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Chautauqua Health Connects (CHC)

  • Need: To address care coordination and the integration of services in a rural, aging population
  • Intervention: This program used health information technology and dedicated staff to manage clinical and community services for patients with complex needs.
  • Results: Hospital readmissions have decreased, follow-up rates have increased, and patients' perceived health status has improved.


Chautauqua County Health Network logo Along the Chautauqua Ridge lie some of New York's poorest communities as well as a shrinking and aging population. A growing number of seniors in the area are unable to continue living independently due to physical or mental limitations. Addressing long-term care needs has become a serious issue.

The Chautauqua County Health Network created Chautauqua Health Connects (CHC), which focused on rebuilding independent primary care practices into an integrated network of Patient-Centered Medical Homes (PCMHs). This program utilized many evidence-based models, including the Chronic Care Model (CCM) and the PCMH model.

CHC was established in partnership with the Chautauqua County Office for the Aging and Heritage Ministries to improve communications for care transitions and facilitate the integration of referrals to community-based services/programs into the workflows of the PCMH. CHC served as a local health information exchange (HIE) and included a secure messaging and referral application. Participating facilities were able to connect to this exchange through admission, discharge and transfer feeds, clinical data exports, and secure messaging. This allowed care coordination to take place.

CHC also implemented a Guided Care (GC) program based on the Guided Care model, in which a Registered Nurse (RN) within each practice was trained to manage clinical and community-based care services for complex, ill patients. As a result, CHC was able to bring an array of health, social, and support services into a more cohesive service delivery system.

This program received support from a 2012-2015 Federal Office of Rural Health Policy (FORHP) Rural Health Care Services Outreach grant.

After the grant ended, the Chautauqua County Health Network continued providing technical assistance and facilitating the development of PCMHs within the primary care practices. CCHN also uses a different electronic referral process. Since Direct Secure Messaging is available to most practices with an electronic health record (EHR) system and to community-based organizations for free through the Regional Health Information Exchange, a third-party vendor was no longer needed. This program is more sustainable due to lower costs and easier workflow.

The GC program officially ended in 2016, but financial support continued until early 2017 for the practices that utilized GC-trained nurses. Practices were encouraged to adopt utilization of the Chronic Care Management Services program, which would help provide financial reimbursement to the practices for the GC nurse's time.

Services offered

The HIE services included:

  • Identification of key staff from partner agencies to participate in workgroup meetings
  • Sending information including patient history, transfer feeds, discharge instructions, healthcare proxies, referrals, and outcomes
  • Development of a referral feedback report
  • Training of facility staff
  • Monitoring utilization

At the height of the Guided Care program, the network had 9 nurses in 8 different practices. GC services included:

  • Identification and recruitment of RNs to participate in training
  • Development of protocols and processes to identify, enroll, assess, manage, and monitor complex, ill patients
  • Creation of monthly GC Nurse Learning Collaborative to share experiences and orient them to community resources and utilization of the HIE

Currently, the network has a health information technology committee that meets regularly. This committee shares opportunities to add services or receive funding and informs network partners of changes in the HIE.

The network also has the Care Coordinator Learning Collaborative, which brings in guest speakers from community-based and larger organizations. This learning collaborative helps participants keep their knowledge base current, learn about new community services and resources, and build relationships that will encourage referrals to those organizations. Currently, 7 organizations participate in the learning collaborative.


During the grant period, CHC:

  • Connected 26 organizations to the HIE
  • Increased utilization of secure messaging and referrals over one year, resulting in approximately 17,000 transactions as of March 2015
  • Produced a replicable electronic referral process that has been adopted by 6 practices
  • Improved care transitions, with 45% of patients following up with their primary care provider within 7-14 days of discharge

In addition, CHC saw the following results:

  • 3% reduction in hospital readmissions
  • Approximately 237 patients served by a GC nurse from 2012 to 2015
  • 4.5% decrease in 2014 readmission rate for GC patients compared to 2013 rate
  • 102% increase in referrals from 2012 to 2015
  • 30% of patients with improved Patient Activation Measure score
  • 25% of patients with improved RAND 36 Health Survey score, a health-related quality of life survey

In 2018, the Chautauqua County Health Network was named Champion of Impact in HRSA's list of Rural Health Champions.


Only RNs were eligible to participate in the GC program and some small practices don't have one on staff. Program coordinators also thought that coding and billing for chronic care management services would have paid for the nurses' time and eventually for the program itself. But the chronic care management services billing codes at the time proved to be significant barriers. Now, a number of these barriers have gone away, making this type of program easier to implement and potentially more sustainable.

Additional challenges this program faced include:

  • Timing constraints due to vacancies, budget cuts, facility closures, and internal technology
  • Financial struggles of network partners
  • Turnover and the expense of training new staff (GC training used to cost $2,000 per person)
  • Recruitment of nurses: Training was often seen as another responsibility to an already busy schedule.
  • Services attrition
  • Delayed response time for referrals due to limited staffing
  • Limited capacity and funding, causing some patients to be placed on waitlists
  • Confusing eligibility requirements for community services
  • Practices struggling with the gap between a fee-for-service system and value-based payment structures
  • GC program competing with other projects


In order to create a similar program, it is important to:

  • Gain buy-in with leadership early on and have a physician who can champion the program.
  • Start small with 2-3 organizations to conduct a pilot program.
  • Coordinate a technology audit of partnering organizations.
  • Develop protocols and processes as a group.
  • Conduct staff training to familiarize workers with available community resources and referral technology.
  • Work with partners systematically and collectively on clinical integration, care coordination, and the implementation of evidence-based practices.
  • Make necessary workflow adjustments to utilize the GC network.
  • Invest in infrastructure and redesigned care processes.
  • Monitor progress.

Contact Information

Lisa Smith, Interim Director
Chautauqua County Health Network
716.338.0010 Ext. 1202

Care coordination
Health information technology
Medical homes
Networking and collaboration

States served
New York

Date added
September 16, 2015

Date updated or reviewed
December 12, 2018

Suggested citation: Rural Health Information Hub, 2018. Chautauqua Health Connects (CHC) [online]. Rural Health Information Hub. Available at: [Accessed 28 October 2020]

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.