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Rural Care Coordination Resources

Selected recent or important resources focusing on Rural Care Coordination.

Meadville Medical Center: Care Coordination for Adults and Children
Describes the Meadville Medical Center Community Care Network (CCN), an interdisciplinary team of clinicians who focus on using care coordination to help patients manage chronic conditions and achieve their health and wellness goals. CCN's goal is to engage patients and encourage them to take ownership of their health, thereby reducing hospital readmissions, conserving resources, and improving the health of the population.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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Improving Healthcare Value in Rural America
Identifies and explains the challenges facing rural communities as they work to improve healthcare value. Discusses the distinct differences between urban and rural value initiatives, highlights promising strategies for achieving rural value, and makes the case for using customized approaches rather than one-size-fits-all models.
Date: 10/2017
Type: Document
Sponsoring organization: Healthcare Value Hub
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Mountain-Pacific Quality Health Pilot: Closing the Gaps in Rural Complex Care
Profiles Mountain-Pacific Quality Health, a nonprofit corporation working to connect rural residents of Montana's Flathead Valley with high quality care. Mountain-Pacific is part of a pilot program aimed at improving the health of high-need, rural patients through the use of technology and interdisciplinary care teams. Mountain-Pacific also received a $1 million innovation award from the Center for Medicare and Medicaid Innovation to support their use of ReSource Teams and help care for high-cost, high-need Medicare patients in the region.
Date: 10/2017
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Coordinated Whole-Person Care that Addresses Social Determinants of Health
Presents approaches used and lessons learned from five projects funded by Data Across Sectors for Health (DASH) - an initiative to align various health-related sectors and promote the collection, sharing, and effective use of data. Each DASH project is working to develop the infrastructure necessary to support cross-sector data sharing, enhance care coordination, and address social determinants of health. One of the five projects is based on the White Earth Indian Reservation in rural northwest Minnesota.
Date: 09/2017
Type: Document
Sponsoring organization: Data Across Sectors for Health
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State Innovation Models (SIM) Initiative Evaluation: Model Test Year Three Annual Report
Third annual report detailing the findings of CMS's State Innovation Models (SIM) Initiative, which tests the ability of the governments in six states - Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont - to accelerate health system transformation in the areas of delivery systems, payment models, information technology, workforce development, and more. Focuses on sharing cross-state progress and findings, state-specific findings and lessons learned, and lessons for policymakers. Additional emphasis is placed on monitoring healthcare experience, utilization, and expenditures in participating SIM states.
Date: 09/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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State Innovation Models (SIM) Round 2: Model Design Final Report
Shares results from a federal evaluation of the Round 2 State Innovation Models (SIM) Initiative awards. Provides a summary and review of each awardees' final State Health System Innovations Plan (SHSIP). Includes several suggestions and recommendations for improving rural healthcare delivery, payment, and access.
Date: 08/2017
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Providing Patient-Centered Enhanced Discharge Planning and Rural Transition Support: Building a Rural Transitions Network Between Regional Referral and Critical Access Hospitals
Manual describing procedures used in Western Montana to develop a model improving likelihood of a good recovery for patients and decreasing chances of re-hospitalization. Includes a guide to ethical considerations in discharge and rural transition planning.
Author(s): Tom Seekins, Heidi Boehm, Jennifer Wong, Linda Yearous, AnnaJean Smith
Date: 08/2017
Type: Document
Sponsoring organization: Rural Institute for Inclusive Communities
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Transitions in Care among Rural Residents with Congestive Heart Failure, Acute Myocardial Infarction, and Pneumonia
Findings brief examining continuum of care of Medicare patients as they are transferred from a hospital to another facility. Features statistics including patient residence and condition, admitting facility type, proportion of hospitalizations with a transfer, transfer patterns, and discharge status following transferred admission, with breakdowns by urban and rural locations.
Author(s): Kevin J. Bennett, Jarrod Bullard, Yu-Hsiu Lin, Janice C. Probst
Date: 08/2017
Type: Document
Sponsoring organization: South Carolina Rural Health Research Center
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Medical Home Plus
Video featuring the Medical Home Plus project, which works to reduce diabetes, depression, and stroke risk in rural Idaho via a collaborative care model and a medical home model.
