Care Coordination
Mountain-Pacific Quality Health Breaks Down Rural Health Care Coordination Barriers in Wyoming and Montana
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Rural and frontier communities have unique health care needs and opportunities. According to the Health Resources and Services Administration (HRSA), “Rural areas generally have a greater elderly population than urban areas…with physical access to care the greatest challenge that many elderly rural patients face.”

This is particularly true in Wyoming and Montana, where the population is aging at a faster rate than other parts of the country, meaning more people are facing multiple chronic conditions and an increased need for coordinated care. Patients and providers in these locations deal with additional barriers to coordinated health care, such as distance from providers and basic necessities; few safety net resources; turnover and shortages of providers and specialists; geography and weather; and lack of infrastructure supporting collaboration.

In March 2017, Mountain-Pacific Quality Health, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Alaska, Hawaii, Montana, Wyoming and the U.S. Pacific Territories of Guam, American Samoa and the Commonwealth of the Northern Mariana Islands—in collaboration with the University of Wyoming’s Wyoming Center on Aging (WyCOA)—was awarded a Centers for Medicare & Medicaid Services (CMS) Special Innovation Project (SIP) to support this unique care transitions need with clinically-based Project ECHO (Extension for Community Healthcare Outcomes). The project’s mission is to expand Montana's and Wyoming’s capacity to safely and effectively provide best practice care for chronic, common and complex diseases in the rural and underserved areas.

The ECHO model breaks down walls between specialty and primary care through a hub-and-spoke model. Mountain-Pacific developed a Hub Team—an inter-professional community of regional and national care coordination experts, including a pharmacist, geropsychologist, patient engagement expert and more. This team holds face-to-face meetings with spoke sites—primary care physicians in local communities—to foster positive relationships and encourage practice change in the field of care transitions.

Since launching the project, Mountain-Pacific has seen a decrease in providers feeling isolated in Wyoming and Montana. Also, there has been a notable increase in knowledge of best practices for effective transitions of care, and comfort and self-efficacy in dealing with care coordination.

Notably, 91 percent of ECHO participants feel they gained new information from presentations, and 87 percent feel an increased connection with providers across the state. Participants also report the intent to change their practice by providing better care to patients, improving communication between providers and patients/caregivers, improving the education of patients, and educating other providers.

Mountain-Pacific plans to hold bi-weekly sessions with primary care providers through August 2018 to continue reducing isolation barriers and providing access to quality care for patients.