A trail mapped over an image of a mountain.
Reach the Summit in Four Steps

Rural Health Innovations’ (RHI) services include education, resources, and facilitation for cohorts of hospitals that are ready to climb toward population health and improve the health status of their communities. Change takes time and the rural path to value is a multi-year approach.

A Flexible Approach

A successful path to value and population health is determined uniquely by each rural community. With collaboration in mind, we support rural communities in a variety of ways because every community is different.

Health care and community leaders can better understand the changing health care landscape and find innovative solutions to address health outcomes when they help each other learn and engage in designing and implementing care coordination solutions. When the community comes together for planning, care coordination can be designed to address social determinants of health. This allows rural hospitals and their community partners to do the important work of integrating care between primary care, long term care, behavioral health, and other community services. 

Step One: Aiming for the Summit

Get everyone on the same page and understand why the journey toward population health is important for long-term community wellness. Engage all of the partners to collectively aim toward solutions that are right for their communities.

Activities Example Outcomes
  • Group education via workshops and webinars
  • Virtual Population Health Readiness Assessment
  • Individual community profiles that include population health needs and organizational readiness for population health management utilizing secondary data and assessment
  • Individualized strategic planning events
  • Improved awareness and understanding of concepts regarding population health, partner strengths, and resources
  • Identified gaps and knowledge in community resources
  • Customized community population health profile
  • Customized organization strategic plan

Step Two: Collaborating for Success

Bring diverse care teams from different communities together to learn about putting the right care coordination model into place. Identify actionable steps to coordinate care for topics like chronic care management, substance use disorders, behavioral health, or wellness initiatives.

Activities Example Outcomes
  • Cohort workshops
  • Peer learning calls
  • Individual community planning events
  • One on one coaching calls
  • Customized organization care coordination models
  • Improved referral patterns
  • Decreased no-show rates
  • Improved patient satisfaction
  • Improved medication reconciliation

Step Three: Navigating Toward Wellness

Focus attention on integrating care between, and within, care team partners, including community stakeholders and partners. Provide solutions to improve health status when navigating social determinants of health. Integrate care coordination with community partners to break down silos and encourage sustainable solutions that improve community health status.

Activities Example Outcomes
  • Cohort workshop or group education
  • Peer learning calls
  • Individual community planning events
  • One on one coaching calls
  • Customized action plans
  • Sustainable model that can measure behavior change or improved health status, such as decreased inappropriate emergency department use, increased referrals to primary care, reduced readmissions, and improved chronic care management

Step Four: Staying the Course

One on one action planning with individualized technical assistance and support to ensure implementation sticks and progress can be thoroughly evaluated. This is vital for helping each community monitor their progress and adapt to whatever comes their way.

Activities Example Outcomes
  • Individual action planning events
  • Peer learning calls
  • One on one coaching calls
  • Measures and targets for each action plan step that funnel into overall strategic planning

Get Started

To get started, contact Tracy Morton at (218) 216-7027 or tmorton@ruralcenter.org.