Rural Health
Resources by Topic: Care coordination
Medicare Accountable Care Organizations: Quality Performance by Geographic Categories
Using CMS 2014 and 2015 Medicare Accountable Care Organization (ACO) data, this brief examines the differences in ACO performance on 4 domains of quality measures: Patient/Caregiver Experience (PCE), Care Coordination/Patient Safety (CCP), Preventive Health (PH), and At-Risk Population (AtR) in rural and urban areas, and discusses the overall quality score of Medicare Shared Savings ACOs by geographic category.
Author(s): Xi Zhu, Keith Mueller, Thomas Vaughn, Fred Ullrich, A. Clinton MacKinney
Date: 09/2016
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Using CMS 2014 and 2015 Medicare Accountable Care Organization (ACO) data, this brief examines the differences in ACO performance on 4 domains of quality measures: Patient/Caregiver Experience (PCE), Care Coordination/Patient Safety (CCP), Preventive Health (PH), and At-Risk Population (AtR) in rural and urban areas, and discusses the overall quality score of Medicare Shared Savings ACOs by geographic category.
Author(s): Xi Zhu, Keith Mueller, Thomas Vaughn, Fred Ullrich, A. Clinton MacKinney
Date: 09/2016
Type: Document
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
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Project ECHO's Complex Care Initiative: Building Capacity to Help "Superutilizers" in Underserved Communities
Describes a case study from the University of New Mexico's Project ECHO (Extension for Community Health Outcomes) program, which uses telehealth to support primary care clinicians in underserved areas. Focuses on a project targeting Medicaid beneficiaries with substance abuse and mental health issues, with details on two primary care teams being supported, including one in a rural New Mexico community.
Author(s): Martha Hostetter, Sarah Klein, Douglas McCarthy
Date: 08/2016
Type: Document
Sponsoring organization: Commonwealth Fund
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Describes a case study from the University of New Mexico's Project ECHO (Extension for Community Health Outcomes) program, which uses telehealth to support primary care clinicians in underserved areas. Focuses on a project targeting Medicaid beneficiaries with substance abuse and mental health issues, with details on two primary care teams being supported, including one in a rural New Mexico community.
Author(s): Martha Hostetter, Sarah Klein, Douglas McCarthy
Date: 08/2016
Type: Document
Sponsoring organization: Commonwealth Fund
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Integrated Care in a Frontier Community
Examines the Southeast Health Group (SHG) in La Junta, Colorado, which coordinates physical and behavioral health using patient-centered, wellness-based care coordination to empower patients and promote self-directed care. Focuses on hiring providers who share SHG's philosophy of care, using community resources, and engaging peer support specialists.
Date: 07/2016
Type: Document
Sponsoring organization: Rural Health Value
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Examines the Southeast Health Group (SHG) in La Junta, Colorado, which coordinates physical and behavioral health using patient-centered, wellness-based care coordination to empower patients and promote self-directed care. Focuses on hiring providers who share SHG's philosophy of care, using community resources, and engaging peer support specialists.
Date: 07/2016
Type: Document
Sponsoring organization: Rural Health Value
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National Healthcare Quality and Disparities Chartbook on Care Coordination
A summary of trends in Care Coordination from the National Healthcare Quality and Disparities Report (QDR) for 2015. Includes data and statistics by metropolitan statistical area with a focus on groups with disparities in care coordination regarding hospital and emergency department visits, discharge, readmission, use of ED for chronic healthcare, and potentially avoidable hospitalizations. Also highlights the use of electronic health records and electronic exchange and how that affects care coordination and quality.
Date: 06/2016
Type: Document
Sponsoring organization: Agency for Healthcare Research and Quality
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A summary of trends in Care Coordination from the National Healthcare Quality and Disparities Report (QDR) for 2015. Includes data and statistics by metropolitan statistical area with a focus on groups with disparities in care coordination regarding hospital and emergency department visits, discharge, readmission, use of ED for chronic healthcare, and potentially avoidable hospitalizations. Also highlights the use of electronic health records and electronic exchange and how that affects care coordination and quality.
