Rural Health
Resources by Topic: Care coordination
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: Rural and Minority Health Research Center (formerly the South Carolina Rural Health Research Center)
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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: Rural and Minority Health Research Center (formerly the 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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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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Williamson Health and Wellness Center
Video highlighting a West Virginia community health worker program that helps patients with chronic illness connect with services and manage their health.
Date: 07/2017
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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Video highlighting a West Virginia community health worker program that helps patients with chronic illness connect with services and manage their health.
Date: 07/2017
Type: Video/Multimedia
Sponsoring organization: Rural Health Information Hub
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Care Coordination for Community Transitions for Individuals Post-Stroke Returning to Low-Resource Rural Communities
Assesses the Kentucky Care Coordination for Community Transitions (KC3T) program of employing a specially trained community health worker (CHW) as a navigator to aid in the transition of individuals who have had a stroke from acute in-patient care to their rural community. The goal of the study was to determine the community navigation and resources required by people who have had a stroke in order to transition back to rural communities with few resources and to facilitate positive health outcomes.
Author(s): Patrick Kitzman, Keisha Hudson, Violet Sylvia, Johnnie Lovins
Citation: Journal of Community Health, 42(3), 565-572
Date: 06/2017
Type: Document
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Assesses the Kentucky Care Coordination for Community Transitions (KC3T) program of employing a specially trained community health worker (CHW) as a navigator to aid in the transition of individuals who have had a stroke from acute in-patient care to their rural community. The goal of the study was to determine the community navigation and resources required by people who have had a stroke in order to transition back to rural communities with few resources and to facilitate positive health outcomes.
Author(s): Patrick Kitzman, Keisha Hudson, Violet Sylvia, Johnnie Lovins
Citation: Journal of Community Health, 42(3), 565-572
Date: 06/2017
Type: Document
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Medical Center Barbour Reduces Readmission Rates
Highlights the accomplishments of Medical Center Barbour (MCB), a prospective payment system (PPS) hospital located in Eufaula, Alabama, as it progressed through a Small Rural Hospital Transition (SRHT) quality of care and transition of care project. MCB's top accomplishments include reducing readmissions, improving communication among staff and patients, and enhancing the discharge process.
Additional links: One-Page Summary
Date: 06/2017
Type: Document
Sponsoring organization: National Rural Health Resource Center
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Highlights the accomplishments of Medical Center Barbour (MCB), a prospective payment system (PPS) hospital located in Eufaula, Alabama, as it progressed through a Small Rural Hospital Transition (SRHT) quality of care and transition of care project. MCB's top accomplishments include reducing readmissions, improving communication among staff and patients, and enhancing the discharge process.
Additional links: One-Page Summary
Date: 06/2017
Type: Document
Sponsoring organization: National Rural Health Resource Center
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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
Citation: Rural Monitor
Date: 05/2017
Type: Document
Sponsoring organization: Rural Health Information Hub
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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
Citation: Rural Monitor
Date: 05/2017
Type: Document
Sponsoring organization: Rural Health Information Hub
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Integrating Community Health Workers into Complex Care Teams: Key Considerations
Examines effective strategies for integrating community health workers (CHWs) into complex care teams. Discusses factors to consider, such as recruiting and hiring, training and career progression, team integration, support and retention, and more. Includes a brief description of characteristics that are particularly important for CHWs working in rural areas.
Author(s): Jim Lloyd, Caitlin Thomas-Henkel
Date: 05/2017
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Examines effective strategies for integrating community health workers (CHWs) into complex care teams. Discusses factors to consider, such as recruiting and hiring, training and career progression, team integration, support and retention, and more. Includes a brief description of characteristics that are particularly important for CHWs working in rural areas.
Author(s): Jim Lloyd, Caitlin Thomas-Henkel
Date: 05/2017
Type: Document
Sponsoring organization: Center for Health Care Strategies
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Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring: Third Annual Report
Third annual evaluations of 24 Health Care Innovation Awards Round One projects focused on enhancing care coordination and healthcare access through the use of health information technology, care coordination/patient navigation, and health promotion and prevention services. Discusses awardees' progress and impact over the 3-year funding period from 2012 to 2015. Includes profiles of rural-focused projects, as well as projects serving rural and urban areas.
Additional links: Addendum, August 2017
Date: 03/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Third annual evaluations of 24 Health Care Innovation Awards Round One projects focused on enhancing care coordination and healthcare access through the use of health information technology, care coordination/patient navigation, and health promotion and prevention services. Discusses awardees' progress and impact over the 3-year funding period from 2012 to 2015. Includes profiles of rural-focused projects, as well as projects serving rural and urban areas.
Additional links: Addendum, August 2017
Date: 03/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Rural Promising Practice Issue Brief: VA Coordinated Transitional Care (C-TraC) Program
Highlights a promising practice in providing coordinated transitional care for rural veterans. Details the Coordinated Transitional Care (C-TraC) Program and discusses implementation and results from the pilot program at a VA medical center in Madison, WI.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Highlights a promising practice in providing coordinated transitional care for rural veterans. Details the Coordinated Transitional Care (C-TraC) Program and discusses implementation and results from the pilot program at a VA medical center in Madison, WI.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Rural Promising Practice Issue Brief: Osteoporosis Risk Assessment Using Osteoporosis Self-Assessment Tool (OST) and Other Interventions at Rural Facilities
Outlines the Osteoporosis Self-Assessment Tool (OST) as a promising practice for assessing osteoporosis risk in rural veteran populations. Features examples in three Veterans Affairs (VA) medical facilities.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Outlines the Osteoporosis Self-Assessment Tool (OST) as a promising practice for assessing osteoporosis risk in rural veteran populations. Features examples in three Veterans Affairs (VA) medical facilities.
Additional links: Overview
Date: 02/2017
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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