Understanding and Facilitating Rural Health Transformation

Tools & Resources

Care Management

Care integration and coordination that facilitates patient-centered care, improved clinical outcomes, and efficient resource use.

Medical-Legal Partnership Addresses Social Determinants of Health - FirstHealth of the Carolinas integrates a medical-legal partnership into the evidence-based Chronic Care Model used in its new transitional care clinics. (Rural Health Value, September 2017)

Care Management Medicare Reimbursement Strategies for Rural Providers - Keep beneficiaries healthy and at home by better understanding the Medicare billing codes for appropriate services. (Rural Health Information Hub, 2017)

Integrated Care in a Frontier Community - Support patients in frontier communities utilizing an integrated care model that focuses on care coordination for wellness and addresses nonmedical obstacles to overall health. (Rural Health Value, July 2016)

Care Coordination: A Self-Assessment for Rural Health Providers and Organizations - Develop, expand or enhance care coordination efforts and the critical factors needed for organizations. (Rural Health Value, October 2014)

Population Health: A Self-Assessment Tool for Rural Health Providers and Organizations - Develop, expand, or enhance population health approaches and the critical success factors needed for rural organizations. (Rural Health Value, September 2014)

The Role of Teamwork in Improving Value in Rural Health - Take action with resources at no cost. TeamSTEPPS is an evidence-based teamwork system designed to optimize patient outcomes. (Rural Health Value and Agency for Healthcare Research and Quality, October 2013)

Quality Improvement in Primary Care: External Supports for Practices - Improve quality with external supports for primary care practices. (Agency for Healthcare Research and Quality, June 2014)

Care Coordination Resources for Rural Organizations - Implement a care coordination program with these evidence-based resources (Improving Chronic Illness Care, October 2013)

The Physician's Accountable Care Toolkit - Succeed as an Accountable Care Organization using resources to assist providers in the transition. (Towards Accountable Care (TAC) Consortium, 2012)

Responding to Rural Health's Unique Challenges - Review effective strategies for health care in rural areas. (The Patient-Centered Outcomes Research Institute-PCORI)

Rural Accountable Care Organization Care Coordination - Learn about care coordination at MaineHealth, a not-for-profit, integrated, healthcare delivery network ACO (MHACO). (Rural Health Value, December 2015)