Date: 08/2017
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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State Innovation Model Testing Awards From the Center for Medicare & Medicaid Innovation: Highlighting Rural Focus
Summarizes the activities and accomplishments of rural-specific State Innovation Models (SIM) in six states: Arkansas, Colorado, Idaho, Oregon, Minnesota, and Vermont. The SIM initiative was started in 2012 to support states that are committed to designing and testing strategies for payment model and delivery system reform.
Date: 07/2017
Type: Document
Sponsoring organization: Rural Health Value
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Community Hospitals Thrive Under ACO Model
Analysis of 2014 and 2015 cost report data from community hospitals participating in Accountable Care Organizations (ACOs) supported by Caravan Health. Results are used to show the impact of ACO participation on community hospitals' gross inpatient revenue, gross outpatient revenue, and net patient revenue.
Date: 07/2017
Type: Document
Sponsoring organization: Caravan Health
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Rural Health Philanthropy Partnership: Leveraging Public-Private Funds to Improve Health
Highlights the work of two grantees funded through the Rural Health Care Coordination Network Partnership Program, a combined effort of the Federal Office of Rural Health Policy and philanthropy organizations. Discusses how the coordinated efforts of the grantees and their philanthropy partners benefit patients.
Author(s): Kay Miller Temple
Location: Rural Monitor
Date: 05/2017
Type: Document
Sponsoring organization: Rural Health Information Hub
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Building Partnerships: Articulating the Value of Care Coordination
Webinar discussing Accountable Communities of Health (ACH) and how to build partnerships to support coordinated care. Includes an explanation and demonstration of the value proposition tool, which helps organizations articulate what the target market really cares about for each product and service. Value proposition worksheet and value proposition canvas diagram also available. 90 minutes.
Additional links: Audio Recording, Presentation Slides, Webinar Recording
Author(s): Kap Wilkes, Debra Laine
Date: 02/2017
Type: Video/Multimedia
Sponsoring organization: National Rural Health Resource Center
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Characteristics of Primary Care Physicians in Patient-centered Medical Home Practices: United States, 2013
Describes the characteristics of primary care physicians participating in patient-centered medical home (PCMH) practices. Includes charts and graphs to help visualize the differences between PCMH practices and non-PCMH practices. Figure 2 presents data on the percentage of primary care physicians in PCMH practices, comparing them by location in metropolitan or non-metropolitan statistical area.
Author(s): Esther Hing, Ellen Kurtzman, Denys T. Lau, Caroline Taplin, Andrew B. Bindman
Date: 02/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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Payment and Delivery System Reform in Medicare: A Primer on Medical Homes, Accountable Care Organizations, and Bundled Payments
Describes three payment models that the Centers for Medicare and Medicaid Services (CMS) is currently testing within Medicare - medical homes, Accountable Care Organizations (ACOs), and bundled payments. Reviews each model in terms of goals, financial incentives, scope, and potential. Also discusses the early results of each payment model, and how they fit in the larger context of transitioning to value-based care, with the goal of improving quality and reducing cost.
Author(s): Susan Baseman, Cristina Boccuti, Marilyn Moon, Shannon Griffin, Tania Dutta
Date: 11/2016
Type: Document
Sponsoring organization: Kaiser Family Foundation
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Spread of Accountable Care Organizations in Rural America
Uses data through December 2015 to reveal trends in rural Medicare Accountable Care Organization (ACO) activity, and discusses motivations behind the recent increase in rural ACO participation. Includes maps of ACO presence by county, which illustrate changes that occurred between 2013 and 2015.
