Rural Mental Health Network: Expanding and Strengthening Care Coordination

March 2019


Network Name Randolph County Caring Community/Rural Mental Health Network
Location Moberly, MO
Key Contact Chelsea Zabski, Network Director
Mission The mission of the Rural Mental Health Network is to advance the health and well-being of our rural communities through partnerships that engage individuals and organizations.
Vision A thriving rural community that promotes positive choices that cultivates optimal health.

Chelsea Zabski, Network Director of Rural Mental Health Network, was interviewed by the Network TA team to share valuable tips and creative ideas for building a diverse and engaged community care coordination team.

In a nutshell, how would you describe your network?

The Rural Mental Health Network is a developing network focused on providing care coordination services to address our clients’ social determinants of health needs. By addressing our clients’ needs, we help decrease barriers and increase access to physical and mental health care.

What types of organizations are you partnering with?

We are really proud of our diverse group of partners. We have two different local public health departments in our network as well as a pharmacy, behavioral health providers, a faith-based counseling center, local hospitals, a Federally Qualified Health Center (FQHC), ambulance district, medical equipment provider, home health services and several social service agencies. We also partner with the University of Missouri’s Health Management & Informatics department, who provides guidance on data and assessment.

What network accomplishments are you most proud of?

I am really proud that the relationships we built through the Rural Mental Health Network made it possible for us to receive a HRSA opioid planning grant. We are very excited about this grant because it will allow us to dive even deeper into barriers to access. We expect that this grant will also allow us to build capacity among our mental health providers by educating them on medication-assisted treatment (MAT) and additional ways to address substance abuse

I’m also very happy about the level of acceptance and buy-in of the Community Health Workers (CHWs) from our partners. We continue to see awareness and referrals grow, and our CHWs are expanding their reach into the community as a result.

Another aspect of our network that I’m really excited about is the diverse groups of partners we have. It can certainly be a challenge to have a wide variety of perspectives at the table, but it’s really exciting to see the group come together to solve the issues we’re facing.

What are your biggest challenges?

Our biggest challenge is getting all of our partners to use the CCMO system – our shared electronic health record (EHR) – as a common referral system. Many of our bigger partner organizations have their own EHRs, as well as a team of attorneys concerned about privacy. Even though our memorandum of understanding calls for partners to use the system, we still have trouble with buy-in.

We’ve been working to address this in a few ways. One is to target our smaller-sized partners first, since they don’t already have an EHR in place. If we can help them to have a positive experience, our hope is that they’ll spread the word with other partners. Another strategy we’re using is to bring in the software developer to talk to our network partners directly about their concerns.

As I mentioned, it can be challenging to work with a broad spectrum of partners. Our partners come from a variety of fields, and each field has its own language and has a different perspective on client barriers and social determinants of health (SDOH).  I make an effort to sit in on different partner meetings trying to soak up the terminology and learn about the different viewpoints.

What advice would you give to other network leaders?

Learn as much as you can. Attend webinars, go to workshops and conferences, and continue to open your eyes to different experiences and topics. Reach out to your existing connections to bounce ideas around, learn what they’re struggling with, and find out how they’re talking about behavioral health, social determinants of health, and other topics.

If you don’t understand something, be honest, say you don’t understand, and ask for clarification. If you’re willing to be vulnerable, it can make a relationship much stronger.

And speaking of building relationships: Sometimes we get so focused on what we’re trying to do as a network that we don’t take the time to get to know others as a person. When you take someone out for coffee and learn more about them as a person and the challenges they face, you strengthen connections and gain a lot of insight into ways the network can help them.  

What role do you see networks playing in population health?

It would be almost impossible to improve population health without the involvement of networks, because you need multidisciplinary teams to make it happen. Our network is developing a “no wrong door” system so that no matter what agency a client visits initially, the partner can connect the client to additional resources and services that he or she may need. This type of initiative has a significant impact on population health and can only be possible through a diverse network of partners.

You have been able to establish a successful care coordination program and continue to expand your program by hiring additional Community Health Workers. What would you say are the keys to your success?

First, we got off to a good start with our CHW program. Through funding from the Centers for Disease Control, the state of Missouri provided CHW training for free. We experienced several benefits as a result of this program. One was that all of our CHWs came through the same program, so they share a common knowledge base. Another was that because the program was statewide, it had credibility associated with it. Our partners understand that CHWs go through a formal education program and build valuable knowledge and skills as a result.

Another key to our success has been having CHWs working out of locations throughout our community. This allows CHWs to build relationships with others at their location and gives partners the opportunity to see for themselves the impact that CHWs have on clients. Some of these partners have grown to feel so strongly about the value of CHWs that they’re working to figure out how they can get more CHWs. For example, a pharmacist in our network is considering having the drivers who deliver medications to be trained as CHWs because he sees the value that they could bring to patients.

I’ve also learned the power of storytelling. At first we weren’t very good at sharing our success stories, but we’ve learned that it’s essential to do it if we want to get buy-in. At many of our partner meetings, we’ll share at least one story of how we helped move someone toward self-sufficiency. This really helps partners understand the impact that all of these activities have on members of our community.

As far as our care coordination program as a whole, it was really helpful to have Debra Laine from RHI come for a site visit. She helped us solidify our move toward care coordination by educating our partners about what care coordination looks like, because a lot of our partners didn’t know much about care coordination at all. The care coordination canvas has been really helpful to us as well. As new members join our network, we always work through the canvas with them.

What have you learned during the process of expanding your care coordination program?

We’ve learned that many partners were already doing some component of care coordination, but they just weren’t aware of it. We’ve also learned that care coordination can be more challenging in a diverse network. It looks different for everyone in our diverse group. For example, it looks different for the Fatherhood program than it does for the pharmacy. We’re not going to have one care coordination plan that fits the entire network. It’s our job to define how all of the pieces fit together and serve as the entity that keeps all of the groups connected.

Do you have any other advice for networks looking to increase buy-in and engagement from partners?

Number one: Don’t give up. We’ve had several partners who really didn’t get what we were doing at first, but we kept them informed and continued to learn more about where their struggles are and found ways that the network could address their challenges. You have to find out what the organization needs or wants from the network and then figure out how the network fits with them.

When building relationships, you never know how one relationship will connect you to another relationship. For example, we wanted to invite a health department from outside our immediate area to join us, so I asked a current health department partner who already had a relationship with them to invite them to join the group. Few people like to show up to a meeting where they’re not going to know anyone, so having those established relationships is important. Even if it’s a brand-new relationship, like when a new person is going to be coming to a meeting for the first time, I try to meet with them ahead of time to fill them in on the history of the network and get them up to speed before they join the whole group.

We’ve also started working to deepen our partners’ understanding of care coordination. At a few meetings, we’ve put together descriptions of a few scenarios that our CHWs have experienced with clients, then put members into small groups and ask them how they’d handle that client. This helps them see that one agency can rarely solve all of the problems a client may have. It also helps me, because I get to see how each agency views their own role in solving the problem.

One other strategy we’ve used to increase member participation in meetings related to strategic planning, marketing planning, etc. is to break things down into smaller pieces. When we created our marketing plan, for example, we did it over the course of two to three meetings. This takes more time, but it makes it more doable for members, and we get better participation.

Click here to see a news clip about the network’s efforts to combat the opioid crisis: