Rural Health
Resources by Topic: Care coordination
Third Annual Report: HCIA Disease-Specific Evaluation
Findings from the third year for 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Provides information on program effectiveness based on Medicare and Medicaid claims data and awardee-collected data. Includes projects that serve a variety of rural areas and address conditions such as diabetes, cancer, cardiovascular disease, and chronic pain. Approaches discussed include care coordination, education, and telehealth.
Additional links: Addendum, June 2017
Date: 02/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Findings from the third year for 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Provides information on program effectiveness based on Medicare and Medicaid claims data and awardee-collected data. Includes projects that serve a variety of rural areas and address conditions such as diabetes, cancer, cardiovascular disease, and chronic pain. Approaches discussed include care coordination, education, and telehealth.
Additional links: Addendum, June 2017
Date: 02/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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HCIA Complex/High-Risk Patient Targeting: Third Annual Report
Third annual evaluations of Health Care Innovation Awards Round One projects focused on patients with medically complex conditions at high risk for hospitalization, re-hospitalization, emergency department visits, or nursing home stays. Presents program effectiveness findings based on Medicare and Medicaid claims data, surveys, site visits, and interviews. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches.
Additional links: Addendum, April 2017
Date: 02/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Third annual evaluations of Health Care Innovation Awards Round One projects focused on patients with medically complex conditions at high risk for hospitalization, re-hospitalization, emergency department visits, or nursing home stays. Presents program effectiveness findings based on Medicare and Medicaid claims data, surveys, site visits, and interviews. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches.
Additional links: Addendum, April 2017
Date: 02/2017
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Native Americans with Diabetes: Better Diabetes Care Can Decrease Kidney Disease
Provides an overview of diabetes and related kidney disease among American Indians and Alaska Natives. Describes an Indian Health Service (IHS) approach using population health and team-based approaches to diabetes and kidney care.
Additional links: Podcast
Date: 01/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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Provides an overview of diabetes and related kidney disease among American Indians and Alaska Natives. Describes an Indian Health Service (IHS) approach using population health and team-based approaches to diabetes and kidney care.
Additional links: Podcast
Date: 01/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives — United States, 1996–2013
Reports on diabetes-related end-stage renal disease by race/ethnicity from 1996-2013. Discusses clinical, public health, and population management approaches used by Indian Health Service that may have positively impacted incidence rates among American Indians and Alaska Natives.
Author(s): Ann Bullock, Nilka Ríos Burrows, Andrew S. Narva, et al.
Citation: MMWR (Morbidity and Mortality Weekly Report), 66(1), 26-32
Date: 01/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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Reports on diabetes-related end-stage renal disease by race/ethnicity from 1996-2013. Discusses clinical, public health, and population management approaches used by Indian Health Service that may have positively impacted incidence rates among American Indians and Alaska Natives.
Author(s): Ann Bullock, Nilka Ríos Burrows, Andrew S. Narva, et al.
Citation: MMWR (Morbidity and Mortality Weekly Report), 66(1), 26-32
Date: 01/2017
Type: Document
Sponsoring organization: Centers for Disease Control and Prevention
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Social Determinants of Health and Vulnerable Populations in Rural Maryland
White paper discussing how social determinants of health impact those who face barriers to health and are susceptible to poor health due to circumstances such as environmental conditions, housing concerns, lack of transportation, and poverty. Includes strategies and examples of programs that have worked in rural communities to address topics such as substance use disorder and care coordination.
Date: 12/2016
Type: Document
Sponsoring organizations: Maryland Community Health Resources Commission, Maryland Rural Health Association
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White paper discussing how social determinants of health impact those who face barriers to health and are susceptible to poor health due to circumstances such as environmental conditions, housing concerns, lack of transportation, and poverty. Includes strategies and examples of programs that have worked in rural communities to address topics such as substance use disorder and care coordination.
Date: 12/2016
Type: Document
Sponsoring organizations: Maryland Community Health Resources Commission, Maryland Rural Health Association
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Rural Health Networks and Care Coordination: Health Care Innovation in Frontier Communities to Improve Patient Outcomes and Reduce Health Care Costs
Discusses the findings of a single-case, community-based participatory design study in a frontier community in northern Minnesota to determine the effectiveness of developing a community care team focused on collaboration and care coordination to improve patient outcomes and reduce emergency room use.
Author(s): Pat Conway, Heidi Favet, Laurie Hall, Jenny Uhrich, Jeanette Palcher, et al.
Citation: Journal of Health Care for the Poor and Underserved, 27(4A), 91–115
Date: 11/2016
Type: Document
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Discusses the findings of a single-case, community-based participatory design study in a frontier community in northern Minnesota to determine the effectiveness of developing a community care team focused on collaboration and care coordination to improve patient outcomes and reduce emergency room use.
Author(s): Pat Conway, Heidi Favet, Laurie Hall, Jenny Uhrich, Jeanette Palcher, et al.
Citation: Journal of Health Care for the Poor and Underserved, 27(4A), 91–115
Date: 11/2016
Type: Document
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Rural Promising Practice Issue Brief: Caring for Older Adults and Caregivers at Home (COACH)
Describes the efforts of the Durham Department of Veterans Affairs Medical Center (VAMC) to provide home-based care for veterans with moderate to severe dementia and their caregivers, through its COACH program. Helps VA providers to improve access for rural veterans and can be used as a model for other VAMCs.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Describes the efforts of the Durham Department of Veterans Affairs Medical Center (VAMC) to provide home-based care for veterans with moderate to severe dementia and their caregivers, through its COACH program. Helps VA providers to improve access for rural veterans and can be used as a model for other VAMCs.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Rural Promising Practice Issue Brief: Telehealth Collaborative Care for Rural Veterans with HIV Infection
Features a report on promising practices in providing access to care for rural veterans with HIV via telehealth enabled collaborative care. Details an organizational model and implementation information.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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Features a report on promising practices in providing access to care for rural veterans with HIV via telehealth enabled collaborative care. Details an organizational model and implementation information.
Additional links: Overview
Date: 11/2016
Type: Document
Sponsoring organization: Veterans Health Administration's Office of Rural Health
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"How Can We Talk about Patient-centered Care without Patients at the Table?" Lessons Learned from Patient Advisory Councils
Reports on a survey of patient advisory council (PAC) members associated with 8 primary care clinics and Federally Qualified Health Clinics (FQHCs), both rural and urban, in Northern California. Focuses on how PACs are developed, challenges faced, and the benefits of effective PACs.
Author(s): Anjana E. Sharma, Rachel Willard-Grace, Andrew Willis, et al.
Citation: Journal of the American Board of Family Medicine, 29(6), 775-784
Date: 11/2016
Type: Document
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Reports on a survey of patient advisory council (PAC) members associated with 8 primary care clinics and Federally Qualified Health Clinics (FQHCs), both rural and urban, in Northern California. Focuses on how PACs are developed, challenges faced, and the benefits of effective PACs.
Author(s): Anjana E. Sharma, Rachel Willard-Grace, Andrew Willis, et al.
Citation: Journal of the American Board of Family Medicine, 29(6), 775-784
Date: 11/2016
Type: Document
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Innovations in Rural Health System Development: Service Delivery Advances in Care Coordination, Emergency Care, and Telehealth
Offers examples of emergency services, telehealth technology, and care coordination initiatives with a focus on Maine, and how they impact rural service delivery and safeguard rural access to critical health services.
Author(s): Amanda Burgess, Andrew Coburn
Date: 10/2016
Type: Document
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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Offers examples of emergency services, telehealth technology, and care coordination initiatives with a focus on Maine, and how they impact rural service delivery and safeguard rural access to critical health services.
Author(s): Amanda Burgess, Andrew Coburn
Date: 10/2016
Type: Document
Sponsoring organizations: Maine Health Access Foundation, Maine Rural Health Research Center
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