to Care Coordination & Older Adults, when care coordination is team-based, interdisciplinary, and operates in open communication, patients feel supported and the quality of care improves.

This team approach often offers a technological component to improve communication among providers, such as health information technology or telehealth services.

In a rural context, the efficiencies that result from the use of interprofessional teams are even more important given chronic shortages of healthcare professionals.

An example of interprofessional teams working in a rural area is High Plains Community Health Center Care Teams.


Last Reviewed: 10/28/2015