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Care Coordination in Rural Communities: Supporting the High Performance Rural Health System

Care coordination has emerged as a key strategy under new health care payment and delivery system models that aspire to achieve Triple Aim objectives—better patient care, improved population health, and lower per capita cost. Achieving these objectives requires conceptualizing and planning care delivery in a new way that not only involves coordinating medical care, but helping people get the care and the support services they need to address the “upstream” social determinants of health. In rural places, these are especially important considerations. While care coordination models vary, all include multidisciplinary teams and networks, a person-centered focus, and timely access to and exchange of information. The purpose of this paper is to examine care coordination programs and processes that affect rural people and places to discover what is happening now in rural communities, how different programs and approaches are working, who benefits, and make policy recommendations that will facilitate care coordination efforts in support of high performance rural health system development.