Understanding and Facilitating Rural Health Transformation

Tools & Resources

Clinical Care

Clinical care foci and processes are designed to deliver Value-Based Care within traditional medical care settings.

Getting Started on the Road to Value: Assessing Your Organization - The Triple Aim encourages health care providers to improve patient care, improve community health, and lower per capita costs. Health care organizations can use this brief 6-question self-assessment to assess the organization’s readiness to pursue the Triple Aim.

Hospital Guide to Reducing Medicaid Readmissions - The Agency for Healthcare Research and Quality (AHRQ) recently released this guide aimed toward hospitals at all stages of readmissions reduction work. It has six sections with topics ranging from how to analyze root causes of readmissions to suggestions on providing enhanced services to patients at high risk of readmission. It also includes a set of 13 tools, (available as individual downloads), which range from a Readmission Risk Tool to a Discharge Information Checklist.

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.

Compendium of Rural Best Practices/Models Innovations to Strengthen Rural Health Care - The National Rural Task Force brought together this collection of innovative programs occurring in rural areas across the country. Examples include advancement of medical homes, improving efficiency with Lean methods, using telehealth for patient monitoring, and a rural behavioral health network.

Diabetes Telephonic Care: - An RHV innovation profile: This pilot project, conceived of by a Rural Health Clinic physician, aims to increase diabetes patients' understanding of their disease processes and improve their overall health status. The project uses a team approach and telephonic nurse management for diabetes support, educations, and care management and has produced some very promising results.

Rural Care Coordination Toolkit - The Rural Assistance Center and NORC Walsh Center for Rural Health Analysis developed this toolkit to help rural communities identify and implement a care coordination program. Developed by NORC on behalf of the Federal Office of Rural Health Policy (ORHP), the toolkit contains resources to help communities develop care coordination programs by building on best practices of successful care coordination program models.

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.