Need: To help reduce diabetes, depression, and stroke risk in rural residents.
Intervention: A collaborative care model was implemented in the Idaho counties of Clearwater, Idaho, and Lewis.
Results: Increased number of patients with controlled blood sugar, controlled blood pressure, and higher depression screening rates.
Mary's Hospital and Clearwater Valley Hospital and
Clinics serve approximately 28,000 people in 3 counties
of North-Central Idaho, Clearwater, Idaho, and Lewis,
including parts of the Nez Perce Indian Reservation.
The Medical Home Plus project was created in partnership
with 9 consortium members to connect frontier residents
with primary care providers, active nurse case managers,
and integrated community referral coordinators.
The project utilizes a collaborative care model and a
medical home model. Nurse case managers worked as team
members in a patient-centered medical home to help set
patient health goals, discuss barriers, identify
solutions along with monitoring patients' progress. They
also encouraged patients to get needed diagnostic
testing. The case managers additionally discover issues
with medication management and help create solutions.
Other activities included transportation assistance for
appointments, and assisting with issues stemming from
social isolation and poverty.
The model further integrated case management with
community referral coordinators, 1 hired at each
hospital. Coordinators maintained an online database of
community resources such as mental health resources,
substance abuse counselors, and weight loss programs.
Additionally, case managers sent service requests to the
referral coordinators, who then helped track specialty
referrals, appointments, and results. Medical Home Plus
received support from a 2012-2015 Federal Office of Rural
Health Policy Rural Health Care Services Outreach grant.
Grant funds were used to hire nurse case managers and
community referral coordinators at 3 primary care clinics
managed by 2 Critical Access Hospitals.
Case managers were assisted by community referral
coordinators, who were hired at each of the 2 Critical
Access Hospitals. Coordinators maintained an online
database of community resources such as mental health
resources, substance abuse counselors, and weight loss
programs. Case managers sent service requests to the
referral coordinators, who then then helped track
specialist referrals, appointments, and results.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.