Author(s): Keith Mueller, Fred Ullrich
Date: 10/2016
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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State Innovation Models (SIM) Initiative Evaluation: Model Test Year Two Annual Report
Second annual report detailing the findings of CMS's State Innovation Models (SIM) Initiative, which tests the ability of the governments in six states - Arkansas, Maine, Massachusetts, Minnesota, Vermont, and Oregon - to accelerate health system transformation in the areas of delivery systems, payment models, information technology, workforce development, and more. Presents results from the second of three planned site visits to the states, including interviews, focus groups, and surveys. Connections made throughout to issues specifically affecting rural healthcare.
Date: 08/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Costs of Accountable Care Organization Participation for Primary Care Providers: Early Stage Results
Analyzes data from 2012 and 2013 Medicare cost reports to determine whether joining an Accountable Care Organization (ACO) is associated with an increase in a Rural Health Clinic's (RHC) per visit cost, particularly during the first two years of participation.
Author(s): Richard A. Hofler, Judith Ortiz
Location: BMC Health Services Research, 16(315)
Date: 07/2016
Type: Document
Sponsoring organization: BioMed Central
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National Healthcare Quality and Disparities Chartbook on Care Coordination
A summary of trends in Care Coordination from the National Healthcare Quality and Disparities Report (QDR) for 2015. Includes data and statistics by metropolitan statistical area with a focus on groups with disparities in care coordination regarding hospital and emergency department visits, discharge, readmission, use of ED for chronic health care and potentially avoidable hospitalizations. Also highlights the use of electronic health records and electronic exchange and how that affects care coordination and quality.
Date: 06/2016
Type: Document
Sponsoring organization: Agency for Healthcare Research and Quality
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The Continuing Spread of ACO Presence in Rural Places
Discusses the participation and characteristics of non-metropolitan health practice sites in Medicare Accountable Care Organizations (ACOs) throughout the U.S. Slides from a presentation given May 11, 2016, at the National Rural Health Annual Conference in Minneapolis, MN.
Author(s): Keith Mueller
Date: 05/2016
Type: Presentation Slides
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists
Discusses a care coordination project that included 3 Federally Qualified Health Centers (FQHCs) and 502 patients in rural West Virginia, and a tertiary care referral hospital in southern West Virginia to determine if expanded use of care coordinators and clinical pharmacists could improve the care experience and healthcare outcome of dual eligible patients.
Author(s): Daniel Doyle, Mary Emmett, Amber Crist, Craig Robinson, Michael Grome
Location: Journal of Primary Care & Community Health, 7(2) 118-121
Date: 04/2016
Type: Document
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Rural ACO Leaders Speak: What Have Been the Biggest Challenges and the Biggest Advantages to Creating Your ACO?
Five rural Accountable Care Organization (ACO) leaders discuss the biggest challenges and advantages they've experienced in building an ACO.
Author(s): Zachary Toliver
Location: Rural Monitor
Date: 03/2016
Type: Document
Sponsoring organization: Rural Health Information Hub
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Accountable Care Organizations: Looking Back and Moving Forward
Identifies key lessons from Accountable Care Organization (ACO) activities from their inception through 2015, examines how ACOs can build on successes, and informs policymakers and others about ways to further the development of effective ACOs. Includes a brief overview of virtual and rural ACO development.
Author(s): Rob Houston, Tricia McGinnis
Date: 01/2016
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Upper Middle Tennessee Rural Health Network
Describes the Upper Middle Tennessee Rural Health Network which brings together hospitals, clinics, and other healthcare providers in rural Tennessee to improve the care they provide to their communities through care coordination. Another aim of the network is to prepare and position member providers for future participation in alternative payment models such as bundling and Accountable Care Organizations.
Date: 2016
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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ENHANCE Health Network
Describes the ENHANCE Health Network based in Lincoln, Nebraska that has grown to include 66 healthcare systems and hospitals to improve the health of communities they serve through care integration and coordination.
Date: 2016
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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ACO Investment Model, Rural Hospital Collaboration
Describes the implementation of the Center for Medicare & Medicaid Services' Accountable Care Organization Investment Model (AIM) among three rural Minnesota healthcare systems. The AIM model was designed to encourage health systems in rural and underserved areas to participate in the CMS Shared Savings Program by providing upfront and ongoing payments to support infrastructure and the redesign of care processes.
