Susquehanna Family Health Clinic: Improving Whole-Family Care

The National Rural Health Resource Center (The Center) and Stratis Health traveled to Susquehanna Family Health (SFH) on June 30 and July 1, 2026, for a Rural Healthcare Provider Transition Project (RHPTP) on-site technical assistance (TA) visit. SFH is an independent, family-owned rural health clinic located in Susquehanna, PA, serving a 7-zip code region and shares its service area with two critical access hospitals. The facility offers a full range of primary care services, prenatal care up to 20 weeks, well baby and well child visits, pediatric and adolescent care, men’s and women’s health, family planning, geriatric care and vaccines. SFH is a member of the Pennsylvania Independent RHC Network and the National Association of Rural Health Clinics.

Stratis Health provided technical assistance focused on care coordination, data and performance measurement, and community resource mapping. The visit supported SFH leadership and staff in strengthening care coordination processes by developing a shared vision for the initiative. Additional discussions focused on social drivers of health, improving data accuracy and collection methods, identifying meaningful performance measures, and enhancing dashboards and tracking systems to support ongoing quality improvement.

The Center and Stratis Health met with Carrie DeWitt, Director of Operations, Dr. Warren DeWitt and clinic staff to provide guidance on building and sustaining a community care coordination program. Discussions included strategies for streamlining referrals, identifying meaningful data to support patient care and reimbursement, and leveraging community resources to address social drivers of health. The team also explored approaches to collecting and using data over time, including the development of dashboards to better understand patient populations, monitor outcomes, and measure the impact of care coordination efforts.
 

Upon completion of the visit, opportunities for continued development included:

• Developing structured documentation templates with Athena to improve data capture and trend analysis
• Expanding staffing capacity by adding social work support and an additional primary care provider
• Improving transportation resources, particularly for patients traveling across county lines
• Expanding access to mental health and crisis intervention services
• Strengthening referral processes and care coordination support
• Implementing Advanced Primary Care Management (APCM) services

Next steps include enhancing documentation and tracking systems for non-medical needs and referrals to better demonstrate program impact, addressing staffing needs, potentially through formal collaboration with Wayne Health System, and identifying reimbursement opportunities.  Stratis Health will continue partnering with the clinic to explore strategies and tools that strengthen comprehensive care planning and care coordination.  Efforts will focus on leveraging social drivers of health data to inform staff decisions, support reimbursement, and build a sustainable, patient-centered care coordination model that meets the evolving needs of the community.

Key Takeaways
SFH has a dedicated and compassionate team that remains deeply committed to meeting the needs of its patients and community. Staff are continuously refining care coordination processes, strengthening referral pathways, connecting patients with appropriate community resources, and providing meaningful follow-up to improve health outcomes. Their ongoing commitment to collaboration and continuous improvement positions the organization well for success in a value-based care environment.