Practice Perspectives on Care Coordination in Rural Settings

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.

Ten years from propagule to mature plant of Butia purpurascens Glassman (Arecaceae): an endemic and endangered palm of the Brazilian Cerrado

With occurrence mainly in the southwest Goiás, Butia purpurascens has fruits and leaves widely extracted by the regional population. Coexists with exotic grasses, frequent burnings and cattle's grazing and trampling. Young individuals are rarely seen. We aim to provide information about propagules, seedling formation and the monitoring of saplings of B. purpurascens until adults in reproductive phase. Fruits were selected, measured and benefited after harvest. Of 6,000 fruits collected 3,112 were discarded for being perforated by Conotrachelus weevils. The experiment divided 2,600 fruits into 13 treatments, distributed in ripe and immature fruits, with and without pulp. In addition, we adopt mechanical and chemical break dormancy mechanisms, different storage periods and seeding depths. After sixteen months of monitoring, the formation of eleven seedlings was obtained without distinction of any treatment. Seedlings and saplings developed slowly, taking two years to emit the first metaphyll. Over time, ten individuals died, most from fungal attack. After ten years, the only surviving palm generated two inflorescences, which produced fruit. The inefficient seedling production and the slow development of saplings, combined with the impact of the extractivism and the high rate of predation of the pyrenes, suggest the low recruitment rate of the species observed, in natural conditions. This type of data is one of the important tools for creating guidelines for the species conservation. Therefore, we suggest considering the reclassification of B. purpurascens as a Critically Endangered species in the Official List of Threatened Brazilian Species of Extinction.

Vegetative and reproductive phenology of Butia purpurascens Glassman (Arecaceae) under the effects of leaf harvesting

Butia purpurascens is an endemic and threatened palm tree species that occurs in open areas of the Brazilian Cerrado, predominantly in southwestern Goiás. The leaves of this palm tree are harvested by local people to fabricate brooms. This study evaluated changes in vegetative and reproductive phenology in two different natural populations of this palm tree: one population with leaf harvesting and another non-harvested population. Twenty plants were monitored in each area for 23 months. The phenophases were related to the temperature and precipitation averages for a 30-year period. Leaf sprouting occurred throughout the year, with a slight reduction in periods of low temperatures and low rainfall. The first spathes emerged in March and flowering began during the dry season (June), continuing until January of the following year, concurrent with the period of most intense fruiting. Flowering and fruiting appear to be triggered by periods of drought, which are commonly observed in the Cerrado. The harvested sites produced significantly fewer leaves, spathes, inflorescences and infructescences than the non-harvested sites. Thus, the supply of resources to the local fauna is possibly reduced in sites under leaf exploitation, which in the long term can represent damage to the palm tree population's structure and dynamics. Other socioeconomic and ecological studies about the effects of leaf harvesting in B. purpurascens are necessary to enable strategies for sustainable use, devise management alternatives and conserve this threatened palm species.