• Sarah Derrett, Kathryn E Gunter, Robert S Nocon, Michael T Quinn, Katie Coleman, Donna M Daniel, Edward H Wagner, and Marshall H Chin.
• *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.
• Med Care. 2014 Nov 1; 52 (11 Suppl 4): S39-47.

BackgroundIntegrated 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.ObjectiveTo examine challenges to care integration in rural safety net clinics and strategies to address these challenges.Research DesignQualitative case study.ParticipantsThirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative.MethodsInterviews 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.ResultsParticipants 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.ConclusionsCare 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.

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