Date: 2016
Type: Document
Sponsoring organization: American Hospital Association Section for Small or Rural Hospitals
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Senior Housing and Services: Challenges and Opportunities in Rural America
Summary report of a panel of housing and health experts convened to discuss needs, barriers, and experiences with aging in place, and feasibility of programs to support independence for rural seniors. Includes discussion of emerging trends and potential service models.
Date: 10/2015
Type: Document
Sponsoring organization: U.S. Department of Housing and Urban Development
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Converging Forces, Emerging Opportunities
Slides from a July 2015 NRHA Rural Quality Forum presentation addressing the transition from volume- to value-based care. Describes opportunities from this transition, including payment, care delivery, and governance redesign to improve quality outcomes in rural areas. Identifies resources and strategies rural healthcare systems can use to transition from volume to value.
Author(s): Jennifer P. Lundblad
Date: 07/2015
Type: Presentation Slides
Sponsoring organization: Stratis Health
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Care Coordination in Rural Communities: Supporting the High Performance Rural Health System
Examines current care coordination programs and processes to see how they impact rural communities, and determine how well different approaches to care coordination are working. Also makes policy recommendations that support care coordination and help facilitate a high performance rural health system.
Author(s): Charles Alfero, Andrew Coburn, Jennifer Lundblad, et al.
Date: 06/2015
Type: Document
Sponsoring organization: Rural Policy Research Institute Rural Health Panel
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An Overview of the Patient-Centered Medical Home for Rural Patients, Caregivers, and Healthcare Stakeholders
Summary of a project designed to prepare rural stakeholders to participate in comparative effectiveness research (CER), obtain baseline information to learn more about patient-centered medical homes from a rural perspective, select an area in need of CER, and create channels for sharing those results.
Date: 05/2015
Type: Document
Sponsoring organization: University of Kansas School of Social Welfare Center for Children and Families
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CPC Practice Spotlights
A collection of short features on primary care practices participating in the CMS Comprehensive Primary Care (CPC) initiative, a multi-payer initiative offering population-based care management fees and shared savings opportunities to participating practices. Includes examples of participating practices that serve rural areas.
Date: 01/2015
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
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Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace
Discusses the results from a survey of rural health clinics (RHC) that identified their capability to be eligible as a NCQA Patient-Centered Medical Home (PCMH) and examines the need for technical assistance and support of RHCs in the development of the PCMH model.
Author(s): John Gale, Zach Croll, David Hartley, Andrew F. Coburn
Date: 01/2015
Type: Document
Sponsoring organization: Maine Rural Health Research Center
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Grantee Directory: Rural Health Care Coordination Network Partnership Grant Program, 2015-2018
Provides contact information and brief overviews of the 8 initiatives funded under the Rural Health Care Coordination Network Partnership Grant Program in the 2015-2018 funding cycle. The initiatives focus on care coordination activities for diabetes, congestive heart failure, and chronic obstructive pulmonary disease.
Date: 2015
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Rural Health Networks and New Forms of Governance
Profiles Wilderness Health, a formal network of rural and urban independent hospitals in Minnesota focused on performance improvement. The network participates in the Integrated Health Partnership, Minnesota’s Medicaid Accountable Care Organization (ACO) model.
Date: 2015
Type: Document
Sponsoring organization: Rural Health Value
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Rural Accountable Care Organization Care Coordination
Profile of the MaineHealth Accountable Care Organization (MHACO), which uses regional teams to provide care coordination to patients with complex medical profiles.
Date: 2015
Type: Document
Sponsoring organization: Rural Health Value
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State Innovation Models (SIM) Initiative Evaluation: Model Test Base Year Annual Report
First annual report on 6 states - Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont - that received federal support in the first round of the State Innovation Model (SIM) initiative to design and implement health care innovation plans. Presents results of the first site visits to the states, including information from interviews and focus groups, and baseline data on care coordination, quality of care, healthcare utilization, and healthcare expenditures. Includes some discussion of issues specific to rural healthcare.
