Healthcare provider organizations looking to coordinate care across rural areas might want to look at how one Texas hospital has pulled the feat off. Rolling Plains Rural Health Clinic, a branch of Rolling Plains Memorial Hospital, is located in Sweetwater and serves a lightly populated area of West Texas. The rural setting presents challenges in coordinating services in order to meet the needs of an aging population with limited mobility, but has figured out ways to make it work.
Overcoming the Challenges of Coordinating Care in a Rural Setting
42 percent of Rolling Plains Rural Health Clinic’s patients are on Medicare, and many are dealing with multiple chronic conditions that make them prime candidates for Medicare’s Chronic Care Management program. Coordinating services in between primary care visits proved to be tough, so the organization turned to TruBridge, a health IT vendor, for assistance.
“(They were able) to develop a call center that would contact our patients,” explained Edgar Branch, clinic administrator at Rolling Plains Memorial Hospital Rural Health Clinic. “Trained clinical specialists would assess their needs via a phone conversation and a nurse would develop a care plan specific to the individual needs of the patient.”
This plan involved ongoing care via monthly conversations between the clinical specialist and patient. Branch knew coordination of care was dependent not on new technology, but rather the integration of existing technology. They would need to share information between various stakeholders including the TruBridge team at the call center, nurses and nurse practitioners, doctors, and registration staff. Because the hospital used the same practice management system as their vendor, it was possible to instantly share communication about patients through an electronic chart. This information is saved to the patient’s clinical history and can be retrieved by nursing staff and physicians within seconds.
While still in the early testing stages, patients with a variety of chronic conditions are already benefiting; these include diabetes, hypertension, anemia, weight, chronic kidney disease, and hyperlipidemia.
Branch says other providers can utilize similar technologies in order to achieve results. He says, “I think it is as much about the power of information as it is about the power of technology. Being on one integrated system, developing a call center model to reach out to patients. This is about technology being used to develop an integrated service model that at the end of the day improves the lives of the people served.”
He goes on to state that focused, relevant, timely clinical information is key to making informed clinical decisions. Providers that make an effort at integration are sure to see similar positive results.