Date: 06/2016
Type: Document
Sponsoring organization: Agency for Healthcare Research and Quality
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Integrated Behavioral Health In Montana: A Baseline Assessment of Benefits, Challenges, and Opportunities
Presents results from a baseline assessment of Montana's behavioral health system of care. Evaluates the possibility of addressing system deficiencies by implementing an integrated behavioral health model. Describes rural-specific benefits and challenges associated with system integration.
Additional links: Issue Brief
Author(s): Katie Loveland
Date: 04/2016
Type: Document
Sponsoring organization: Montana Healthcare Foundation
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Presents results from a baseline assessment of Montana's behavioral health system of care. Evaluates the possibility of addressing system deficiencies by implementing an integrated behavioral health model. Describes rural-specific benefits and challenges associated with system integration.
Additional links: Issue Brief
Author(s): Katie Loveland
Date: 04/2016
Type: Document
Sponsoring organization: Montana Healthcare Foundation
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Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists
Discusses a care coordination project that included 3 Federally Qualified Health Centers (FQHCs) and 502 patients in rural West Virginia and a tertiary care referral hospital in southern West Virginia to determine if expanded use of care coordinators and clinical pharmacists could improve the care experience and healthcare outcome of dual eligible patients.
Author(s): Daniel Doyle, Mary Emmett, Amber Crist, Craig Robinson, Michael Grome
Citation: Journal of Primary Care and Community Health, 7(2) 118-121
Date: 04/2016
Type: Document
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Discusses a care coordination project that included 3 Federally Qualified Health Centers (FQHCs) and 502 patients in rural West Virginia and a tertiary care referral hospital in southern West Virginia to determine if expanded use of care coordinators and clinical pharmacists could improve the care experience and healthcare outcome of dual eligible patients.
Author(s): Daniel Doyle, Mary Emmett, Amber Crist, Craig Robinson, Michael Grome
Citation: Journal of Primary Care and Community Health, 7(2) 118-121
Date: 04/2016
Type: Document
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Second Annual Report: HCIA Disease-Specific Evaluation
Second annual evaluations of 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Discusses experiences common across grantees and profiles each project. 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.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Second annual evaluations of 18 Health Care Innovation Awards Round One projects targeting patient populations with specific diseases. Discusses experiences common across grantees and profiles each project. 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.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Evaluation of the Health Care Innovation Awards: Community Resource Planning, Prevention, and Monitoring: Second Annual Report
Second 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 project impacts and challenges common across grantees. Includes profiles of 5 rural-focused projects, as well as projects serving rural and urban areas.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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Second 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 project impacts and challenges common across grantees. Includes profiles of 5 rural-focused projects, as well as projects serving rural and urban areas.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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HCIA Complex/High-Risk Patient Targeting: Second Annual Report
Second annual evaluations of 23 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. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches. Discusses common experiences of grantees serving rural areas, as well as profiles of each project.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Second annual evaluations of 23 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. Several projects serve rural areas, offering caregiver education and support, telehealth services, and various care coordination approaches. Discusses common experiences of grantees serving rural areas, as well as profiles of each project.
Date: 03/2016
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, NORC at the University of Chicago
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Evaluation of the Frontier Community Health Care Coordination Network Grant
Policy brief analyzing the effectiveness of using community health workers as community healthcare coordinators during a 3 year period (2012–2015) in frontier Montana. Includes recommendations to other communities that may consider implementing this model. Project was supported by the Federal Office of Rural Health Policy (FORHP) Frontier Community Health Care Network Coordination (FCHCNC) grant program.
Date: 09/2015
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Policy brief analyzing the effectiveness of using community health workers as community healthcare coordinators during a 3 year period (2012–2015) in frontier Montana. Includes recommendations to other communities that may consider implementing this model. Project was supported by the Federal Office of Rural Health Policy (FORHP) Frontier Community Health Care Network Coordination (FCHCNC) grant program.
Date: 09/2015
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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