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. Comprehensive care coordination is an essential person-centered element of a high performance system that builds on local rural resources and assets.

Evidence, Methods, & Models

Care Coordination in Rural Communities: Supporting the High Performance Rural Health System - Prepared by the Rural Policy Research Institute (RUPRI) Health Panel, this report examines care coordination programs and processes that affect rural people and places to discover how different programs and approaches are working. (2015)

Serving High Need/High Cost Patients in the Emergency Department - This brief describes design, implementation, operation, and assessment of programs to serve high-need, high-cost patients in the Emergency Department. (2021)

Reducing Potentially-Preventable Readmissions in Critical Access Hospitals - This article was published by the Flex Monitoring Team to identify and disseminate information about successful evidence-based interventions that have been conducted to reduce readmissions in CAHs and other small rural hospitals. (2016)

Rural Hospital Care Coordination and Population Health Management Summit Report - The National Rural Health Resource Center hosted the 2019 Rural Care Coordination and Population Health Summit to consider how community care coordination plays a key role in assisting health care leaders in preparing for in population health. (2019)

Telehealth Models for Increasing Access to and Engagement with Care Outside of Healthcare Settings - In rural communities, telehealth is used as a tool to help patients access care outside of clinical settings and to better engage patients in the care that they receive. Using telehealth to reach patients in non-healthcare settings, outside of medical facilities, can be critical to overcoming persistent barriers to care, including lack of access to transportation and stigma associated with seeking help for a condition. (2019)

Tools & Resources

Care Coordination: A Self-Assessment for Rural Health Providers and Organizations - This Rural Health Value tool helps healthcare leaders assess the current state of critical elements in care coordination and develop and enhance care coordination efforts. Fillable MS-Word version (2020)

Community-Based Care Coordination: A Comprehensive Development Toolkit - The Community-based Care Coordination (CCC) Toolkit from Stratis Health provides tools for use at different stages in the development of a CCC program - including how to begin a program. Tools focus on people, functions, policy, and processes to achieve success in the community-based care coordination environment. (2014)

Community Care Coordination and Chronic Care Management - From the National Rural Health Resource Center, these hospital best practices and recommended strategies help leaders with community health planning, development and implementation of patient-centered medical home (PCMH) and other community care coordination models, as well as chronic care management services.

Hospital Guide to Reducing Medicaid Readmissions - Learn how to analyze root causes of readmissions, provide enhanced services to patients at high risk of readmission, and more through this Agency for Healthcare Research and Quality (AHRQ) resource. (2017)

High-Need, High-Cost Patients - This collection from the Commonwealth Fund highlights publications, tools, issue briefs focused on improving care for high-need, high-cost patients.

Rural Care Coordination Toolkit - Identify and implement a care coordination program using this toolkit developed by NORC Walsh Center for Rural Health Analysis, in partnership with the University of Minnesota's Rural Health Research Center, and in collaboration with the Rural Health Information Hub. (2018)

Profiles & Case Studies

Behavioral Health Integration into Primary Care - This Rural Health Value profile describes how a rural health clinic delivers behavioral health services as part of its comprehensive health and wellness approach in its Rural Health Clinic. (2018)

Medical-Legal Partnership Addresses Social Determinants of Health - This profile by Rural Health Value of FirstHealth of the Carolinas describes the integrated medical-legal partnership into the evidence-based Chronic Care Model used in its new transitional care clinics. (2017)

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

Predictive Analytics Shape Care Processes - This Rural Health Value profile describes how Community Care Partnership of Maine, a collaboration of nine federally qualified health centers and three community hospital systems, uses predictive analytics software to identify patients with the highest risk and plan interventions to support care management. (2018)

Rural Health Network Thrives on Innovation in Whole-Person Care - This Rural Health Value profile describes Health Care Collaborative (HCC) of Rural Missouri, a rural health network comprised of more than 55 member organizations, wraps social service support around the patients who receive care at four HCC health care clinics. (2019)

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