Date: 11/2014
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Transforming Care for Vulnerable Populations: Lessons from the Safety Net Medical Home Initiative
Thematic issue focused on the Commonwealth Fund's Safety Net Medical Home Initiative (SNMHI), a project to develop a replicable approach for establishing a patient-centered medical home (PCMH) in practices serving vulnerable and underserved populations. SNMHI included rural practices and the articles included in this issue are applicable to rural facilities.
Location: Medical Care, 52(11), S1-S63
Date: 11/2014
Type: Document
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How 3 Rural Safety Net Clinics Integrate Care for Patients: A Qualitative Case Study
Case study of two Rural Health Clinics and one rural Federally Qualified Health Center that were part of the Commonwealth Fund's Safety Net Medical Home Initiative (SNMHI), a project to implement and evaluate the patient-centered medical home (PCMH). Reports on challenges encountered related to a transition to team-based care and practical approaches for rural care coordination.
Author(s): Sarah Derrett, Kathryn E. Gunter, Robert S. Nocon, et al.
Location: Medical Care, 52(11), S39-S47
Date: 11/2014
Type: Document
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Transforming the Workforce to Provide Better Care: The Role of Obstetric Nurse Coordinators in North Carolina
A case study describing how nurses are helping improve prenatal care for high-risk pregnant women via North Carolina's statewide Medicaid Pregnancy Medical Home (PMH) program. Includes a section on support for rural practices participating in the PMH program.
Author(s): Mary Takach, Rachel Yalowich
Date: 09/2014
Type: Document
Sponsoring organizations: AARP Public Policy Institute, National Academy for State Health Policy
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The Role of Hospitals in Medical Home Initiatives and Strategies to Secure their Support and Participation
Discusses the spread of the Patient Centered Medical Home (PCMH) initiative and the associated pressures and challenges with adoption of the new payment and delivery system for hospitals. Makes the case for the new approach, clarifies the hospitals' role in a PCMH, and offers strategies to successfully secure hospitals' support and participation. It specifically recognizes the unique considerations for small/rural and Critical Access Hospitals when securing support and participation in medical home initiatives.
Author(s): Charles Townley, Kimm Mooney
Date: 09/2014
Type: Document
Sponsoring organization: National Academy for State Health Policy
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Care Coordination Comparative Matrix
Identifies rural health networks that are developing or implementing value-based models and recaps brief interviews with the network leaders that are implementing or developing care coordination initiatives. The matrix allows rural health networks to share features and lessons learned through the process of implementing the care coordination programs with one another.
Date: 08/2014
Type: Document
Sponsoring organization: National Rural Health Resource Center
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An Interview with John Halfen, MD
Halfen, the Medical Director of Lakewood Health System in Staples, Minnesota, discusses the challenges of transitioning to a patient centered medical home model.
Author(s): Beth Blevins
Location: Rural Monitor, 2014(Summer)
Date: 08/2014
Type: Document
Sponsoring organization: Rural Health Information Hub
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State Innovation Models (SIM) Initiative Evaluation: Model Design and Model Pre-Test Evaluation Report
Reports on the experiences of 19 states that received federal support to work on state health care innovation plans focused on developing innovative healthcare delivery and payment models. Discusses rural concerns in these states, as well as strategies to address rural healthcare needs. Some topics addressed include patient-centered medical homes, accountable care organizations, workforce, broadband access, electronic health record adoption, and telehealth.
Date: 07/2014
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Realizing Rural Care Coordination: Considerations and Action Steps for State Policy-Makers
This brief draws from health initiatives undertaken in Alabama, Colorado, Montana, New Mexico, North Carolina, and Vermont to identify common policy considerations and action steps for coordinating care in rural areas.
Author(s): Michael Stanek, Carrie Hanlon, Tess Shiras
Date: 03/2014
Type: Document
Sponsoring organization: Robert Wood Johnson Foundation
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Seizing the Opportunity: Early Medicaid Health Home Lessons
Compiles the findings from states that were early adopters of health homes in urban and rural settings, and provides recommendations for states wanting to develop their own health home programs.
