Practice Perspectives on Care Coordination in Rural Settings

Abstract

Purpose:

Social needs and nonmedical health determinants are increasingly incorporated into care coordination models. However, little is known about the practice of operationalizing enhanced care coordination, particularly in rural settings. The objective of this study was to determine care coordination practices in rural settings that integrate social services with health care.

Primary Practice Settings:

Staff and administrators in rural Missouri health and health care settings were interviewed about their organization's implementation of enhanced care coordination practices.

Methodology and Sample:

This is a mixed-methods study; 16 key informant structured interviews were conducted across 14 organizations.

Results:

Organizations reported a median care coordination population of 800 (range: 50–21,500) across a median of 11 case managers (range: 3–375). The percentage of organizations reporting social determinants of health services included the following: 100% transportation, 86% mental health, 79% food, 71% housing, and 50% dental. Implementation of the essential indicators of care coordination quality ranged from 41.7% to 100%. We report organizations' innovative solutions to care coordination barriers.

Implications for Case Management Practice:

This study contributes to a very limited literature on the practice of rural care coordination by assessing the quality of care provided compared with a recommended standard. This study also contributes an in-depth reporting on the variety of service models being implemented. Finally, this study uniquely contributes innovative interprofessional examples of enhanced care coordination initiatives. These examples may provide inspiration for rural health care organizations. As the care coordination landscape evolves to include social determinants of health, there remain important fundamental barriers to ensuring quality of care.

U.S.-based health care organizations are transforming their delivery models by integrating health care and social services. Traditionally, care coordination has focused on continuity of health care services and bridging transitions, often in the form of case management (Duan-Porter et al., 2020). “Enhanced” care coordination expands services to include social services and linkages to resources for social needs (Albertson et al., 2021). For example, Accountable Health Communities connect Medicare and Medicaid beneficiaries to community resources in order to address transportation challenges, housing instability, difficulty paying utilities, food insecurity, and interpersonal violence, including elder abuse and child maltreatment, with the understanding that this connection results in improved health outcomes and reduced costs (RTI International, 2020).

Actualizing enhanced care coordination is challenging, given financial models, service delivery cultures, perspectives, and organizational structures. Health care organizations are biased toward acute and episodic care (Kuluski et al., 2017), whereas development of interprofessional, interorganizational partnership models for integrated care addressing social needs is a long-term, multicomponent process (Minkman, 2012). Perceived risks of interorganizational collaboration include reputation, sustainability, and compliance with regulatory or funder requirements (Petchel et al., 2020). The rural context adds complexity. Hospitals with more care coordination indicators are less likely to be in rural areas (Gill et al., 2020). Barriers to care planning in rural settings include a paucity of specialists, substantial patient travel time (Derrett et al., 2014), poverty, limited broadband service, and limited transportation to specialist appointments (Gill et al., 2020).

A review of care coordination models with social services identified variability in target populations and services (Albertson et al., 2021). Although early results of enhanced care coordination suggest promise for improved patient well-being and reductions in key social determinants of health (SDoH) barriers (Bradley et al., 2018; Singer & Porta, 2022), this field is still emerging and significant literature gaps remain related to rural settings. Developing a more contextually relevant understanding of the rural care coordination setting is critical. This study investigates how enhanced care coordination is implemented in rural practice.

Methods

Study Design

This mixed-methods design included an environmental scan and structured qualitative interviews of staff in rural Missouri health and health care settings about their organization's implementation of enhanced care coordination activities.

Eligibility

In September and October 2021, the authors conducted an environmental scan to identify key health and health care organizations in rural Missouri. Eligibility criteria including organizations that served rural Missouri counties, with a multisector care coordination model extending beyond health care needs to include social services and/or SDoH. For brevity, the authors refer to SDoH to include social needs. Critical case methodology (Gill et al., 2020) guided identification of organizations likely to “yield the most information and have the greatest impact on the development of knowledge” (Patton, 2015, p. 276). On the basis of their primary service area, organizations were classified as rural or nonrural in accordance with guidelines (Health Resources & Services Administration, 2018). The scan included websites and publicly available documents such as online reports and IRS Form 990 to identify social services. Prioritized organization types included Federally Qualified Health Centers (FQHCs), MO HealthNet (Missouri Medicaid) Primary Care Health Homes, and Missouri Community Mental Health Center Healthcare Homes.

In November 2021, six key stakeholders reviewed the list of candidate organizations for confirmation of eligibility and to identify known gaps. Stakeholders were affiliated with medical institutions, statewide health care and policy networks, or experts in care coordination, rural health care, or related fields. This inquiry affirmed the list of organizations and identified additional organizations.

