Rural Project Examples Addressing Integrated service delivery

TeleStroke/Vascular Neurology Patient Navigator Program
Added March 2019

Need: Improve post-hospital stroke care access in order to improve physical function and well-being for stroke patients living in a 6-county area in rural Minnesota.
Intervention: Implementation of an evidence-based patient navigator program paired with telehealth services for post-hospital care of rural stroke patients.
Results: In addition to other successes, more than 120 individuals enrolled in the navigator program, the Modified Rankin Score assessments at baseline and 6 months showed functional improvements.

Healthy Outcomes Integration Team
Updated/reviewed November 2018

Need: To provide integrated treatment planning and coordinated healthcare services to rural residents.
Intervention: The Healthy Outcomes Integration Team was designed to treat adults who have a serious mental health condition and those who have, or are at risk of developing, chronic health conditions.
Results: Clients received coordinated care, substance abuse treatment, crisis services, and wellness planning. Many also improved their physical health outcomes.

Cross-Walk: Integrating Behavioral Health and Primary Care
Updated/reviewed October 2018

Need: To address and treat substance abuse and depression in the Upper Great Lakes region.
Intervention: Cross-Walk, a program that integrates behavioral healthcare into primary care services, was developed in Michigan's Marquette County.
Results: The collaborative efforts strengthened care management services in local healthcare facilities as primary care patients were referred to a behavioral health specialist.

Physical and Behavioral Health Integrated Care Project
Updated/reviewed October 2018

Need: To provide unified and seamless access to primary care to adult patients in Pennsylvania's rural Clearfield and Jefferson counties who have been diagnosed with Serious and Persistent Mental Illness.
Intervention: A "one-stop shop" of healthcare services addressed the physical and behavioral health and medication needs of adults in the region.
Results: Results indicated better behavioral and physical health outcomes for participants as well as increased adherence to medications.

Recovery-Oriented System of Care (ROSOC)
Updated/reviewed September 2019

Need: To serve adults in Mendocino County, California with chronic substance use disorders, mental health diagnoses, and/or complex medical conditions who frequently utilize emergency departments and jail services.
Intervention: A safety net organization was formed that works with medical providers and law enforcement to reduce the high cost of caring for frequent utilizers through intensive care coordination activities.
Results: Greater overall stability in the lives of clients, with less utilization of low-efficacy, crisis-oriented services, hospitalizations, and incarcerations.

Morrison County Accountable Community for Health
Updated/reviewed August 2019

Need: To combat prescription drug misuse in rural Morrison County, Minnesota.
Intervention: The Morrison County ACH brings together primary care, social services, law enforcement, and other partners to make sure that patients receive treatment and support.
Results: One pharmacy saw a 40% reduction in the number of prescribed opioids, and the ACH was able to taper 684 patients off opioids completely.

MORE Care
Updated/reviewed July 2019

Need: To improve rural residents' oral healthcare.
Intervention: MORE Care creates interprofessional oral health networks to 1) better integrate oral health into primary healthcare and 2) coordinate oral health between primary and dental healthcare.
Results: MORE Care has led to increases in fluoride varnish administration, improvement in interprofessional communication, and patients' improved self-management of their daily oral health.

Families Plus Comprehensive Health and Mentoring for Underserved Youth
Added March 2019

Need: Pediatric behavioral health services in Delta County, Colorado.
Intervention: Multi-organizational and community-wide effort to increase healthcare access for underserved children and to integrate behavioral health care into the area's primary care clinics.
Results: Sustainable increases in access to pediatric behavioral health services.

TeleTEAM Care for Diabetes Program
Updated/reviewed November 2018

Need: The rate of diabetes and diabetes mortality in North Carolina is higher than in many other states, but is even higher in the eastern part of the state.
Intervention: TeleTEAM provided integrated care for patients with diabetes during regular primary care visits, using telehealth to connect them with off-site behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist.
Results: Patients who have received care from TeleTEAM providers showed decreases in blood sugar, as well as in weight, depression, and diabetes-related distress.

Fostering Futures in Menominee Nation
Updated/reviewed September 2018

Need: Since the late 1800's, trauma caused by historic events have greatly affected the way of life for Menominee Indians living on the Menominee Reservation. Economic, socioeconomic, behavioral health, and physical health issues have risen and are causing direct implications for Menominee youth.
Intervention: Through Fostering Futures, clinic, school, and Head Start/Early Head Start staff are trained in administering trauma-informed care and building resilience among children.
Results: Behavioral health visits at the Menominee Tribal Clinic have increased, school suspension rates have decreased, and graduation rates have improved from 60% to 85% since 2008.

Rural Project Examples: Integrated service delivery