Need: A healthcare delivery model to improve health and well-being of Pennsylvania patients with serious mental illness in Pennsylvania, especially those in rural settings.
Intervention: County human service administrators, patients, families, a behavioral health provider network, and a nonprofit behavioral health managed care organization implemented 2 versions of a behavioral home health model focusing on a complete culture of wellness.
Results: These unique models significantly increased patient activation, engagement in both primary and specialty care, and improved client perception of their mental health status.
Need: Improving outcomes for Outer and Lower Cape Cod residents in need of social, behavioral health, and substance use disorder services while reducing the burden and costs to town agencies and hospital emergency rooms.
Intervention: The Community Resource Navigator Program works with local social services, town agencies, faith-based institutions, hospitals, the criminal justice system, and others to identify and connect clients to needed services.
Results: Clients are gaining access to the care they were once lacking, as measured by improvements in self-sufficiency. The program also helps community partners and stakeholders work together to reduce the impact of risks associated with behavioral health symptoms, substance use disorder, and social determinants of health.
Need: For adults with chronic conditions, skipping a dose or two is common, but can also be risky. Frequent medication in-adherence has accounted for emergency department visits, hospitalizations, and even death.
Intervention: The Scheffe Prescription Shop in Enid, Oklahoma started a medication synchronization program. Pharmacists serve as care coordinators for patients by prepackaging pills, scheduling recheck appointments, and providing pickup reminders and medication education over the phone.
Results: The program has reduced the number of trips patients have to take to the pharmacy to pick up their pills and has increased medication adherence rates over 4 years.
Need: Transitioning from fee-for-service models to valued-based payment models in rural Iowa.
Intervention: In 2011, the Trinity ACO was formed in rural Iowa after being selected by the Center for Medicare and Medicaid Innovation as 1 of the 32 planned Medicare Pioneer Accountable Care Organizations.
Results: Now part of the Next Generation ACO, Trinity continues to bring attention to rural-specific organizations using its focus on palliative medicine and effective strategies to distribute value-based services.
Need: Meeting both advanced practice pharmacy student education needs and patient healthcare needs in a nearby rural/underserved area.
Intervention: With support from multiple organizations, students in the Ohio Northern University's College of Pharmacy program use a motor coach to deliver a wide range of healthcare services during scheduled outreach visits.
Results: In the program's first two years, point-of-care screening, immunizations, and chronic disease prevention and management education have been provided to 800+ Hardin County, Ohio, residents.
Need: Clinicians in rural areas are often unprepared to treat sexual assault victims after an assault.
Intervention: The National TeleNursing Center (NTC) in Massachusetts uses telemedicine to connect Sexual Assault Nurse Examiners to clinicians in remote areas, offering them guidance through examinations.
Results: Clinicians report that the help gives them confidence through the examination process and NTC has assisted in the care of over 300 patients.
Need: To ensure the quality and sustainability of rural West Central Missouri's health services through the use of technology.
Intervention: The Health Care Coalition of Lafayette County convened a Health Information Technology (HIT) workgroup to establish electronic medical and prescription records, telemedicine capabilities, and training for Lafayette County and surrounding areas.
Results: The workgroup fully equipped a local emergency department with HIT, launched electronic prescriptions for nearly a dozen Lafayette County providers, and identified acute needs hindering the adoption of electronic health records.
Need: The North Georgia Medical Center (NGMC) of Ellijay, Georgia had been slowly losing money and patients for years. Many residents living in Ellijay were seeking hospital care elsewhere, leaving NGMC treating an average of only 6 patients per day in the year prior to closing their doors in 2016.
Intervention: With approval from the state, Piedmont Mountainside Hospital (PMH) leased the space from NGMC and opened the state's first freestanding emergency department (ED). Medical services were again made available for patients in Ellijay and surrounding areas.
Results: After one year of being open, the freestanding ED continues to average 30 patients per day and has reached over 11,000 emergency room visits.
Need: The shortage of mental health professionals in rural South Carolina resulted in an influx of patients admitted to emergency departments who were in need of psychiatric care.
Intervention: South Carolina Department of Mental Health (SCDMH) partnered with The Duke Endowment to create the SCDMH Emergency Department Telepsychiatry Program. Rural emergency departments can now reach a psychiatrist to assess a patient via telehealth.
Results: The Program has improved access, affordability, and provided quality care for rural providers and patients with mental illness.