Structured Interview

No standards exist for the implementation of enhanced care coordination delivery. Schor (2019) recommended 10 essential characteristics of care coordination (see Table 2) to serve as a shared set of assumptions developed from a review of key indicators of health care coordination quality. A structured interview script was developed on the basis of the 10 essentials, as well as care coordination program elements linking health and social services (Albertson et al., 2021). The script was piloted internally and then with an external expert. The interview script is reported in Figure 1.

TABLE 2. Percentage of Respondents From 12 Rural Health Care Organizations That Reported Implementing the Essential Characteristics of Care Coordination and Representative Quotes.

10 Essentials	%
Essential 1. Process is family-centered, team-based, and has well-defined goals, infrastructure, and responsibilities (reporting all three)	66.7
Family is not always available to participate in the care plan, but we do recognize that it's a huge influence in the success of a care plan ... we always try to identify a couple items, how families can support. (FQHC)
Essential 2. Comprehensive assessment of the patient's health and psychosocial needs.	91.7
We ... have a standard process for any patient who comes in our door ... our goal is to see all of our patients ... and determine ... what is their home situation like, do they have money for food, do they have heat, do they have running water? So, do they have those basic needs of living? Do they need assistance with home health? Do they need a placement in a skilled nursing facility for short term? Do they have insurance? Is their insurance adequate for what their needs are? Do we need to get them set up to apply for insurance? Do they have a primary care provider? Do we need to get them set up with a specialty care provider to make sure that they're being followed? (Hospital)
Essential 3. Written care plan jointly developed by the family and/or patient and key health care professionals.	91.7
We have care plans on any of our patients in our health home and patients that we do chronic care management on.... They're individualized based on the patient's wants and needs. The family is included if the patient wants. (Hospital)
Essential 4. Care plan is regularly reviewed and modified.	91.7
We have those two nurses (two care coordinators). They call patients on a monthly basis and spend at least 20 minutes with the patients talking to them: “How are you doing? How's your diabetes?” Or whatever it may be that they are working with them on and to see are there any other needs that they have ... they do check ins with them. (FQHC)
Essential 5. Face-to-face communication between the care team and patient/family, augmented by synchronous and asynchronous modalities.	66.7
[Communication] has to be at least once a month face-to-face unless something's going on, like we're quarantined and we can't see them.... But a lot of times our staff will check on a client, even if they only see them face-to-face once a month, they'll check with them by phone at least every week or every ... other week. (Behavioral health)
Essential 6. Information and other supports provided to help the patient/family with management.	91.7
We are an organization that is heavy on stages of change. So, if somebody is on precontemplation or contemplation stage of change, then ... we're focused on patient-centered, but we are assisting them throughout that until they get to the stage of action and maintenance stage, then we let them do their work. (Behavioral health)
Essential 7. Coordination occurs between health care and social service and/or community service providers.	91.7
We actually did just hire a housing liaison: a person who focus[es] strictly on housing ... we work with ... housing authorities ... landlords ... to assist people in obtaining housing. We also work with the ... food bank and they have a few other resources, you know, used clothing and ... other things. (FQHC)
Essential 8. Patient has an identified care coordinator who has regular contact with the family and clinician.	75.0
[What] I've seen overall is that it's really a connection point for these patients....“Hey, you know, I need you to get me some transportation. I need you to talk to the provider. I can't do this or whatever.” I think we're really just kind of a bridge there to help them meet the resources that they need. (Hospital)
Essential 9. Electronic health information system facilitates communication between providers, patient, and family.	41.7
We do have an email option. And we have a patient portal as well. We are looking into, in the very near future, to add text capabilities as well. ...most of our referrals, unless it is to a completely higher level of care, are within our facility, and so they all have access to the same EHR. (Hospital)
Essential 10. Transitions of care are proactively planned.	100.0
We do not want a client to have to navigate the services that we address through the SDoH on their own and that's what our care coordinator does. [They] are the ones that make sure that this person gets connected to the next service that their previous provider referred them to. (Behavioral health)
Met all 10 essentials	16.7

Note. EHR = electronic health record; FQHC = Federally Qualified Health Center; SDoH = social determinants of health.

FIGURE 1.

Key informant interview survey instrument.

Recruitment

Organizations were invited for interview following purposive sampling based on representation of organization type and geographical diversity, targeting care coordination managers or a similar role. An email was sent first, followed by a scripted phone call if no response. If an email address could not be located, then contact was initiated by phone. If the invitation generated a positive response, an interview time was scheduled, generally within 7–10 days. When interviewees suggested additional individuals to contact within their organization, those individuals were also invited to participate as snowball sampling. All interviews were held and recorded via the software program Zoom, and verbal consent to record was affirmed at the start of each interview. Zoom generated a preliminary transcript, which was then corrected as needed against the audio recording. Interviews occurred January through April 2022.