Author(s): Kathy Moses, Brianna Ensslin,
Date: 03/2014
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Supporting Iowa Rural Provider Capacity Through Community Care Coordination Teams
Provides an overview of a collaborative effort between Medicaid and safety net providers in establishing a community care coordination team pilot in Iowa to demonstrate success for implementation in other states. Care-coordination teams are growing in popularity to build provider capacity and improve quality of care in small and rural communities.
Author(s): Mary Takach
Date: 02/2014
Type: Document
Sponsoring organization: National Academy for State Health Policy
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Physicians Assemble: Integrating Small Groups to Preserve Independent Practice
Discusses how small practices, including rural, are combining together as networks to provide value-based care, and at the same time are able to keep some autonomy.
Author(s): David Twiddy
Location: Family Practice Management, 20(6), 12-17
Date: 11/2013
Type: Document
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Effects of Patient-Centered Medical Home Attributes on Patients' Perceptions of Quality in Federally Supported Health Centers
Analyzes patient survey results that rated the quality of care and the patient-centered medical home attributes provided at federally supported health centers in both rural and urban locations.
Author(s): Lydie A. Lebrun-Harris, Leiyu Shi, Jinsheng Zhu, et al.
Location: Annals of Family Medicine, 11(6), 508-516
Date: 11/2013
Type: Document
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Rural Service Delivery Integration and Patient Engagement
Profile of Aligning Forces Humboldt, a care coordination and patient engagement initiative in rural Humboldt County, California. The initiative focuses on patient engagement, reduction of unnecessary surgery, and care management for frequent users of the emergency department.
Date: 09/2013
Type: Document
Sponsoring organization: Rural Health Value
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The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships
Explains how small and rural hospitals and their systems can develop community and other partnerships to effectively implement population health management and improve their community's health status. Includes five case studies.
Date: 06/2013
Type: Document
Sponsoring organization: Health Research & Educational Trust
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Care Management for Medicaid Enrollees Through Community Health Teams
Presents data from a 2011–2012 review of state Medicaid medical home programs in eight states. Identifies community health team programs including FQHCs and RHCs that provide an array of services, including care coordination to self-management coaching. Includes small or rural practices.
Author(s): Mary Takach, Jason Buxbaum
Date: 05/2013
Type: Document
Sponsoring organization: Commonwealth Fund
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What is a Patient-Centered Medical Home?
As defined by the National Committee for Quality Assurance (NCQA), a patient-centered medical home is a model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship.
Location: Rural Monitor, 2013(Winter)
Date: 02/2013
Type: Document
Sponsoring organization: Rural Health Information Hub
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Care Coordination Keeps Patients, Providers in the Loop
Provides an update on three providers' coordinated care services and the progress they've made since their stories were first published in the Rural Monitor. Includes programs in North Carolina, Idaho, and Missouri.
Author(s): Candi Helseth
Location: Rural Monitor, 2013(Winter)
Date: 02/2013
Type: Document
Sponsoring organization: Rural Health Information Hub
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Health Homes for Medicaid Beneficiaries with Chronic Conditions
Profiles four states that were the first to receive federal approval to take up a state option under the Affordable Care Act to implement health homes for Medicaid beneficiaries with chronic conditions. Focuses on Missouri, Rhode Island, New York, and Oregon. Mentions rural throughout.
Date: 08/2012
Type: Document
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
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Care Coordination in Rural Communities: Preliminary Findings on Strategies Used at 3 SNMHI Sites
Recorded webinar presenting an overview of case studies conducted at three rural clinics participating in the Safety Net Medical Home Initiative. Includes similarities, differences, and highlights in how the three clinics implemented the care coordination change concept. One hour in length.
Author(s): Sarah Derrett, Katie Gunter
Date: 07/2012
Type: Document
Sponsoring organization: Commonwealth Fund
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Patient-Centered Medical Home Services in 29 Rural Primary Care Practices: A Work in Progress
Examines the progress of rural primary care practices as they implement the processes and services of Patient Centered Medical Homes (PCMHs) across five domains: access to care, population-based, quality, care management, and clinical information management. Findings are based on responses from a national survey of 29 rural physician practices.
