Understanding and Facilitating Rural Health Transformation

Tools & Resources

Clinical Care

Clinical care models and processes designed to deliver Value-Based Care within and outside of traditional medical care settings.

Evidence, Methods, & Models

Choosing Wisely - Choosing Wisely is an initiative of the American Board of Internal Medicine (ABIM) Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures.

Emergency Department Super Utilizer Programs - This Rural Health Value brief describes super utilizer program design, implementation, operation, and assessment. (Updated 2021)

Innovative Health Care Provider Roles - Address health care workforce challenges in creative ways, by expanding current provider roles and employing community members in new health care capacities using this Rural Health Value resource. (2020)

Project ECHO - Using proven adult learning techniques and interactive video technology, the ECHO Model connects groups of community providers with specialists at centers of excellence in regular real-time collaborative sessions. The sessions, designed around case-based learning and mentorship, help local workers gain the expertise required to provide needed services. Providers gain skills and confidence; specialists learn new approaches for applying their knowledge across diverse cultural and geographical contexts. As the capacity of the local workforce increases, lives improve.

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)

Taking Action on Overuse - Taking Action on Overuse is a framework for health care organizations to engage their care teams in reducing overused, unnecessary care and make those efforts last. It identifies evidence-based strategies for obtaining buy-in, motivating behavior changes, and providing the necessary support and infrastructure for health care providers to engage and lead their peers in making the changes that improve the value of health care.

Tools & Resources

Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults - The John A. Hartford Foundation (JAHF) and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA), set a bold vision to build a social movement so that all care with older adults is age-friendly care. Becoming an Age-Friendly Health System entails reliably providing a set of four evidence-based elements of high-quality care, known as the "4Ms," to all older adults in your system. (2020)

Center of Excellence for Integrated Health Solutions - Supported by the Substance Abuse and Mental Health Administration's (SAMSHA) National Center of Excellence for Integrated Health Solutions, provides evidence-based resources, tools and support for organizations working to integrate primary and behavioral health care.

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.

Primary Care Team Guide - The Primary Care Team Guide created by the MacColl Center for Health Care Innovation provides step-by-step directions on how to establish high-functioning teams and implement new functions essential to team-based care. The guide provides tools and resources from 31 exemplary practices nationwide.

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)

Rural Telehealth Toolkit - Resources and information focused on developing, implementing, evaluating, and sustaining telehealth programs for rural community health programs. produced by the NORC Walsh Center for Rural Health Analysis in collaboration with the Rural Health Information Hub. (2019)

Screening for Social Needs: Guiding Care Teams to Engage Patients - Developed as part of the American Hospital Association's Value Initiative, this guide is intended to support hospitals in developing screening and support programs to help patients address social needs. (2020)

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)

Integrated Care in a Frontier Community - Southeast Health Group has developed a fully integrated care model to support patients in frontier communities in southeastern Colorado. Its care coordination focuses on wellness and addresses nonmedical obstacles to overall health. ( 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)