Rural Project Examples Addressing Care coordination

Outer Cape Health Services Community Resource Navigator Program

Updated/reviewed March 2023

Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance use disorder services while reducing the burden and costs to town agencies and hospital emergency rooms.
Intervention: The Community Resource Navigator Program works with local social services, 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, as measured by improvements in self-sufficiency. 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.

Updated/reviewed August 2022

Need: Since the late 1800s, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 94% since 2008.

Added April 2021

Need: Population health approach to decreasing area deaths from cardiovascular disease.
Intervention: A health system-level investment in level II cardiac catheterization services and the required specialized cardiology workforce.
Results: Since August 2018, the Avita Health System in north central Ohio has provided local cardiovascular services that have decreased hospital transfers, increased care coordination, and provided education and prevention activities that, with time, will impact population health cardiovascular outcomes.

Updated/reviewed September 2020

Need: Coordinated approach to healthcare delivery in central and southern West Virginia.
Intervention: Creation of a nonprofit organization that focused on quality and collaboration.
Results: With an ability to provide services that meet the evolving needs of patients, providers, and communities, the organization provides unique services, such as a credentialing service and web-based data sharing care management tool.

Updated/reviewed December 2019

Need: Organized effort targeting COPD patients' medical needs in order to prevent hospital readmission in Zanesville, Ohio.
Intervention: Creation of an integrated system model using nurse navigators that incorporates evidence-based chronic disease care management approaches to COPD care.
Results: Improved readmission rates and overall improved acute and chronic care for the area's COPD patients.