title: Pathfinding on the Frontier.
abstract: In rural settings, referrals to specialists from primary care providers can be difficult for patients and families to follow up on, sometimes requiring that patients travel great distances. Patient care coordination has been shown to decrease the number of ED visits and hospitalizations, but little is known about its effectiveness in assisting with referrals in rural primary care. This article presents three case studies showing how a nurse care coordinator at a rural primary care practice resolved complex issues involving medications, specialists, and diagnoses.
authors.affiliation: Eldonna Sylvia is evaluator, Greeley County Health Services in Tribune, KS, and Sharon Springs, KS, where Burlay Parks is coordinator of the patient care coordination program and Chrysanne Grund is administrator of the Robert Wood Johnson Foundation grant that funded it. Contact author: Eldonna Sylvia, eldonnasylvia1@gmail.com. The authors have disclosed no potential conflicts of interest, financial or otherwise.
authors.forename: Eldonna
authors.initials: E
authors.lastname: Sylvia
authors.forename: Burlay
authors.initials: B
authors.lastname: Parks
authors.forename: Chrysanne
authors.initials: C
authors.lastname: Grund
mesh_terms: D000368:Aged; D019090:Case Management / Q000458:organization & administration*; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008875:Middle Aged; D062526:Patient Navigation / Q000458:organization & administration*; D011320:Primary Health Care; D012017:Referral and Consultation / Q000458:organization & administration*; D019035:Rural Health Services