Rural health networks and care coordination: Health care innovation in frontier communities to improve patient outcomes and reduce health

Pat Conway, Heidi Favet, Laurie Hall, Jenny Uhrich, Jeanette Palcher, Sarah Olimb, Nathan Tesch, Margaret York-Jesme, Joe Bianco

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Rural residents’ health is challenged by high health care costs, chronic diseases, and policy decisions affecting rural health care. This single- case, embedded design study, guided by community- based participatory research principles and using mixed methods, describes outcomes of implementation of a community care team (CCT) and care coordination to improve outcomes of patients living in a frontier community. Seventeen organizations and 165 adults identified as potential care coordination candidates constituted the target populations. Following CCT development, collaboration and cohesion increased among organizations. Patients who participated in care coordination reported similar physical and lower emotional health quality of life than national counterparts; emergency department use decreased following care coordination. Key components identified as successful in urban settings seem applicable in rural settings, with emphasis on the key role of team facilitators; need for intense care coordination for people with complex health needs, especially behavioral health needs; and access to specialty care through technology.

Original languageEnglish (US)
Pages (from-to)91-115
Number of pages25
JournalJournal of health care for the poor and underserved
Issue number4
StatePublished - Nov 2016

Bibliographical note

Funding Information:
State Innovation Model (SIM) Accountable Communities for Health (ACH) Pilot. Ely Community Care Team Pilot 7/1/11-6/30/12, Second Phase 11/4/14-12/31/16. This project is part of a $45 million State Innovation Model (SIM) cooperative agreement, awarded to the Minnesota Departments of Health and Human Services in 2013 by The Center for Medicare and Medicaid Innovation (CMMI) to help implement the Minnesota Accountable Health Model, awarded to Essentia Health Ely Clinic. MDH Practice Transformation grant 3/26/15-10/31/2015: Awarded to Well Being Development to plan for behavioral health network. Essentia Foundation July 1, 2012-June 30, 2013. Ely Community Care Team. Enhanced Evaluation of the Ely Community Care Team 11/1/2012-6/30/2014. Supplementing funding available for evaluation through the SIM programmatic grants. Ely Community Health Worker Pilot 2/1/2014-6/30/2015. Funds awarded to the Essentia Health Ely Clinic to pilot the use of community health workers. Made possible with funds from the Essentia Health Foundation. University of Minnesota Clinical and Translational Science Institute, Rural Community Capacity Enhancement 8/1/2012-7/31/2013. North St. Louis County Family Services Collaborative January 1, 2013-December 31, 2013. HRSA Network Planning Grant June 1, 2015-May 31, 2016: Planning and development of the Ely Behavioral Health Network, a network within the Ely Community Care Team, under the Rural Health Network Development Planning Grant Program (Grant # P10RH28450) to Well Being Development. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Publisher Copyright:
© Meharry Medical College.


  • Case management
  • Community health workers
  • Continuity of patient care
  • Medically underserved area
  • Mental health
  • Patient care team
  • Patient- centered care
  • Primary health care
  • Quality of life
  • Rural health
  • Social determinants of health


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