Grantee Spotlight

Rural Health Care Coordination Program  

The Georgia Health Policy Center recently spoke to Amy Kohanski, the project director for the Chronic Disease Care Coordination Network at North Country Healthy Heart Network, and Katy Margison, the director of partner engagement and communications for Adirondack Health Institute, about launching a new referral network. 

To date, what has been the biggest accomplishment or win in your Care Coordination program?  
Katy: Our biggest accomplishment is our engagement and the network that we built. We consistently have anywhere from 32 to 40 individuals that join our monthly meetings, and that type of attendance is certainly on the higher side of most work groups that I have been involved with. Additionally, the focus groups that we developed specific to data collection and care coordination are getting eight to 15 participants. Folks are engaged with what we are doing even if the process sometimes feels sticky and slow. They have stayed with us and have remained engaged. 

Amy: Our grant began as a different HRSA care coordination grant was coming to an end. Although that grant had a different focus, many of the same people and organizations wanted to stay involved with ours. In many ways we were able to pick up where they left off and keep the momentum going. We are in a large rural region up here in the North Country and we are known for our willingness to collaborate. It’s been great to see so many health systems and CBOs come together and talk about systems change.  

What is a tip or early learning that you would share with an organization launching a similar program?  
Amy: We walked into a grant and workplan that we did not write. It was very broad, and there were several roads we could go down. We learned right off the bat that we really needed to focus on narrowing it down to what is actually doable within the timeframe that we had. My advice would be to not to bite off more than you can chew. It is better to do less and do it really well than to do a lot poorly.  

Katy: Not being a part of the grant writing team was definitely a drawback, so I might recommend trying to keep at least one person on the grant writing team that is ultimately going to do the work. Additionally, Amy and I are not clinical care coordinators. There has been a learning curve, which is not a bad thing, and we have been relying on our great partners, but it would be helpful to have a care coordinator in the core group. 

How do you see participation in FORHP’s Care Coordination Program as impacting your broader health improvement efforts? 

Katy: This type of transformative work takes a long time. Broader health improvement is whole-person care for us and that is looking at the total cost of care and value-based care and what type of arrangements can we get into with payers. It will take some changes to make this sustainable and get away from grants. We need to figure out a way to engage in a value-based contract arrangement or some sort of payment arrangement to reimburse our providers for offering the chronic disease self-management programs, tobacco treatment, and food and nutrition supports. With emphasis on health-related social needs or social determinants of health, we have to get payers on board. We have done some side projects showing that with wraparound support high utilizers do not come back to the hospital if they get the food support they need or the housing or transportation. We need somebody to believe in us and engage in some sort of more permanent arrangement.