Skip to main content
Rural Health Information Hub

Rural Health
Resources by Topic: Care coordination

The Impact of the Vermont Support and Services at Home Program on Healthcare Expenditures
The Support and Services at Home (SASH) program helps rural and urban program participants access healthcare and support services in order to maintain their health and age securely and safely in their homes. Report estimates the impact of the Vermont SASH program on Medicare expenditures.
Author(s): Amy Kandilov, Vince Keyes, Martijn van Hasselt, et al.
Citation: Cityscape, 20(2)
Date: 2018
Type: Document
view details
Connected Care Toolkit: Chronic Care Management Resources for Health Care Professionals and Communities
A guide for healthcare professionals to support them in offering chronic care management (CCM) services. Provides links to CMS resources, including guides targeted to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). Also includes educational materials to help patients understand CCM services.
Date: 2018
Type: Document
Sponsoring organization: Centers for Medicare and Medicaid Services
view details
Quality Improvement and Care Coordination: Implementing the CDC Guideline for Prescribing Opioids for Chronic Pain
A guide to help primary care providers, practices, and healthcare systems manage patients who are on long-term opioid therapy. Provides an evidence-based prescribing guideline, quality improvement measures, and practice-level care coordination strategies. Appendix F provides examples of comprehensive management approaches, including discussion of telehealth approaches that could be used in rural communities.
Date: 2018
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
view details
Maryland Rural Health Plan 2018
Details the current state of rural healthcare in Maryland, including areas of need, success of existing health plans, and corresponding recommendations. Presents county-level data, including the health priorities for each rural county.
Additional links: Maryland Rural Health Plan Website
Date: 2018
Type: Document
Sponsoring organization: Maryland Rural Health Association
view details
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 Rural Health Services
view details
Kalispell Regional Healthcare: Managing the Needs of Medically and Socially Complex Patients or Superutilizers
Details how Kalispell Regional Healthcare teamed with Mountain-Pacific Quality Health to introduce a modified transitional care model, which is designed to reduce service utilization and improve the health of high-cost, high-need patients. Initiative is part of a special innovations project through the Centers for Medicare and Medicaid Services (CMS) and uses multidisciplinary "ReSource" teams to coordinate care and services across rural and underserved areas of Montana.
Date: 11/2017
Type: Document
Sponsoring organization: American Hospital Association Rural Health Services
view details
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 and highlights effective and ineffective strategies for rural areas. Covers health workforce issues, telehealth, care coordination, and payment models.
Date: 10/2017
Type: Document
Sponsoring organization: Healthcare Value Hub
view details
Behavioral Health Trends in Ohio
Covers publications focusing on behavioral health research in Ohio. Includes research briefs on a variety of topics, such as housing retention, care coordination, employment, social connectedness, and others, as they relate to behavioral health.
Date: 10/2017
Type: Document
Sponsoring organization: Ohio Department of Mental Health and Addiction Services
view details
Evaluation of the Minnesota Accountable Health Model
Describes the final results of Minnesota's State Innovation Model (SIM) initiative evaluation sponsored by the Centers for Medicare and Medicaid (CMS). Includes information on SIM investments in rural counties, considerations to strengthen and support infrastructure to advance integrated health partnerships in rural areas, and engagement strategies to include rural clinics and providers in Health Care Homes care coordination cost study.
Author(s): Donna Spencer, Christina Worrall, Emily Zylla, et al.
Date: 09/2017
Type: Document
Sponsoring organization: State Health Access Data Assistance Center
view details
Barriers and Facilitators to Implementation of VA Home-based Primary Care on American Indian Reservations: A Qualitative Multi-case Study
Highlights a study on the efficacy of the Veterans Health Affairs (VA) home-based primary care program at providing non-institutional long-term care for rural American Indian veterans living on reservations. Bases findings on a qualitative analysis of interviews conducted with staff, clinicians, and managers who oversaw the program's implementation. Discusses the challenges, barriers, and facilitators related the program's expansion into Indian Country.
Author(s): B. Josea Kramer, Sarah D. Cote, Diane I. Lee, Beth Creekmur, Debra Saliba
Citation: Implementation Science, 12, 109
Date: 09/2017
Type: Document
view details