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.

Population Health Strategies of Critical Access Hospitals - Hospitals and health systems are increasingly embracing population health strategies as they move toward accountable care models of health care delivery and financing and seek to demonstrate accountability to local stakeholders. The Flex Monitoring Team released a full-length briefing paper examining the population health strategies of eight CAHs that have made substantial commitments to population health and community health improvement.

Understanding the Social Determinants of Health: A Self-Guided Learning Module for Rural Health Care Teams - Developed to help rural health care organizations learn more about the concept of social determinants of health, and encourage rural leaders and care teams to support activities that help address these issues and improve health in their communities. No time? Try the Brief Overview and Discussion Guide

Hospital Based Strategies for Creating a Culture of Health - As the United States health care system transforms, hospitals are playing a greater role in building a culture of health in their communities. Use this resource to help you in your transformation efforts.

Rural Taxonomy of Population and Health-Resource Characteristics - The Rural Health Value team has developed a rural taxonomy of community population and health-resource characteristics to provide a systematic tool for classifying and identifying similar rural communities and places. The classification tool can be utilized by policy makers and rural communities to assess the community's own profile, identify similar communities, and develop strategies for improving health and health care using a comparative framework.

The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships - Inter-organizational partnerships are an efficient and effective way to reduce costs and improve population health. Small and rural hospitals can use strategies outlined in this resource to leverage local community partnerships and relationships.

Rural Community Health Gateway - The Rural Community Health Gateway can help you build effective community health programs and improve services you offer. Resources and examples in the Gateway are chosen for effectiveness and adaptability and drawn from programs with a strong history of service and community success.  Current evidence-based toolkits include a focus on oral health, obesity prevention, and community health workers.

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.

Improving Population Health: A Guide for Critical Access Hospitals - The National Rural Health Resource Center convened subject matter experts from around the country to create this tool for rural hospital leaders in support of incorporating population health principles and programs into strategic planning and operations. Tools, resources, suggested readings, case studies and materials on how to integrate population health as culture change are included.

Innovative Health Care Provider Roles (updated 8/18/2014) - Innovative rural communities seek to address some health care workforce challenges in creative ways, such as by expanding current provider roles and employing community members in new health care capacities. Read on to learn about some of these rural health workforce strategies and how you might implement them in your own community.

Mobilizing Community Partnerships in Rural Communities: Strategies and Techniques - Building partnerships among hospitals, health care providers, local health departments (LHDs), social services agencies, non-profit organizations, and the private sector is essential to meet the needs of rural communities and build value in health care delivery. The National Association of County and City Health Officials (NACCHO) considers partnership at the local level critical in safeguarding the health of all communities. This guidebook describes how rural communities can develop and maintain partnerships and provides stories from the field.

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).

Rural Matters Online Data Event - Data is increasingly important to help tell your story. To learn more about how you can use public data (through maps, reports, and other data visualizations) to evaluate and share information about your rural community, watch this series of three 19 minute webinars from Community Commons. Scroll to the bottom of the linked page for the video recordings.

Emergency Department Super Utilizer Programs - 'Super utilizer' patients often present to the emergency department with chronic and low acuity health concerns that are inappropriately addressed in a setting designed to care for acute, episodic, and emergent health conditions. Super utilizer programs identify super utilizers and facilitate alternative care models such as primary care coordination and social service assistance. Super utilizer programs generally improve participant health, reduce emergency department visits, and decrease hospital charges. This Rural Health Value white paper describes super utilizer program design, implementation, operation, and assessment.

Frontier Extended Stay Clinics (FESC): The RHV Team has summarized this innovative rural health care demonstration, that expands service in existing clinics to include extended stay (up to 48 hours) and emergency services.

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 Service Delivery Integration & Patient Engagement: - An RHV innovation profile: Engaging local resources to tackle local health care challenges is an effective community health improvement strategy. Learn how a rural California county is working toward a fully integrated and responsive health care delivery system through patient engagement, unnecessary surgery reduction, and emergency department "super utilizer" care management.

Using Data to Drive Change: Targeting High Service Utilizers: - An RHV innovation profile: Faculty members at the University of Oklahoma are using data to identify high utilizers of emergency department and other hospital services and then support care in more appropriate settings. Learn how one physician focuses on high-need/high-cost patients to understand fundamental patient needs and meet those needs with targeted services.

A Rural Accountable Care Organization: - An RHV innovation profile: Accountable Care Organizations (ACOs) currently operate in rural areas in every region of the country. Learn from the Executive Director of the South East Rural Physicians Alliance (SERPA) ACO, who is coordinating the design and implementation of the rural-based and physician-led Advance Payment ACO in rural Nebraska.

Using Community Connectors to Improve Access: - An RHV innovation profile: The Community Connector Program aims to 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 Hospital Community Outreach: - An RHV innovation profile: The Richland Parish Hospital Pre-Diabetes Program is a health screening and follow-up model that was designed to prevent or delay early onset diabetes. Evaluation after three years showed a "statistically significant association" between program participation and reduced rates of progression from pre-diabetes to true diabetes.

Investing in Population Health: - An RHV innovation profile: A community health system, in consortium with state stakeholders, has established a Medicaid population health support system in rural and frontier areas that is viable and transferable across all patient populations.

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.

Using Data to Understand Your Community - For rural communities or organizations seeking to address the Triple Aim©, using data to better understand your community's population can be a useful starting point. Read on to find useful websites (and how you might best use them) that include demographic, population, health, and other data for ZIP code, city, county, and state-level geographic areas.

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.