Author(s): A. Clinton MacKinney, Fred Ullrich, Keith J. Mueller
Date: 09/2011
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Developing Federally Qualified Health Centers into Community Networks to Improve State Primary Care Delivery Systems
Highlights three states that are collaborating to build community networks, including small rural practices, to make medical home services available for vulnerable populations to improve their primary care delivery systems.
Author(s): Mary Takach, Jason Buxbaum
Date: 05/2011
Type: Document
Sponsoring organization: National Academy for State Health Policy
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Use of Health Information Technology in Support of Patient-Centered Medical Homes Is Low Among Non-metropolitan Family Medicine Practices
Discusses the concept of a patient-centered medical home (PCMH) and examines if physician practices, especially non-metropolitan primary care practices, are ready to become PCMHs.
Author(s): Keith J. Mueller, Fred Ullrich, A. Clinton MacKinney
Date: 04/2011
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Care Transitions: “Time to Come Home” (Policy Brief)
Examines care coordination with a focus on the transitions from inpatient care back to the rural community and suggests ways of measuring the quality of care coordination on discharge from the hospital.
Author(s): Shailendra Prasad, Jill M. Klingner, Ira Moscovice
Date: 03/2011
Type: Document
Sponsoring organization: Upper Midwest Rural Health Research Center
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Care Transitions: “Time to Come Home” (Full Report)
Examines care coordination with a focus on the transitions from inpatient care back to the rural community and suggests ways of measuring the quality of care coordination on discharge from the hospital.
Author(s): Shailendra Prasad, Jill M. Klingner, Ira Moscovice
Date: 03/2011
Type: Document
Sponsoring organization: Upper Midwest Rural Health Research Center
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The Medical Home: Health Care Access and Impact for Children and Youth in the United States
Study, using data from the HRSA 2007 National Survey of Children’s Health, identifies the number of children who have access to a medical home in both rural and urban locations. Same study also examines disparities in medical home access among racial and ethnic groups.
Author(s): Bonnie B. Strickland, Jessica R. Jones, Reem M. Ghandour, Michael D. Kogan, Paul W. Newacheck
Date: 03/2011
Type: Document
Sponsoring organization: American Academy of Pediatrics
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Medical Homes Offer Comprehensive Care Approach
Describes the successes experienced by two health care centers that offer medical home services to their patients. Advocates in the Community Care of North Carolina and the Lakewood Health System in Staples, Minnesota describe their programs.
Author(s): Candi Helseth
Location: Rural Monitor, 2009(Spring)
Date: 05/2009
Type: Document
Sponsoring organization: Rural Health Information Hub
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Care Management Medicare Reimbursement Strategies for Rural Providers
Information for rural healthcare providers on Medicare billing codes for services to keep beneficiaries healthy and better coordinate services to support beneficiaries at home. Addresses Annual Wellness Visits, Chronic Care Management, and Transitional Care Management.
Type: Website
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, Rural Health Information Hub
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Primary Care Innovations and PCMH Map
Interactive map of the U.S. showing public and commercial programs using patient-centered medical homes (PCMH) and enhanced primary care teams to improve healthcare delivery. Map can be toggled between national, state, and list view, and also provides a description of each program. Programs can be narrowed by using "rural" as a keyword when in list view.
Type: Map/Mapping System
Sponsoring organization: Patient-Centered Primary Care Collaborative
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Integrating Health and Human Services in Rural Communities
April 2016 webinar discussing the newly released Rural Services Integration Toolkit, developed by the NORC Walsh Center for Rural Health Analysis for the Federal Office of Rural Health Policy (FORHP). Focuses on how services integration can be implemented in your community and provides examples of models, resources, and best practices. Presented by Alycia Bayne, Senior Research Scientist at the NORC Walsh Center for Rural Health Analysis; Laura Watters, Network Director of Florissa & Day Services; and Cassalyn David, Community-Clinic Linkages Manager for the Mariposa Community Health Center. 60 minutes.
