Tools & Resources
Care integration and coordination (particularly during medical care transitions and for clinically complex patients) that facilitate 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.
Care Management Medicare Reimbursement Strategies for Rural Providers - Care Management Medicare Reimbursement Strategies for Rural Providers: This resource will assist providers in understanding the Medicare billing codes for services intended to keep beneficiaries healthy and to better coordinate services to support beneficiaries at home. (Rural Health Information Hub, 2017)
Integrated Care in a Frontier Community: - An RHV innovation profile: 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.
Care Coordination: A Self-Assessment for Rural Health Providers and Organizations - Developed specifically for rural organizations by the Rural Health Value Team, this assessment is designed to provide a preliminary review of critical factors for organizations looking to develop, expand, or enhance care coordination efforts.
Population Health: A Self-Assessment Tool for Rural Health Providers and Organizations - Developed specifically for rural organizations by the Rural Health Value Team, this assessment tool is designed to provide a preliminary review of critical success factors for rural organizations looking to develop, expand, or enhance a population health focused approach.
The Role of Teamwork in Improving Value in Rural Health - As health care financing shifts to reward a more comprehensive approach to patient and community health, teamwork will play an increasingly critical role. In a rural health care environment, teamwork is essential not only within specific settings of care, but across multiple organizations in health care and in the community. TeamSTEPPS is an evidence-based teamwork system designed to optimize patient outcomes by improving communication and teamwork skills among health care professionals. This guide helps rural health leaders take action using TeamSTEPPS resources available at no cost from AHRQ (Agency for Healthcare Research and Quality).
Quality Improvement in Primary Care: External Supports for Practices - A new brief from the Agency for Healthcare Research and Quality describes the importance of quality improvement in primary care and outlines external supports - which can be used alone or in combination - to assist primary care practices in improving quality.
Care Coordination Resources for Rural Organizations - Both patients and providers can reap the benefits of care coordination. But how does a rural organization get started in care coordination? Improving Chronic Illness Care (ICIC) is a set of evidence-based resources to help develop and implement a care coordination program. Learn about free ICIC resources and hands-on tools to get your care coordination program off the ground.
The Physician's Accountable Care Toolkit - The Physician's Accountable Care Toolkit has been developed by the Towards Accountable Care (TAC) Consortium, a consortium of over 40 North Carolina medical associations and organizations. The TAC provides resources (guides, articles, and webinars) to assist providers understand, participate, navigate, lead, and succeed in a value-driven healthcare system. The Physician's Accountable Care Toolkit details Accountable Care Organization (ACO) implementation strategies and operations guidance for physicians. In addition, the TAC has developed unique ACO guides for several physician specialties and community partners.
Responding to Rural Health's Unique Challenges - The Patient-Centered Outcomes Research Institute (PCORI) is investing in research that will build a body of evidence on effective strategies for health care in rural areas. Learn more about PCORI's various rural innovation projects, such as telehealth care for Parkinson Disease patients and hospital discharge improvement for rural areas. Information on how to get involved in PCORI efforts is also provided.
Rural Accountable Care Organization Care Coordination: - An RHV innovation profile: MaineHealth, a not-for-profit, integrated, healthcare delivery network, established the MaineHealth Accountable Care Organization (MHACO) to engage the Centers for Medicare &Medicaid Services and other payers in various ACO contracts.