Blog Post

How one rural hospital offers care for their most vulnerable patients

January 16, 2018

    Providing care management to high-risk patients is challenging for any provider organization—particularly for rural providers, whose communities tend to be sicker, lower-income, and have higher uninsured rates. More specifically, rural provider challenges are compounded when managing higher-risks given barriers to primary care access. 

    To succeed in care management, some rural providers are focusing on innovative solutions to bring care management and primary clinical care to their patient homes—even under a limited budget.

    Using non-clinical staff and video chats to increase access

    Kalispell Regional Medical Center in Kalispell, Montana, formed an RN/community health worker dyad called the ReSource team to perform high-risk care management for patients post-discharge. The dyad meets with enrolled patients during their inpatient stay to begin building trusted relationships. Patient trust is key to the success of the program, as care is provided in nontraditional settings to ensure access to care: in the home and over video chat. However, Kalispell uses a non-clinical staff member to perform the plurality of the in-person visits and brings the specialized RN into the conversations using a simple telehealth solution.

    Both members of the dyad attend the patient's first home visit, the initial touchpoint post-discharge, where they survey the patient's most pressing clinical and non-clinical needs. For up to 90 days, the community health worker continues to perform home visits to assess patient progress. During these visits, the community health worker facilitates a video chat between the RN and the patient. This allows the RN to address clinical needs without spending hours travelling per patient. Kalispell finds that a relatively simple technology investment allows more patients to have access to their provider on-demand, reducing the likelihood of clinical escalation and readmission.

    To learn how organizations are developing care management programs in the ambulatory setting, check out our brief Advancing Your Approach to Ambulatory Care Management here.

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