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Rural Care Coordination Models and Innovations

These stories feature model programs and successful rural projects that can serve as a source of ideas and provide lessons others have learned. Some of the projects or programs may no longer be active. Read about the criteria and evidence-base for programs included.

Effective Examples

funded by the Federal Office of Rural Health Policy Perinatal Health Partners Southeast Georgia
Updated/reviewed February 2017
  • Need: In the 11 rural southeast Georgia counties, high-risk pregnant women potentially face adverse birth outcomes, including maternal or infant mortality, low birthweight, very low birthweight, or other medical or developmental problems.
  • Intervention: An in-home nursing case management program for high-risk pregnant women in order to maximize pregnancy outcomes for mothers and their newborns.
  • Results: Mothers carry their babies longer and the babies are larger when born, leading to improved health outcomes.

Promising Examples

funded by the Federal Office of Rural Health Policy Healthy Outcomes Integration Team
Updated/reviewed November 2017
  • Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
  • Intervention: This program was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
  • Results: Thus far, 84 clients have received integrated health and mental health services.
funded by the Federal Office of Rural Health Policy Nurse Navigator and Recovery Specialist Outreach Program
Updated/reviewed October 2017
  • Need: To properly address and treat patients who have concurrent substance abuse and chronic healthcare issues.
  • Intervention: A referral system was created that utilizes Community Health Workers (CHWs) in a drug and alcohol treatment setting.
  • Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.
Atlantic General Hospital Patient Centered Medical Home
Added September 2017
  • Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
  • Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
  • Results: From the program’s care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.
funded by the Federal Office of Rural Health Policy Bridges to Health
Updated/reviewed September 2017
  • Need: To reduce barriers to accessing healthcare for migrant farmworkers in the rural areas of Vermont.
  • Intervention: Bridges to Health uses care coordination and health promoters to reduce the barriers to accessing healthcare and provides services and education.
  • Results: Some barriers to accessing healthcare have been reduced or removed for migrant farmworkers in certain counties in Vermont.
Kitsap Mental Health Services: Race to Health!
Added August 2017
  • Need: To improve the physical health of individuals seeking mental healthcare.
  • Intervention: Race to Health! in Washington integrates mental health, substance use disorder treatment, and primary care for individuals with severe mental illness.
  • Results: Race to Health! helps reduce emergency department visits, hospitalizations, and costs (a total savings of $5,144,000 for Medicare patients).
Proactive Palliative Care and Palliative Radiation Model: Making MyCourse Better
Updated/reviewed July 2017
  • Need: To provide palliative care to patients with stage 4 cancer.
  • Intervention: The Emily Couric Clinical Cancer Center in Charlottesville, Virginia, has implemented a three-part program to help these patients manage their symptoms.
  • Results: The Proactive Palliative Care and Palliative Radiation Model enrolled 646 patients during its three-year funding period of 2012-2015.
Reducing Hospitalizations in Medicare Beneficiaries
Added June 2017
  • Need: To reduce hospital readmissions for Medicare patients in rural Kentucky and Tennessee.
  • Intervention: Two quality improvement tools called IMPACT and INTERACT helped older patients transition from Vanderbilt University Medical Center to a skilled nursing facility.
  • Results: Practitioner follow-up visits have increased, while emergency department visits have decreased.
funded by the Federal Office of Rural Health Policy MI-Connect Community Health Worker Program
Updated/reviewed March 2017
  • Need: To improve healthcare access for rural Michigan residents managing chronic diseases.
  • Intervention: Community health workers (CHWs) were used to link chronically ill patients with the healthcare services in the Michigan counties of Alcona, Iosco, Arenac, Ogemaw, and Oscoda.
  • Results: This program has provided assistance to more than 400 individuals in the 5-county service area.
Northland PACE (Program of All-Inclusive Care for the Elderly)
Updated/reviewed January 2017
  • Need: Older adults who are nursing home eligible need assistance in order to remain living safely and independently in their own homes.
  • Intervention: Northland PACE (Program of All-Inclusive Care for the Elderly) offers, plans, and coordinates a wide range of healthcare, in-home, and day center services to promote independence at home.
  • Results: Older adults remain safely in their homes for a longer period of time with this support. The PACE program sites in North Dakota work to preserve, enhance, and, in many cases, restore the independence, health, and well-being of their participants.
Patient Care Connect
Added September 2016
  • Need: Cancer patients living in the Deep South encounter multiple barriers in accessing regular cancer treatment.
  • Intervention: The University of Alabama at Birmingham Comprehensive Cancer Center developed a program that uses patient navigators to support and direct patients to appropriate resources to overcome barriers to accessing care.
  • Results: The program has become a model for improving cancer care quality, decreasing unnecessary utilization (ER visits and hospitalizations), removing barriers to care, and enhancing patient satisfaction.
funded by the Federal Office of Rural Health Policy High Plains Community Health Center Care Teams
Updated/reviewed October 2015
  • Need: To meet demand for health care with a limited number of physicians, in a region where recruiting additional providers was impractical
  • Intervention: Implement care teams of 3 medical assistants to support each provider, with additional patient support through health coaches
  • Results: More patients seen per provider hour, with improved patient outcomes and clinic cost savings
funded by the Federal Office of Rural Health Policy Prevention through Care Navigation Outreach Program
Added October 2015
  • Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
  • Intervention: Community Health Workers were utilized to create a system of coordinated care in the counties of Montrose, Ouray, and San Miguel.
  • Results: 1,192 people were screened for diabetes and cardiovascular disease. As a result, many at-risk patients lowered their cholesterol levels and blood pressure through this program.

