Rural Health
Resources by Topic: Care coordination
Sourcebook: Rural Health Network Development Program, 2020-2023
Provides brief program descriptions and overviews of the sustained impact of the 44 rural health networks funded during the 2020-2023 grant period. Programs used integrated rural healthcare networks to address health needs including behavioral/mental health, care coordination, chronic disease, social determinants of health, and telehealth. Grantee profiles include a network overview, program outcomes, partners involved, and program sustainability.
Date: 07/2023
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
Provides brief program descriptions and overviews of the sustained impact of the 44 rural health networks funded during the 2020-2023 grant period. Programs used integrated rural healthcare networks to address health needs including behavioral/mental health, care coordination, chronic disease, social determinants of health, and telehealth. Grantee profiles include a network overview, program outcomes, partners involved, and program sustainability.
Date: 07/2023
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
Related funding:
Rural Health Network Development Program
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Transforming Tribal Health: Addressing American Indians and Alaska Natives Health Disparities
Recording of a June 8, 2023, conference session on addressing tribal health disparities as part of the Centers for Medicare & Medicaid Services (CMS) Health Equity Conference. Includes presentations from the Arizona Health Care Cost Containment System on the use of care coordination and care management strategies and the National Indian Health Board on rethinking how CMS approaches health equity for American Indians and Alaska Natives. Transcript available in the video description.
Additional links: Carrie Field, National Indian Health Board - Presentation Slides, Leslie Short, Arizona Health Care Cost Containment System - Presentation Slides
Date: 06/2023
Type: Video/Multimedia
Sponsoring organization: Centers for Medicare and Medicaid Services
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Recording of a June 8, 2023, conference session on addressing tribal health disparities as part of the Centers for Medicare & Medicaid Services (CMS) Health Equity Conference. Includes presentations from the Arizona Health Care Cost Containment System on the use of care coordination and care management strategies and the National Indian Health Board on rethinking how CMS approaches health equity for American Indians and Alaska Natives. Transcript available in the video description.
Additional links: Carrie Field, National Indian Health Board - Presentation Slides, Leslie Short, Arizona Health Care Cost Containment System - Presentation Slides
Date: 06/2023
Type: Video/Multimedia
Sponsoring organization: Centers for Medicare and Medicaid Services
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2023 National Survey on MIH-CP Programs
Results of a February 2023 survey of approximately 400 emergency medical services (EMS) agencies nationwide that have launched mobile integrated healthcare and community paramedicine (MIH-CP) programs. Features statistics on nontraditional services offered, and programs by demographic region served, with breakdowns by 3 levels of population density.
Date: 05/2023
Type: Document
Sponsoring organization: National Association of Emergency Medical Technicians
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Results of a February 2023 survey of approximately 400 emergency medical services (EMS) agencies nationwide that have launched mobile integrated healthcare and community paramedicine (MIH-CP) programs. Features statistics on nontraditional services offered, and programs by demographic region served, with breakdowns by 3 levels of population density.
Date: 05/2023
Type: Document
Sponsoring organization: National Association of Emergency Medical Technicians
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Montana Health Network Provides Care Coordination for Chronic Disease Management
Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Features a regional care coordination program serving eastern Montana that uses registered nurses to check in with adult patients with chronic conditions and connect them with any needed referrals or community resources.
Author(s): Allee Mead
Citation: Rural Monitor
Date: 05/2023
Type: Document
Sponsoring organization: Rural Health Information Hub
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Marshall Browning Spotlight Video
Profiles Marshall Browning Hospital, a participant in the 2019 cohort of the Delta Region Community Health Systems Development Program (DRCHSD). Describes how shifting the Marshall Browning Hospital mission statement led to improvements to care coordination and transitional care services. Transcript available below description.
Date: 05/2023
Type: Video/Multimedia
Sponsoring organization: National Rural Health Resource Center
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Profiles Marshall Browning Hospital, a participant in the 2019 cohort of the Delta Region Community Health Systems Development Program (DRCHSD). Describes how shifting the Marshall Browning Hospital mission statement led to improvements to care coordination and transitional care services. Transcript available below description.
Date: 05/2023
Type: Video/Multimedia
Sponsoring organization: National Rural Health Resource Center
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Evaluation of the Maternal Opioid Misuse (MOM) Model Second Annual Report (Implementation Year 1)
Provides an overview of the Maternal Opioid Misuse Model, which provides evidence-based integrated care and care coordination for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). Describes activities MOM Model awardees undertook during the MOM Model's first implementation year, July 1, 2021–June 30, 2022. Discusses barriers pregnant and postpartum people with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 04/2023
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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Provides an overview of the Maternal Opioid Misuse Model, which provides evidence-based integrated care and care coordination for pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD). Describes activities MOM Model awardees undertook during the MOM Model's first implementation year, July 1, 2021–June 30, 2022. Discusses barriers pregnant and postpartum people with OUD face in accessing high-quality, continuous care, specifically in rural areas.
