Rural Health
Resources by Topic: Care coordination
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
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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
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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
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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
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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
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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
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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
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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
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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 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
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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
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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
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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
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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
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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
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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
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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
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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
Details manual procedures used in Western Montana to develop a model to improve the 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: University of Montana: Rural Institute for Inclusive Communities
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Details manual procedures used in Western Montana to develop a model to improve the 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: University of Montana: Rural Institute for Inclusive Communities
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Research Highlight: The Virtual Specialty Care QUERI Program - Improving Access to High-Quality Specialty Care for Rural Veterans
Highlights the Virtual Specialty Care (VSC) QUERI Program, a measure to support operational partners, such as the Office of Rural Health, Office of Connected Care, and Mental Health Services, as virtual care technologies are implemented to increase access to specialty care for rural veterans. Discusses the challenges of evaluating rapidly evolving technologies without stifling their development.
Author(s): John Fortney, Greg Reger, Alexis Beatty
Date: 08/2017
Type: Document
Sponsoring organization: VA Health Services Research & Development Service
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Highlights the Virtual Specialty Care (VSC) QUERI Program, a measure to support operational partners, such as the Office of Rural Health, Office of Connected Care, and Mental Health Services, as virtual care technologies are implemented to increase access to specialty care for rural veterans. Discusses the challenges of evaluating rapidly evolving technologies without stifling their development.
Author(s): John Fortney, Greg Reger, Alexis Beatty
Date: 08/2017
Type: Document
Sponsoring organization: VA Health Services Research & Development Service
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