Other Project Examples

funded by the Federal Office of Rural Health Policy Chautauqua Health Connects (CHC)
Updated/reviewed December 2017
  • Need: To address care coordination and the integration of services in a rural, aging population
  • Intervention: This program used health information technology and dedicated staff to manage clinical and community services for patients with complex needs.
  • Results: Hospital readmissions have decreased, follow-up rates have increased, and patients' perceived health status has improved.
Beacon Health Accountable Care Organization
Updated/reviewed November 2017
  • Need: To implement coordinated healthcare to improve patient health, increase patient engagement, and reduce the overall cost of medical services in Maine.
  • Intervention: The Beacon Health Network was launched to focus on patient-centered care to improve overall wellness and reduce ever-increasing healthcare costs.
  • Results: Through care coordination, Beacon Health has improved provider efficiency, increased healthcare quality, and lowered costs for patients.
funded by the Federal Office of Rural Health Policy The Community Care Alliance
Updated/reviewed November 2017
  • Need: Rural healthcare networks in Colorado and Washington felt the urgency to help their communities improve population health with better care at lower cost.
  • Intervention: The Community Care Alliance was formed to specifically serve Accountable Care Organizations (ACOs), employer groups, and other patient populations. Benefits for participants include quality improvement and practice transformation activities, comprehensive care coordination, outcomes measurement with quality reporting and data extraction, and analytics.
  • Results: A total of 43 organizational members have received educational, networking, and technical assistance by being a part of the Alliance. Over 22,000 Medicare beneficiaries have been introduced to care coordination, leading to a decrease in emergency room visits, an increase in overall health, and lower medical costs.
Safety Net Medical Home Initiative
Updated/reviewed October 2017
  • Need: To help healthcare providers serving underserved and vulnerable populations become patient-centered medical homes (PCMH).
  • Intervention: A 5-year project was launched to develop a replicable model for practice transformation for safety net providers, including rural practices.
  • Results: Eighty-three percent of participating safety net clinics earned state or national PCMH recognition as of September, 2013.
funded by the Federal Office of Rural Health Policy Medical Home Plus
Updated/reviewed September 2017
  • Need: To help reduce diabetes, depression, and stroke risk in rural residents.
  • Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
  • Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.
Illinois Rural Community Care Organization
Updated/reviewed August 2017
  • Need: To improve value-based care and organize the efforts of rural Illinois' independent providers with a shared vision of population health management.
  • Intervention: A Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) was established that participates in federal and state repayment programs.
  • Results: The newly formed ACO is one of the first statewide ACOs to establish local care coordination programs that encompass hospital, clinic and practice settings.
funded by the Health Resources Services Administration Outer Cape Health Services Community Resource Navigator Program
Updated/reviewed August 2017
  • Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance abuse services while reducing the burden and costs to town agencies, hospital emergency rooms.
  • Intervention: The Community Resource Navigator Program works with local social services and town agencies, faith-based institutions, hospitals, the criminal justice system, and others to identify and connect clients to needed services.
  • Results: Clients are gaining access to the care they were once lacking. The program also helps community partners and stakeholders work together to reduce the impact of risks associated with behavioral health symptoms, substance use disorder, and social determinants of health.
Maryland Faith Health Network
Updated/reviewed May 2017
  • Need: To coordinate formal and informal community-based caregivers for optimal patient experience.
  • Intervention: The Maryland Faith Health Network unites places of worship and healthcare systems in Maryland. This program aims to decrease the amount of potentially avoidable hospitalizations, improve a patient's overall wellness, and cut down on the cost of medical services.
  • Results: This model is currently running in 3 hospitals that serve both rural and urban residents in central Maryland. So far, 68 Christian, Jewish, and Muslim congregations as well as 1,300 congregants have enrolled in the Network.
Patient Centered Medical Home Practicum in Primary Care
Updated/reviewed May 2017
  • Need: Improvement in service quality and patient experience in primary care practices in North Carolina's Blue Ridge region.
  • Intervention: A practicum for healthcare management students to help rural practices achieve Patient Care Medical Home (PCMH) status and identify quality improvement strategies.
  • Results: Rural primary practices have achieved PCMH status and Blue Quality Physician Program Recognition.