Additional links: Findings at a Glance
Date: 04/2023
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, Insight Policy Research
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Rural Healthcare Disparities in the United States: Can Our Payer Structures Help Us Get Upstream?
Describes a care model utilizing community health workers (CHWs) to engage patients by screening for diseases, and offering education and information to help them manage their chronic conditions in an accessible, non-traditional settings such as a food bank distribution centers, county fairs, livestock auctions, and educational events in rural Idaho. Discusses the value of CHWs, along with a primary care team, in improving outcomes for populations at risk, and the absence of payment models to support this model.
Author(s): Kelly McGrath
Citation: Journal of General Internal Medicine, 38 (Suppl 1), 16-17
Date: 03/2023
Type: Document
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Describes a care model utilizing community health workers (CHWs) to engage patients by screening for diseases, and offering education and information to help them manage their chronic conditions in an accessible, non-traditional settings such as a food bank distribution centers, county fairs, livestock auctions, and educational events in rural Idaho. Discusses the value of CHWs, along with a primary care team, in improving outcomes for populations at risk, and the absence of payment models to support this model.
Author(s): Kelly McGrath
Citation: Journal of General Internal Medicine, 38 (Suppl 1), 16-17
Date: 03/2023
Type: Document
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Achieving Whole Health: A New Approach for Veterans and the Nation
Report offers guidance for providers both inside and outside of the VA for filling gaps in veterans healthcare. Discusses a team-based interprofessional care structure for preventing disease and promoting well-being. Highlights some considerations for providing a whole health approach for rural veterans as well.
Additional links: Read Online
Author(s): Board on Health Care Services
Date: 02/2023
Type: Document
Sponsoring organization: Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
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Report offers guidance for providers both inside and outside of the VA for filling gaps in veterans healthcare. Discusses a team-based interprofessional care structure for preventing disease and promoting well-being. Highlights some considerations for providing a whole health approach for rural veterans as well.
Additional links: Read Online
Author(s): Board on Health Care Services
Date: 02/2023
Type: Document
Sponsoring organization: Health and Medicine Division (HMD), National Academies of Sciences, Engineering, and Medicine
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Filling Behavioral Health Gaps in Rural Communities: A Unique Partnership in Washington State
Discusses a collaboration between a Critical Access Hospital (CAH) in Washington and state hospitals to accept patient transfers by utilizing swing beds to care for patients with complex behavioral health and social needs, such as substance use disorder, mental health, homelessness, and more. Includes data on swing bed admissions and information on incorporating behavioral health services into primary care.
Author(s): Sarah Klein, Martha Hostetter
Date: 02/2023
Type: Document
Sponsoring organization: The Commonwealth Fund
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Discusses a collaboration between a Critical Access Hospital (CAH) in Washington and state hospitals to accept patient transfers by utilizing swing beds to care for patients with complex behavioral health and social needs, such as substance use disorder, mental health, homelessness, and more. Includes data on swing bed admissions and information on incorporating behavioral health services into primary care.
Author(s): Sarah Klein, Martha Hostetter
Date: 02/2023
Type: Document
Sponsoring organization: The Commonwealth Fund
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Care Coordination and Community Partnerships for Cancer Care in Critical Access Hospitals
Presents findings from a survey of 135 Critical Access Hospitals (CAHs) regarding care coordination practices for patients with cancer. Describes the types of care coordination services provided by CAHs and the staff that provide these services. Discusses partnerships between CAHs and community organizations regarding cancer initiatives.
Author(s): Megan Lahr, Xiomara Santana, Nathan Bean, Helen Parsons, Ira Moscovice
Date: 01/2023
Type: Document
Sponsoring organization: Flex Monitoring Team
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Presents findings from a survey of 135 Critical Access Hospitals (CAHs) regarding care coordination practices for patients with cancer. Describes the types of care coordination services provided by CAHs and the staff that provide these services. Discusses partnerships between CAHs and community organizations regarding cancer initiatives.
Author(s): Megan Lahr, Xiomara Santana, Nathan Bean, Helen Parsons, Ira Moscovice
Date: 01/2023
Type: Document
Sponsoring organization: Flex Monitoring Team
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