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Resources by Topic: Care coordination

Optimizing Care Coordination to Address Social Determinants of Health Needs for Dual-Use Veterans
Explores a study evaluating a care coordination program that aims to address social determinants of health (SDOH) for veterans who use both Veterans Health Administration (VHA) facilities and non-VA hospitals. Highlights the social worker-led program to help address SDOH factors, such as connecting veterans with transportation, homelessness resources, and financial assistance, among others. Discusses the role rurality plays in veterans' ability to access services and care.
Author(s): Heidi Sjoberg, Wenhui Liu, Carly Rohs, et al.
Citation: BMC Health Services Research, 22(59)
Date: 01/2022
Type: Document
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Technical Assistance Helps Community #SilencetheShameTN
Features behavioral and mental health programming offered by Henry County Medical Center and the community of Paris, Tennessee. Describes technical assistance and resources provided by the Delta Region Community Health Systems Development program to support this effort.
Author(s): Tami Lichtenberg
Citation: Rural Monitor
Date: 11/2021
Type: Document
Sponsoring organization: Rural Health Information Hub
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Health Workforce Strategic Plan
Provides a framework for health workforce improvements and addresses long-standing barriers to strengthening the health workforce. Focuses on recruiting and training health professionals from underserved communities to build a diverse, representative health workforce; ensuring equitable distribution of the workforce across geographic areas and health professions; strengthening the ability of the workforce to deliver high-quality care, including through strengthening cultural and linguistic competency of professionals; and using evidence and data to make better decisions about health workforce education and training investments. Mentions rural throughout.
Additional links: Comments from Federal National Advisory Committees
Date: 10/2021
Type: Document
Sponsoring organization: U.S. Department of Health and Human Services
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Delta Memorial Hospital and DePaul Community Health Centers Spotlight Video
Explores how Delta Memorial Hospital and DePaul Community Health Centers worked together through the Delta Region Community Health Systems Development Program to strengthen their community care coordination.
Date: 09/2021
Type: Video/Multimedia
Sponsoring organization: National Rural Health Resource Center
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Grantee Sourcebook: Rural HIV/AIDS Planning Program, 2020-2021
Detailed descriptions of 7 Rural HIV/AIDS Planning Program grant projects funded in fiscal year 2020. Reports on each grantee's key Ending the HIV Epidemic (EHE) strategies, secondary focus areas, target populations served, network development and planning activities, initial outcomes of their planning work, and sustainability strategies of the HIV/AIDS rural health networks and HIV-related programming beyond the planning year. Grantee profiles identify the geographic areas served, network partners, and primary contact person.
Date: 09/2021
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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"We Got an Invite into the Fortress": VA-Community Partnerships for Meeting Veterans' Healthcare Needs
Evaluates the efficacy of the VA's Veteran's Community Partnership (VCP) initiative across the rural and urban continuum. Bases conclusions on focus group interviews with local representatives of organizations involved with VCP. Highlights program challenges, benefits, and achievements in rural and urban settings.
Author(s): Carol J. Ward, Curtis Child, Bret L. Hicken, et al.
Citation: International Journal of Environmental Research and Public Health, 18(16), 8334
Date: 08/2021
Type: Document
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Understanding Adaptations in the Veteran Health Administration's Transitions Nurse Program: Refining Methodology and Pragmatic Implications for Scale-up
Highlights a study on adaptations to the rural Transitions Nurse Program (TNP) in Veterans Health Administration facilities. Focuses on TNP sites and discusses the adaptations and lessons learned from each.
Author(s): Michaela S. McCarthy, Lexus L. Ujano-De Motta, Mary A. Nunnery, et al.
Citation: Implementation Science, 16, 71
Date: 07/2021
Type: Document
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Grantee Sourcebook: Rural Health Network Development Planning Program, 2020
Detailed descriptions of 20 Rural Health Network Development Planning Program grant projects funded in fiscal year 2020. Reports on each grantee's network infrastructure development, plans for sustaining the network after the grant, and program activities addressing topics such as integrated service delivery, creating efficiencies, integrating health services, chronic disease management, and care coordination. Grantee profiles identify the geographic areas served, network partners, and primary contact person.
Date: 07/2021
Type: Document
Sponsoring organization: Federal Office of Rural Health Policy
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Applied Rapid Qualitative Analysis to Develop a Contextually Appropriate Intervention and Increase the Likelihood of Uptake
Examines an intervention, Telehealth-based Coordination of Non-Veterans Health Administration Care (TECNO Care), designed to improve care coordination between the Veterans Health Administration (VHA) and community providers for veterans living in rural and underserved areas.
Author(s): Allison A. Lewinski, Matthew J. Crowley, Christopher Miller, et al.
Citation: Medical Care, 59(6 Suppl 3), S242-S251
Date: 06/2021
Type: Document
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Evaluation of the State Innovation Models (SIM) Initiative Round 2: Model Test Final Report
Final report on the Round 2 State Innovation Models (SIM) program across eleven participating states - Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Ohio, Rhode Island, Tennessee, and Washington. Discusses the adoption of delivery models and payment reforms related to value-based payment (VBP) and alternative payment models (APMs). Examines whether the implementation efforts and healthcare delivery system reforms impacted the quality of care, health outcomes, population health, and spending.
Additional links: Appendix, Findings at a Glance
Date: 06/2021
Type: Document
Sponsoring organizations: Centers for Medicare and Medicaid Services, RTI International
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