Funder: Robert Wood Johnson Foundation

Author: Derek DeLia, MedStar Health Research Institute and Jolene Chou, Rutgers Center for State Health Policy

March 2019 |

In rural Montana, distance is often a barrier to care for patients with complex needs. Interventions that succeed in urban areas, such as those involving home-visiting, can be logistically challenging in sparsely populated rural communities. Through the Transforming Complex Care initiative, a national initiative led by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation, six complex care programs were tasked with refining and spreading effective care models that addressed the complex medical and social needs of high-need, high-cost patients. One of these programs, Mountain-Pacific Quality Health, a nonprofit quality improvement network/quality improvement organization, developed and tested “ReSource Teams” in three rural Montana communities in Kalispell, Billings, and Helena. The ReSource teams consist of community health workers and volunteers who visit patients in their homes, and consult remotely (either by phone or iPad) with registered nurses, pharmacists, and behavioral health providers.

For this report, developed by MedStar Health Research Institute and the Rutgers Center for State Health Policy, ReSource Team members were interviewed on their methods for addressing the needs of extremely medically complex and socially vulnerable individuals. Additionally, the interviewees shared their perspectives on accessing and combining data sources to track patients’ hospital and social services needs and utilization; using ICD-10 Z-codes to monitor and respond to patients’ social determinants of health needs; and connecting patients to care in the context of limited and highly fragmented community resources.

Although this report is not intended to be a formal program evaluation, the experience of the ReSource Teams provides clear examples of how to set up complex care programs in rural environments. The teams have developed highly customized approaches for patients whom are not well served by traditional systems of care.