Rural Project Examples Addressing Care coordination

Perinatal Health Partnership Southeast Georgia

Updated/reviewed February 2023

Need: In 12 rural southeast Georgia counties, high-risk pregnant individuals 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 individuals 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.

Updated/reviewed December 2024

Need: To properly address and treat patients who have concurrent substance use disorders and chronic healthcare issues.
Intervention: A referral system utilizes community health workers (CHWs) in a drug and alcohol treatment setting. A registered nurse helps with providers' medication-assisted treatment programs.
Results: This program has reduced hospital emergency visits and hospital readmissions for patients since its inception.

Added July 2024

Need: Solutions for Medicare beneficiaries' post-acute care recovery gaps in Arkansas's southeast Delta Region.
Intervention: Supported by federal funding and their membership organization, seven hospitals implemented an evidence-supported Critical Access Hospital transitional care model.
Results: Participating hospitals found a significant increase in swing bed services revenue, an all-cause low readmission rate, high percentage of patients discharged to home or to an assisted living environment, and positive patient satisfaction surveys.

Updated/reviewed March 2024

Need: In Vermont, the growing population of older adults, coupled with a lack of a decentralized, home-based system of care management, poses significant challenges for those who want to remain living independently at home.
Intervention: SASH® (Support and Services at Home), based in affordable housing and their surrounding communities throughout the state, works with community partners to help older adults and people with disabilities receive the care they need so they can continue living safely at home.
Results: Compared to their non-SASH peers, SASH participants have been documented to have better health outcomes, including fewer falls, lower rates of hospitalizations, fewer emergency room visits, and lower Medicare and Medicaid expenditures.

Updated/reviewed December 2022

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, 1,300 congregants from 70 congregations representing Christian, Jewish, and Muslim faiths have enrolled in the Network.

Updated/reviewed May 2020

Need: To reduce the prevalence of diabetes and cardiovascular disease in rural Colorado.
Intervention: Community Health Workers are utilized to create a system of coordinated care in Delta, Montrose, Ouray, and San Miguel counties.
Results: As of 2018, 2,709 people have been screened for diabetes and cardiovascular disease, with many at-risk patients lowering cholesterol, blood pressure, and A1C levels after engaging with a Community Health Worker.

Updated/reviewed November 2024

Need: To reduce rural Oklahoma patients' risks for heart disease and stroke.
Intervention: Heartland OK was a care coordination model in 20 counties.
Results: Using a team-based care model increased patients' ability to reduce their blood pressure or achieve blood pressure control.

Updated/reviewed April 2024

Need: To implement coordinated, integrated, and holistic healthcare to improve patient health and engagement and to reduce the overall cost of medical services in Maine.
Intervention: The Northern Light Health ACO network launched with a focus on patient-centered care to improve overall wellness, reduce healthcare costs, and improve patient engagement and quality.
Results: Through care coordination, Northern Light Health is enhancing provider efficiency and supporting a team approach to delivering care, leading to improved patient engagement and healthcare quality, and lowering the overall cost of care.

Updated/reviewed April 2024

Need: To connect patients to resources in order to reduce use of emergency services, emergency department visits, and hospital readmissions.
Intervention: Patients receive support (by in-person visit, phone call, or telehealth visit) from a paramedic, community health nurse, peer recovery specialist, and pharmacist.
Results: Between July 2016 and March 2024, the program made 1,098 patient contacts and continued to see a reduction in emergency department and inpatient visits and costs.

Added February 2024

Need: To support pregnant or new parents in rural Massachusetts affected by substance use or on medication for opioid use.
Intervention: This program offers a medical and behavioral health home, providing trauma-informed support before, during, and after childbirth.
Results: Six months after enrollment, there was a 20% increase in the number of participants who felt socially connected and a 5% increase in abstinence from all substances.