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Rural health organizations are integrating social services into care coordination, addressing transportation, mental health, food, and housing needs. Despite challenges, innovative solutions are emerging to improve care quality for diverse populations.

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Area of Science:

  • Health Services Research
  • Rural Health
  • Care Coordination

Background:

  • Social needs and nonmedical health determinants are increasingly integrated into care coordination.
  • Operationalizing enhanced care coordination, especially in rural settings, is not well understood.

Purpose of the Study:

  • To determine care coordination practices in rural settings that integrate social services with health care.
  • To assess the quality of care provided compared with a recommended standard.

Main Methods:

  • Mixed-methods study involving 16 key informant structured interviews.
  • Interviews conducted with staff and administrators in rural Missouri health and health care settings.

Main Results:

  • Organizations reported a median care coordination population of 800, with a median of 11 case managers.
  • Prevalence of social determinants of health services: 100% transportation, 86% mental health, 79% food, 71% housing, 50% dental.
  • Implementation of essential care coordination quality indicators ranged from 41.7% to 100%.

Conclusions:

  • This study provides insights into rural care coordination practices and quality assessment.
  • Innovative interprofessional examples of enhanced care coordination initiatives are presented for rural health organizations.
  • Fundamental barriers to quality care persist as care coordination evolves to include social determinants of health.