title: How 3 rural safety net clinics integrate care for patients: a qualitative case study.
abstract: BACKGROUND
  Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients.
  
  
  OBJECTIVE
  To examine challenges to care integration in rural safety net clinics and strategies to address these challenges.
  
  
  METHODS
  Qualitative case study.
  
  
  METHODS
  Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative.
  
  
  METHODS
  Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care.
  
  
  RESULTS
  Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration.
  
  
  CONCLUSIONS
  Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.
authors.affiliation: *School of Health and Social Services, College of Health, Massey University, Palmerston North, New Zealand †Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL ‡MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle, WA §American Medical Association, Chicago IL.
authors.forename: Sarah
authors.initials: S
authors.lastname: Derrett
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: Gunter
authors.forename: Robert S
authors.initials: RS
authors.lastname: Nocon
authors.forename: Michael T
authors.initials: MT
authors.lastname: Quinn
authors.forename: Katie
authors.initials: K
authors.lastname: Coleman
authors.forename: Donna M
authors.initials: DM
authors.lastname: Daniel
authors.forename: Edward H
authors.initials: EH
authors.lastname: Wagner
authors.forename: Marshall H
authors.initials: MH
authors.lastname: Chin
mesh_terms: D003120:Colorado; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D009922:Oregon; D019982:Organizational Case Studies; D010348:Patient Care Team / Q000458:organization & administration*; D018802:Patient-Centered Care / Q000458:organization & administration*; D011216:Practice Management, Medical / Q000458:organization & administration*; D016730:Program Development; D015397:Program Evaluation; D036301:Qualitative Research; D019035:Rural Health Services / Q000458:organization & administration*; D064876:Safety-net Providers / Q000458:organization & administration*