funded by the Health Resources Services Administration West Virginia Community Access Program
Updated/reviewed May 2017
  • Need: Safety net organizations providing healthcare for the uninsured and underinsured in rural south central West Virginia were experiencing fragmented, inefficient care delivery issues.
  • Intervention: Multi-community program for efficient coordination and integration of healthcare services for uninsured and underinsured patients.
  • Results: Safety net providers improved overall quality of care for uninsured and underinsured patients by resource sharing, and improved efficiencies in coordinating patient care.
Heartland OK
Added October 2016
  • Need: Over 9,000 people in Oklahoma die from heart disease each year.
  • Intervention: Heartland OK, which began in 5 rural counties, is a care coordination model that works to reduce heart disease and stroke risks for patients.
  • Results: 25% of patients met their hypertension goals within 90 days.
Becoming the Chautauqua Region Rural Accountable Care Organization
Updated/reviewed June 2016
  • Need: Better care coordination among healthcare facilities and community-based services in order to achieve cost savings and higher quality healthcare for the patients.
  • Intervention: The development of an Accountable Care Organization.
  • Results: Quality performance metrics have continued to improve each year and cost savings have been achieved.
Total HEALTH
Added April 2016
  • Need: A facility that offers both behavioral and primary healthcare services for the ease of patients in Northwestern Pennsylvania.
  • Intervention: A pilot project was launched at one behavioral health facility that added a primary care and pharmaceutical component to provide a one-stop shop for patients.
  • Results: Patients have become more willing to follow through with treatment plans and attend appointments. Partnering healthcare facilities have also experienced positive medical outcomes of enrolled patients.
Recovery-Oriented System of Care (ROSOC)
Updated/reviewed January 2016
  • Need: To serve adults in Mendocino County, California with chronic substance use disorders, mental health diagnoses, and/or complex medical conditions who frequently utilize emergency departments and jail services.
  • Intervention: A safety net organization was formed that works with medical providers and law enforcement to reduce the high cost of caring for frequent utilizers through intensive care coordination activities.
  • Results: Greater overall stability in the lives of clients, with less utilization of low-efficacy, crisis-oriented services, hospitalizations, and incarcerations.
Senior CommUnity Care
Updated/reviewed January 2016
  • Need: Many older adults need some assistance in order to remain independent in their homes.
  • Intervention: A PACE (Program of All-Inclusive Care for the Elderly) provides healthcare services and support for older adults living in the western rural counties of Delta and Montrose in Colorado.
  • Results: Allows older people in western Colorado to maintain their independence in their own homes with a higher quality of life.
funded by the Federal Office of Rural Health Policy Community Connections Program at Hidalgo Medical Services
Added December 2015
  • Need: To provide prevention and self-management healthcare education to rural Grant and Hidalgo counties in New Mexico.
  • Intervention: A community program was created to improve knowledge and skills related to chronic disease prevention and management.
  • Results: Increased chronic condition knowledge and self-care management.
SAMA HealthCare Services, a Patient-Centered Medical Home
Added December 2015
  • Need: The traditional model where providers work independently from one another in treating patients proved to lack care continuity at SAMA Healthcare Services in rural Arkansas.
  • Intervention: The family practice clinic shifted to a team-based model of care where the medical staff works together in pods in order to create a patient-centered medical home.
  • Results: SAMA doubled the amount of patients seen in 1 day and at least 90% of patients receive medical treatment from a provider within their pod.
SERving PAtients-ACO (SERPA-ACO)
Added November 2015
  • Need: To lower the cost, improve the quality, and increase the coordination of patients' healthcare in rural Nebraska.
  • Intervention: Approved by CMS in January 2013, nine clinics across the state of Nebraska came together to form an Accountable Care Organization (ACO).
  • Results: Patient-centered medical homes were established that reduced hospitalizations and unnecessary medical procedures.
Trinity Pioneer ACO
Added November 2015
  • Need: American healthcare is transitioning from fee-for-service models to valued-based payment models, and communities could fall behind the changing national trend.
  • Intervention: The Trinity ACO was formed in rural Iowa after being selected by the Center for Medicare and Medicaid Innovation as 1 of the 32 Medicare Pioneer Accountable Care Organizations.
  • Results: Trinity continues to focus on palliative medicine, produce effective strategies in distributing value-based services, and works closely with government bodies to construct federal ACO methodology, especially when it comes to rural-specific organizations.

Last Updated: 12/6/2017