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Rural Health Information Hub

Montana Department of Public Health and Human Services

  • Project Title: Montana Frontier Community Health Care Coordination Demonstration
  • Program Representative Interviewed: Heidi Blossom, Montana Hospital Association, An Association of Montana Health Care Providers
  • Program Overview: The Montana Department of Public Health and Human Services, in partnership with the Montana Health Research and Education Foundation, and 11 critical access hospitals implemented a community-based care coordination program targeting elderly patients. The program utilizes community health workers (CHWs), hired by each participating hospital, to help these individuals stay in their homes as long as possible, and avoid preventable hospitalizations and emergency department use. CHWs conduct assessments of the patients' needs, connect patients to physical and occupational therapists who can suggest modifications to their home environment to decrease the chance of accidents, help schedule medical appointments, and connect clients to community resources. A Care Transition Coordinator based out of the Montana Health Research and Education Foundation links partner sites to each other and to CHWs, educates additional provider sites about the program, and trains the CHWs. The training lasts one full day and two half days, and covers administrative topics such as home visit safety, approaches including motivational interviewing, and health topic areas like diabetes and hypertension.

Models represented by this program: