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Rural Health
Resources by Topic: Care coordination

Options for Rural Health Care Delivery in Maryland
Presents a high-level overview of rural health care delivery options and considerations for future access to health services in Kent and upper Queen Anne's Counties and other rural Maryland communities. Features demographics and statistics on inpatient discharges from 2014-2018.
Date: 01/2020
Type: Document
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
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Understanding and Addressing the Drivers of Infant Mortality in Maine
Overview of infant mortality data for Maine between 2000 and 2017. Includes county-level data as well as rural and urban comparisons. Discusses causes of mortality, risk factors, challenges for rural residents in the Maine healthcare system, social determinants of health, and more. Makes recommendations for decreasing infant mortality with specific recommendations for rural.
Author(s): Katherine Flaherty
Date: 01/2020
Type: Document
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Post-Acute Care Virtual Summit
Summarizes a May 2020 virtual summit of key stakeholders that examines the state of post-acute care (PAC) in rural America. Discusses issues, challenges, and strategies related to the integration of rural acute and post-acute care. Explores how state Flex Programs can help rural providers address PAC. Includes a collection of PAC best practices.
Date: 2020
Type: Document
Sponsoring organizations: National Rural Health Resource Center, Stroudwater Associates
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The Rural Health Care Coordination Network Partnership Program: Critical Access Hospital Network of Eastern Washington
Describes and examines the impact of a care coordination program developed by the Critical Access Hospital Network (CAHN) of Eastern Washington. Provides care coordination services to Medicaid patients with at least two chronic conditions or one chronic condition and the risk of developing another. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional funding from the Empire Health Foundation.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Avera St. Mary's Completing the Circle Project
Describes and examines the impact of a care coordination program developed by Avera St. Mary's located in Pierre, South Dakota. Used a Patient Centered Medical Home (PCMH) model, providing services to patients with type 2 diabetes, one-third of whom were American Indian. The program's care team connected patients to resources and coordinated the patient's primary care providers, medications, specialists, other health care services, and a variety of social services. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Chautauqua County Health Hospital Network
Describes and examines the impact of a care coordination program developed by the Chautauqua County Health Network in New York. Offers well-coordinated preventive health services and links to community-based services to patients with diabetes, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) who need regular support but are not medically frail. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: South East Rural Physicians Alliance
Describes and examines the impact of a care coordination program developed by the South East Rural Physicians Alliance-Independent Physician Association located in Nebraska. Program focuses on clinic-based care coordination for high-risk patients with diagnosed diabetes or congestive heart failure. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Worcester County Health Department
Describes and examines the impact of a care coordination program developed by the Worcester County Health Department located on the Eastern Shore of Maryland. Describes the program's care team of a registered nurse, masters-level social worker, and community health worker (CHW), working in collaboration with primary care providers. Serves patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), with a home visit and services tailored to the patient's unique needs. Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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The Rural Health Care Coordination Network Partnership Program: Williamson Health and Wellness Center
Describes and examines the impact of a care coordination program developed by the Williamson Health and Wellness Center based in Williamson, West Virginia. Describes the program's use of care teams of community health workers, a registered nurse, and a nurse practitioner providing care coordination to patients with diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Funded under the Rural Health Care Coordination Network Partnership Grant Program from 2015-2018, with additional private funding from a network of local philanthropies.
Date: 2020
Type: Document
Sponsoring organizations: NORC Walsh Center for Rural Health Analysis, University of Minnesota Rural Health Research Center
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Care Coordination: A Self-Assessment for Rural Health Providers and Organizations
Developed to provide a preliminary review of important factors for rural organizations interested in developing, expanding, or enhancing care coordination activities.
Date: 2020
Type: Document
Sponsoring organization: Rural Health Value
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