Additional links: Presentation Slides
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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Rural Services Integration Toolkit
Resources and information to help rural communities integrate health and human services. Describes a range of different program models for service integration. Identifies evidence-based and promising models that have been implemented in rural communities.
Type: Website
Sponsoring organization: Rural Health Information Hub
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Care Coordination: A Self-Assessment for Rural Health Providers and Organizations
Developed to provide a preliminary review of important factors for rural organizations interested in developing, expanding, or enhancing care coordination activities.
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Care Coordination in Rural Communities
February 2014 webinar discussing the Rural Care Coordination Toolkit and provided information on how rural communities can identify and implement a care coordination program. Presented by Alexa Brown, NORC Walsh Center for Rural Health Analysis; Melissa Miles, Bi-State Primary Care Association; and Heidi Blossom, MSN, RN, Care Transitions Coordinator for MHA – An Association of Montana Health Care Providers. 60 minutes.
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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Rural Care Coordination Toolkit
Designed to help identify and implement a rural care coordination program and provide supporting resources and best practices. The toolkit, developed in collaboration with the NORC Walsh Center for Rural Health Analysis, is made up of several modules each concentrating on different aspects of care coordination programs.
Type: Website
Sponsoring organization: Rural Health Information Hub
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State Delivery System and Payment Reform Map
Identifies states with active Medicaid payments to health homes and medical homes underway and describes the related activities in each state.
Type: Website
Sponsoring organization: National Academy for State Health Policy
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Co-Managed Care Toolkit
Designed to address knowledge and communication gaps existing between VA healthcare teams and non-VA teams in cases where veterans utilize both types of providers. Designed to help create a care network for rural veterans.
Type: Website
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Health Homes
Discusses the Affordable Care Act of 2010, Section 2703, which created an optional Medicaid State Plan benefit for states to establish Health Homes to coordinate care for people with Medicaid who have chronic conditions by adding Section 1945 of the Social Security Act.
Type: Website
Sponsoring organization: Centers for Medicare and Medicaid Services
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Integrated Care Resource Center
Helps States learn about best practices for delivering coordinated health care to Medicaid’s high-need, high-cost beneficiaries. 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).
Type: Website
Sponsoring organization: Centers for Medicare and Medicaid Services
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Safety Net Medical Home Initiative
Library of tools and resources to help practices implement the Patient-Centered Medical Home (PCMH) model of care. Includes PCMH assessments, implementation guides and webinars, coaching guides, and a variety of publications on the PCMH model of care.
Type: Website
Sponsoring organization: Qualis Health
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PubMed Search: Rural Care Coordination
Searches PubMed's collection of journal article citations on the topic of care coordination in rural areas.
Type: Literature Search
Sponsoring organization: National Library of Medicine
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NCQA Patient-Centered Medical Home (PCMH) Recognition
Provides information on the patient centered medical home, including the quality standards, content and scoring summary, overview, program training, pricing and fee schedule, and additional medical home resources.
Type: Website
Sponsoring organization: National Committee for Quality Assurance
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National Center for Medical Home Implementation
Works to ensure that children and youth with special needs have a medical home where health care services are accessible and family-centered. Provides access to tools, resources, state specific information, and promising practices in pediatric medical home implementation.
Type: Website
Sponsoring organization: American Academy of Pediatrics
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State Primary Care Offices Directory
Primary Care Offices (PCOs) represent the needs of the underserved populations and the providers who serve them. These offices can provide designation application help and State shortage information as well as information on the Conrad 30 J-1 Visa Waiver program, loan repayment programs, and recruitment and retention.
Type: Directory
Sponsoring organization: Bureau of Health Workforce
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State and Regional Primary Care Associations Directory
Lists address, phone, email, and web addresses for state and regional Primary Care Associations (PCAs). PCAs work to promote, expand, and optimize access to primary care.
Type: Directory
Sponsoring organization: National Association of Community Health Centers
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Additional resources are available related to this guide. See the full list of resources by topic for:


Last Updated: 12/4/2017