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Rural Health Information Hub

Mainline Health Systems, Inc. (MHSI)

  • Project Title: Mainline Health Systems, Inc. (MHSI)
  • Grant Period: FY2021 Rural Health Care Services Outreach Program (Outreach Track), 2021-2025
  • Program Representative Interviewed: Jeni Barham, Chief Quality Officer
  • Location: Portland, Arkansas
  • Program Overview: Mainline Health Systems in Portland, Arkansas follows the NCQA Patient-Centered Medical Home (PCMH) model to provide a variety of centralized health services to rural patients when they visit the health center. The organization aims to address chronic diseases and social determinants of health through innovative approaches to improve health outcomes and efficiently use healthcare resources. MHSI runs several programs including a chronic care and medication management program for Medicare patients with at least two chronic diseases, a nurse health coaching program for Medicaid patients with an integrated pharmacist (funded through a grant for non-Medicare eligible patients) to help manage medications, and a community health worker (CHW) program. The CHW program used the DePaul Community Health Center to train trusted, community-based individuals in small communities to conduct home visits, with the support of a nurse practitioner, with the goal of encouraging use of preventive care services and discouraging use of emergency department services for primary care.

    MHSI's programs are based on the Chronic Care Model, the Penn Center IMPaCT Model and the Asheville Project's integrated clinical pharmacist model. Key features of MHSI's programs include outreach to patients by trusted community-based clinicians and CHWs, information sharing through Arkansas SHARE (State Health Alliance for Records Exchange), a multi-disciplinary quality improvement committee comprised of all program managers, and use of a pre-visit plan within each patient's electronic medical record, based on their health conditions and required screenings and/or treatments, to streamline patient visits.

Models represented by this program: