Francine*, a diabetes patient in rural Montana, lives
about 30 miles away from her provider. She is unable to
visit a diabetic educator due to transportation-related
challenges and financial limitations. Instead, she
receives check-ins from a registered nurse (RN). She told
the RN, Gina Delaney, that she used to test her blood
sugar only once a day. Since Delaney has started checking
in with her, Francine now tests three times a day. Thanks
to Delaney's work, this patient was able to lower her
As a Regional Care Coordinator, Delaney works with six or
seven different healthcare facilities in eastern Montana.
A couple times a week, she logs into each site's
electronic health record (EHR) system to complete chart
reviews of her patients. She contacts patients and
provides referral follow-ups and coordination. She also
helps connect patients to any needed community resources
like transportation or meal delivery.
Delaney's services are part of Montana Health
Network's Regional Care Coordination program, funded by
the Federal Office of Rural Health Policy (FORHP).
Health Network (MHN), with headquarters in rural
Miles City, serves 8 counties in eastern Montana with
regional care coordination. More broadly, MHN serves 17
owner healthcare organizations and approximately 40 other
healthcare entities throughout the state. The for-profit
network provides services like consulting, insurance for
organizations and employees, temporary staffing,
training, and an Area Health Education Center.
2020-2023 FORHP Rural Health Care Coordination Program
grant, MHN offers the Regional Care Coordination
program for adult patients managing chronic conditions.
Nadine Elmore, MHN Project Director, said that care
coordination brings together not only healthcare entities
like primary care, specialty care, and pharmacies but
also community resources like Meals on Wheels, housing
support, and transportation services.
It's people working together to put their arms around
that individual [patient] and support them to be as
healthy as possible as long as possible and remain
independent as long as possible.
“It's people working together to put their arms
around that individual [patient] and support them to be
as healthy as possible as long as possible and remain
independent as long as possible,” Elmore said.
Elmore lives and works in her hometown of rural Ekalaka.
She served in the U.S. Army for 17 years and was her
hometown hospital's CEO for 13 years. Elmore called some
of the towns that MHN serves “some of the
tiniest of tiny communities in all of America.”
She added, “They don't have the capacity to
develop and implement value-based care programs unless
they have the support of someone like Montana Health
Network.” MHN helps these small towns'
healthcare facilities pool their resources and provide
chronic care management through Delaney, the Regional
The MHN Regional Care Coordination program was created
for frontier CAHs (Critical Access Hospitals) that wanted
to create the value-based care to deliver chronic care
“The MHN Regional Care Coordination program was
created for frontier CAHs (Critical Access Hospitals)
that wanted to create the value-based care to deliver
chronic care management,” Elmore said. These
facilities identified a need for chronic care management
but couldn't afford to hire a full-time care coordination
nurse for their small patient populations.
As part of the grant, MHN hosts monthly roundtables,
where the different sites can share their challenges and
successes. Once a year, staff from the various sites meet
in person for a daylong session. Delaney shared that some
sites attending this year are just developing their
programs, while three attendees are considering starting
a program. She added that some organizations providing
community resources attended this year's meeting as well.
Elmore said this is the first program of its kind in
Montana. An early version of this program had five
patients in the first year of a previous FORHP grant, and
that number grew to 138 patients in year two of the
current grant. This growth occurred over a 4-year period.
MHN was also asked to share best practices at the
Cooperative of Health Networks (NCHN) Association
annual conference in April 2023.
Small-Town Connections and Solutions
Delaney, with over 30 years of experience as an RN, has
been a part of the MHN program for just over two years.
She remembers a patient who lived near her primary care
provider but 80 miles away from her psychiatrist. One
time, she ran out of her medications for a mental health
condition while her psychiatrist was on vacation. Since
the psychiatric provider couldn't refill the
prescription, Delaney called the patient's primary care
provider to ask if the patient could get a seven-day
dosage filled instead of her normal prescription. Then
she called the psychiatric provider's office and the
local pharmacy to coordinate getting the seven-day
prescription filled. This coordination and quick thinking
helped the patient avoid any symptoms that she would have
experienced without her medications.
Delaney said that a patient in a similar situation might
not know whom to call, or they might know whom to call
but can only leave their provider a voicemail. Delaney,
on the other hand, was able to connect with providers'
nurses and send messages through one facility's EHR to
get a much quicker response.
Healthcare is forever changing. Patients and family
members are not able to keep up with these changes.
“I've always held myself as a patient
advocate,” Delaney said. “Healthcare
is forever changing. Patients and family members are not
able to keep up with these changes.”
In other cases, having a regional focus helps Delaney
catch what local providers might miss. For example, two
patients from different communities each received a
pulmonology referral. While trying to coordinate services
for one of the patients, Delaney learned that the
pulmonologist the patients were referred to was not
accepting new patients. She then was able to immediately
work to find a different pulmonologist for the second
patient. “Without the regional model, a local
care coordinator may not have realized that the
pulmonologist wasn't taking new patients,”
Elmore said. “Or they may have taken more time
learning that and identifying different opportunities for
the specialty referral.”
Other solutions are simpler yet involve out-of-the-box
thinking. Elmore remembers a patient who had a procedure
coming up and was told she needed to stop taking one of
her medications two days before the procedure. However,
the patient kept her medications in a pill organizer and
couldn't remember what this particular medication looked
like. The RN care coordinator connected with the
patient's pharmacist, who said, “Her house is
on my way home. I'll just stop by her house and take
those pills out of her pill box for those two
One surprising benefit of the program is that seniors in
the community, already connected through events like card
games and congregate meals, bond further by finding out
their relatives or friends are also a part of the MHN
Regional Care Coordination program. In addition, it can
help normalize receiving medical services.
Elmore shared that two of the patients are sisters and
have turned Delaney's check-in call into a friendly
competition, trying to ask Delaney which of the sisters
she called first. Delaney makes sure to alternate which
sister she calls first so that it doesn't seem like she's
In another case, Delaney called a patient who was about
to leave her house to give a friend a ride to a
congregate meal. The patient knew this friend was also in
the chronic care management program, so the patient told
Delaney, “If you haven't called her yet, I'll
give you a few extra minutes and you can call her. And
then that way I'm not interrupting your phone call to
Gaining Buy-In and Planning for Sustainability
While many patients have embraced the program, Elmore
said that there has been some reluctance from a few
healthcare facilities to sign on to the program. Some
CEOs were concerned that a grant-funded program wouldn't
be sustainable after the grant period ended.
“My mindset is 'Well, I'll tell you how you
keep it going. You develop it and make it big so that it
can support itself,'” Elmore said.
Elmore's advice is to plan for sustainability from the
beginning. One strategy she uses is to market the MHN
Regional Care Coordination program to larger facilities.
Even though these facilities might be able to hire a
full-time care coordination nurse on their own, Elmore
tells them that the MHN program is more streamlined and
efficient than if these facilities started a new program
Other, smaller facilities are “hungry for some
support to start a program,” Elmore said. These
facilities don't have the capacity on their own to invest
much time or funds into starting a program like this, but
they can access this program through MHN.
Elmore said there were also some issues with gaining
buy-in from providers, nurses, and other staff who may be
hesitant to have someone outside the community provide
care. “The Regional Care Coordinator must
almost hold themselves to a higher standard than would
even be expected from local staff because even the
smallest misstep or slip in care or communication is
viewed more strictly than with local staff,”
Elmore said. She recommended consistently checking in
with patients and communicating effectively with local
staff in order to ease their concerns.
Delaney argued that one reason that programs like MHN's
Regional Care Coordination are underutilized is provider
turnover. She remembers a provider who worked in the
region for less than a year. In his last three weeks of
employment, he referred three patients for chronic care
management. When Delaney contacted these patients, they
declined to enroll, telling her, “Well, he's
not even my provider anymore, so I don't need this
service.” Retaining providers and building
patient trust are important steps for making a program
like this successful.
Elmore hopes that the program will lead to multiple
nurses in the service area receiving care coordination
training so that MHN can expand this program to more
healthcare facilities. She envisions a network of nurses
providing care coordination services in facilities in
Montana and surrounding states.
“Chronic care management has the opportunity to
have a lot of successful stories,” Delaney
Allee Mead is a web writer for the Rural Health Information Hub. She has written on important rural issues, including maternal mortality and farmers' mental health, and has presented nationally on RHIhub's opioid resources. Originally from rural North Dakota, she has a master's degree in English. Full Biography