Data Analysis

Organizations were characterized with descriptive statistics. The two “other” organizational types were excluded from certain calculations when not applicable. Two members of the research team independently coded the transcript using NVivo 17.0 software following a coding scheme developed from the structured interview. Team discussions resolved any differences. The purposive sampling framed data saturation. The institutional review board did not consider this human subjects research as the study investigated organizational processes.

Results

The environmental scan identified 33 candidate organizations, of which 27 met our inclusion criteria. The authors completed interviews with 16 individuals across 14 organizations (51.9% organizational response rate). Interviews lasted a median of 38 min (range: 10–67 min). Descriptive characteristics are reported in Table 1. The following sections highlight key findings:

TABLE 1. Characteristics Reported By 14 Rural Organizations Participating in Interviews.

Variable	%
Organization type
Behavioral health	35.7
Federally Qualified Health Center	28.6
Hospitals	21.4
Networks/Other entities	14.3
Social determinants of health
Transportation	100.0
Mental health services	85.7
Food	78.6
Housing	71.4
Dental care	50.0
	Median (Range)
Care coordination population size	800 (50–21,500)
Number of case managers	11 (3–375)

Screening Tools and Social Determinants of Health

Common screening tools and assessments implemented by organizations included the Patient Health Questionnaire-9 (41.7%), Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) (33.3%), and Daily Living Activities-20 Functional Assessment (33.3%). Other tools included the General Anxiety Disorder-7; Patient Health Questionnaire-2; Devereux Early Childhood Assessment; World Health Organization Quality of Life assessment; Columbia-Suicide Severity Rating Scale; Screening, Brief Intervention and Referral to Treatment (SBIRT); CAGE-Adapted to Include Drugs (CAGE-AID) questionnaire; and internally developed tools.

The percentages of organizations providing SDoH services or referrals are reported in Table 1. Five organizations (35.7%) provided services for all SDoH listed.

Metrics

When asked about quality improvement or process metrics, respondents reported tracking completed care plans, process improvements, client satisfaction, and patient engagement. Short-term outcomes included health care utilization frequency and patient functionality. Longer term outcomes included readmissions/rehospitalization and health outcomes.

Diversity

Organizations provided diversity training on and/or served a range of subpopulations with unique needs, including Amish, Muslims, Mexican immigrants, Congolese immigrants, low-income, and high utilizer Medicaid clients.

We've done some training with the Amish [community]. We have a pretty significant Amish community.... They don't typically use primary care because they have their nurse midwives [who] do their health care, primarily ... unless it's a really significant issue. (FQHC)

[The Congolese population] don't tend to seek out traditional Westernized mental health services that much, but we do have that ability to seek interpreters. (Behavioral health)

Rurality

The rural setting was specifically mentioned by respondents from 9 out of 14 (64.3%) organizations. Responses mentioned limited local resources and partners, with some better able to overcome challenges than others.

If you've seen one rural community, you've seen one rural community. Because they all have different resources. (Other entity)

We are a rural health network, so we have about 70 different partners ... [such as] food pantries, faith based ministries, social service organizations. We have ... a 7,500 square foot warehouse ... we glean items that would otherwise go in the landfill and they're not trash ... such as laundry detergent, personal hygiene items, shampoo, conditioner, body wash, detergent—things that can't be bought with food stamps. We get gently used mattresses, bed frames, durable medical equipment ... brand new window air conditioners. We [screen], so if someone has a need, then ... we are able to help them. We call it a hand up, not a handout. (FQHC)

Transportation solutions included volunteer programs, partnering with a statewide provider, and developing a custom transportation model.

Transportation is a SDoH squared [because] it affects other SDoH.... How do people get to the pharmacy, the grocery store ... are they employed? ... We're working with the health transportation program to really take a look at not just getting people to health care, but really getting them to other things that affect their health care. (Other entity)

We have volunteer drivers that get reimbursed 80 cents a mile to take folks to and from their ... appointments. [After COVID-19 shut things down, we] started our own initiative.... Since 2018, we have done over 3,000 rides and are still continuing to do that. (FQHC)

Structural challenges included communication across differing health systems.

A hospital might own a rural health clinic where that patient enters. But [the patient] might, during the same year, go to a FQHC ... on a different [electronic health record (EHR)] system and have different ... providers. But let's say they go there for their behavioral health or their dental health. Well then there's ... two ... different patient records and one may not talk to the other. And then they might be receiving services at their community action agency. They might need housing assistance.... That might really tie into their behavioral health services that they might be getting. And what about pharmacy? (Other entity)

COVID-19 created additional challenges in the rural setting.

