Rural Health Care Coordination Program – Kaweah Health
The Georgia Health Policy Center recently spoke to Meredith Alvarado, R.N., assistant director for Rural Health Clinics, and Chelsea Stafford, project manager for population health, at Kaweah Health about how the Care Coordination grant is enabling quality improvement in maternal health care.
To date, what has been the biggest accomplishment or win in your program?
Chelsea: One of our biggest goals with this grant is to grow our network of community partners. We have been able to establish some great partnerships with Tulare County Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the Lindsay Family Resource Center. These partnerships will allow us to create a smooth care coordination system and ensure that our patients have knowledge about these services and how to access these services that are available to them. In our community, people do not always know what is available to them or how to navigate accessing them. Through these partnerships and integrating our community health workers into the health care journey for our maternal patients, we are able to help increase the awareness of these programs and help patients navigate the various systems to access them.
Meredith: It is about giving our patients that support and letting them know that they are not alone in this journey. They have the support of the organization, they have the support of our partners, and to ensure that they feel comfortable and that they know that through this whole process that they have someone in their corner helping them every step of the way.
What is a tip or early learning that you would share with an organization launching a similar outreach program?
Chelsea: We are still in our planning year, but I think that it has been very helpful to us to create that logic model with our technical assistance provider. The logic model has helped us to stay within the scope of this specific grant and project because we want to go out and fix the world. Our inclination is to identify all the inequities and be the superheroes that we so passionately want to be. But we have to start somewhere. Doing that logic model exercise and having that document to refer back to when has been immensely helpful.
Meredith: When you are looking at the grant as a whole, because it is a multiyear grant, you don’t realize how fast the months go by. My advice is to start early and stay organized. When you are doing your logic model you will come across barriers and obstacles and being able to really dive into those and be two steps ahead is going to help you stay on track.
How do you see participation in the Federal Office of Rural Health Policy’s Care Coordination Program impacting your broader health improvement efforts?
Meredith: This grant is solely looking at the Lindsay population of maternal health within Lindsay Clinic, but Lindsay Clinic is just one clinic within the organization. We have multiple Rural Health Clinics. Our long-term objective is sustainability. It is great that we are able to have the resources to implement this into the Lindsay Clinic for that specific population, but really we hope this to be the start of a program that we can implement across the entire organization and be able to bring these resources, processes, and workflows throughout all the Rural Health Clinics to be able to bring that quality of care and service to the other populations.
Chelsea: We have a large Hispanic population here in Tulare County. The 2022 census results showed 66.1% of our community identified as Hispanic. At the beginning of this year, the California Medicaid system, through the CalAIM program, added birthing mothers as a population of focus eligible to receive enhanced care management (ECM) and community supports services. However, the state did not include the Hispanic population as an eligible population. Through research data as part of a University of California Merced study on farm workers, we have been able to identify several disparities in maternal health outcomes amongst the farmworker population. We are hoping that the data that we can collect from this grant will help us advocate to have this population added so that we can create that sustainability via reimbursement through the ECM program.
What is next on the horizon for your grant program?
Meredith: I think we have been busy putting all of our planning down on paper, brainstorming processes and workflows, and building dashboards. It all sounds amazing. I am really excited to actually put the action in place and to actually make an impact in our patient population. Being able to see the quality improvements for our maternal health population is going to be fulfilling and really what this grant is all about.
Chelsea: We have put so much time and energy into this planning year, and it looks so incredible on paper, but it is going to be amazing to see it in action. We already have our Lindsay community health worker in place, and she has been active in helping us develop these workflows. It is very patient centered, as they are the main focus, and I am just excited to see this come to fruition.