Understanding and Facilitating Rural Health Transformation

Tools & Resources

Community Health

Assessments and strategies designed to enhance the health of all individuals in a community across a spectrum of ages and conditions.

Guide for Rural Health Care Collaboration and Coordination - This guide describes how rural hospitals, community health centers, local public health departments, and other rural stakeholders can work together to assess and address their rural communities' health needs. (HRSA, 2019)

Rural Community Health Gateway - Find resources to build effective community health programs and/or improve existing services. (Rural Health Information Hub)

Rural Care Coordination Toolkit - Identify and implement a care coordination program. (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, May 2017)

Population Health Strategies of Critical Access Hospitals - Examine the population health strategies of eight CAHs that have made substantial commitments to population health and community health improvement. (Flex Monitoring Team, August 2016)

Understanding the Social Determinants of Health: A Self-Guided Learning Module for Rural Health Care Teams - Encourages rural leaders and care teams to support activities that help address and improve social determinants of health in their communities. (Rural Health Value, August 2016). No time? Try the Brief Overview and Discussion Guide

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

Investing in Population Health - Establish a Medicaid population health support system in rural and frontier areas. (Rural Health Value, August 2015)

Rural Taxonomy of Population and Health-Resource Characteristics - A systematic tool for classifying and identifying similar rural communities and places, using characteristics of community populations and health resources. (Rural Health Value, March 2015)

Rural Matters Online Data Event - Watch three short videos that show how to use publicly available rural-relevant data in maps and other data. (Community Commons, December 2014)

Hospital Based Strategies for Creating a Culture of Health - Transform the hospital’s culture to a “culture of health in your community”. (Health Research & Educational Trust, October 2014)

Innovative Health Care Provider Roles (updated 8/18/2014) - Address health care workforce challenges in creative ways, by expanding current provider roles and employing community members in new health care capacities. (Rural Health Value, August 2014)

Diabetes Telephonic Care - Learn about promising results from a team approach using telephonic nurse management for diabetes support, education, and care management. (Rural Health Value, July 2014)

Rural Hospital Community Outreach - Prevent or delay early onset diabetes with a health screening and follow-up model showing a "statistically significant association" between program participation and reduced rates of progression from pre-diabetes to true diabetes. (Rural Health Value, May 2014)

Improving Population Health: A Guide for Critical Access Hospitals - Provides support for incorporating population health principles and programs into strategic planning and operations. (National Rural Health Resource Center and Stratis Health, March 2014)

Using Community Connectors to Improve Access - Increase access to home and community-based services by creating alternatives to institutionalized living and improving the quality of life for elderly and adults with physical disabilities while maintaining or decreasing costs. (Rural Health Value, March 2014)

Using Data to Understand Your Community - Address the Triple Aim© by using data to better understand your community’s population. (Rural Health Value, February 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)

Emergency Department Super Utilizer Programs - Describes super utilizer program design, implementation, operation, and assessment. (Rural Health Value, October 2013)

Rural Service Delivery Integration & Patient Engagement - Work towards a fully integrated and responsive health care delivery system through patient engagement, unnecessary surgery reduction, and emergency department "super utilizer" care management. (Rural Health Value, September 2013)

A Rural Accountable Care Organization - Learn about the design and implementation of a rural-based and physician-led Advance Payment ACO in rural Nebraska. (Rural Health Value, September 2013)

Using Data to Drive Change: Targeting High Service Utilizers - Identify high utilizers of emergency department and hospital services with data analysis. (Rural Health Value, August 2013)

Mobilizing Community Partnerships in Rural Communities: Strategies and Techniques - Build partnerships in rural communities that build value in health care delivery. (National Association of County and City Health Officials, August 2013)

Frontier Extended Stay Clinics (FESC) - Expand service in existing clinics to include extended stay (up to 48 hours) and emergency services. (Rural Health Value, July 2013)

The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships - Strategies outlined in this resource provide support to leverage local community partnerships and relationships. (Health Research & Educational Trust, June 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)