COVID-19 only [worked] to ... isolate patients a little bit more [than already is the case in rural areas]. As case managers, they had to really work around how do we address that isolation and separation for patients, as well as everything else that you're working on. (FQHC)

Because we live in a rural area, we are some people's only method of transportation to get food ... the food pantries and stuff around here were very understanding. We could pick up food for our clients and just drop it off with no contact. Just to make sure that they had their needs met. (Behavioral health)

Ten Essentials of Care Coordination

Table 2 summarizes the percentages of organizations reporting each care coordination essential and representative quotes. The most commonly reported essential (100%) included that transitions of care are proactively planned (Essential 10). The least commonly reported essential (41.7%) included an electronic health information system that facilitates communication (Essential 9). Two organizations (one hospital, one FQHC) reported implementing all 10 essentials.

Responses to Essential 1 included co-establishing goals, standardizing processes to screen patients, providing warm handoffs to providers, and seeking a role for the family. Responses to the second essential diverged widely, from deferring to the clinical process and filing results in the EHR to actively and systematically screening patients for needs and then providing access to needed resources. Regarding a codeveloped written care plan, responses ranged from simply filing the plan in the EHR to individualizing plans with the patient's and family's goals in mind. Responses from two FQHCs on the fourth essential represent the range of divergent practices: modifying the plan annually or more often if needed to proactive monthly patient follow-ups to check in on progress. Regarding the fifth essential, infrequent communication included a single face-to-face meeting in the hospital. Frequent communication included once-a-month face-to-face meetings supplemented with weekly phone check-ins (behavioral health). Responses to the sixth essential ranged from simple conversations with patients to actively supporting patients throughout the stages of change continuum. Responses to coordination of services ranged from helping to make appointments to working with the range of SDoH (including housing, Medicaid, behavioral health, food banks, and transportation). Responses to the eighth essential included from communication occurring within the EHR to coordinators serving as a bridge for clinical or other needs that arise. Responses to Essential 9 ranged from not currently having an EHR to having an EHR with an email option, patient portal, access across providers, and soon text capabilities. For the 10th essential, responses ranged from providing patients with printed instructions for managing their own care to partnering with the patient throughout their navigation of services.

Discussion

The need to better address rural health is quite real. This study contributes to the scarcity of literature on rural care coordination by examining how organizations in rural Missouri are implementing enhanced care coordination models in practice using key indicators of quality as a framework. Heartening findings include the innovations implemented by organizations in response to challenges. For example, when local transportation services were discontinued during the pandemic, one of the FQHCs developed their own model. Another FQHC gathers usable items (e.g., toiletries, furniture, bedding) bound for the landfill to redistribute to patients in need. All organizations offered transportation services to their clients, and those services were not restricted to direct medical care but included SDoH needs such as food.

Implementation of the 10 essentials of quality ranged from 41.7% to 100%. Findings suggest promise for the quality of rural care, with seven out of 10 essentials being met by 75% or more of the organizations. However, the degree to which these essentials were met varied. For example, although 100% of organizations “met” the essential of proactively planning transitions of care, responses ranged from providing patients with printed instructions for managing their own care to actively partnering with the patient throughout their navigation of services. Rural populations are subject to higher rates of health inequities than their urban counterparts (Gill et al., 2020), and care coordination is less common in rural settings where the need for coordinating care may be greater (Chen et al., 2020). Care coordination, as opposed to care, includes a proactive plan, active monitoring, follow-up, and responding to change (McDonald et al., 2014). Care coordination, as intended, is difficult to accomplish when care plans are only updated annually or implemented passively.

Policy Implications

Awareness of care coordination models, frameworks, measures, and assessment tools (Peterson et al., 2018) through workforce training could help organizations evolve their practices. Given a lack of standardization of screening instruments, training should include available instruments. PRAPARE (National Association of Community Health Centers, 2020) includes SDoH questions such as family and home, money and resources, and social and emotional health. The Centers for Medicare & Medicaid Services also offers a health-related social needs screening tool (Centers for Medicare & Medicaid Services, n.d.). The lack of policy requiring standardized care coordination may explain health disparities (Gill et al., 2020). Policies should focus on aligning care coordination practices to a standard and evaluation of those practices for improved outcomes.

Limitations

Potential bias is inherent in qualitative coding; risks were mitigated through the use of a framework, structured interview, and blinded coding. It is possible key organizations were not identified; however, our multistep environmental scan review by key stakeholders provided validation. All responses are based on the reporting of the organizations' representative(s).

Implications for Case Management Practice

This study contributes to a limited literature on the practice of rural care coordination by assessing the quality of care provided compared with a recommended standard. This study also contributes an in-depth reporting on the variety of service models being implemented. Finally, this study captures innovative interprofessional examples of enhanced care coordination initiatives. Examples may inspire other rural health care organizations. As care coordination evolves to include SDoH, there remain important fundamental considerations to ensuring quality of care.