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Care Coordination, Health Networks, and Frontier Community Innovations

This session will present a model for care coordination developed as part of health care reform in a frontier community. To address health disparities experienced by residents of rural Northern Minnesota, regional organizations created a community care team, including a primary care clinic, hospital, mental health center, educational settings, behavioral health recovery programs, community members, social services (housing, food, financial assistance), and public health. The Ely Community Care Team (CCT) Project addresses health policy, program development, and care coordination with individuals and families to improve health outcomes. It is data driven, using population data and data from patients participating in care coordination to identify needs and gaps and to guide selection of evidence-based strategies. The primary care clinic, an accountable care organization, committed to integrating behavioral health into their clinic when it became evident that individuals with complex health needs commonly experienced behavioral health challenges. A subgroup of seven CCT organizations developed the Ely Behavioral Health Network to focus more directly on improving access to appropriate behavioral health services in order to improve health outcomes. The presentation will first describe the care coordination model, using a video to vividly picture the impact of care coordination on patients with complex health issues. Barriers to successful care facilitation will be identified, such as state and federal regulations regarding privacy which restrict communications between care facilitators and make follow-up difficult. The audience will be engaged in problem-solving to reduce barriers. Finally, innovative methods for evaluation of network development, integrated primary care teams, and patient outcomes such as social network analysis will be presented and the audience invited to complete tools and critique methods.

1.  Increased understanding about health disparities experienced in rural and frontier communities and the role of care coordination in addressing those disparities.
2. Increased capacity to describe factors that enable interdisciplinary teams within accountable care organizations and interorganizational care teams to operate successfully in rural communities.
3. Increased ability to develop methods for evaluating the process of developing an integrated primary care team and an accountable health community and outcomes for patients and families.