Transforming Access to Care in Rural America: An Innovative Systems Approach

Despite many social and technical advancements over the past decades, the absence of public transportation, limited access to technology and high-speed internet, low digital literacy, and multi-job & child care challenges are often preventing the most socio-economically challenged populations from accessing the care they need. This is disproportionally worse in rural America.

Yet virtual care, when deployed properly and in agnostic ways, can make a real difference in the health of rural residents.

In 2016, as part of the Medicaid Waiver program, Washington State established Thriving Together NCW as one of nine “Accountable Communities of Health” to promote a healthier Washington. In the wake of the Covid-19 health crisis, when video visits became a more acceptable form to access care, Thriving Together NCW (formerly known as North Central Accountable Community of Health, NCACH) explored whether telehealth (or, virtual care as it is now more commonly referred to), could also improve access to care for their population of 260,000 residents in the four counties that form the North Central Washington region.

In 2021, Thriving Together NCW engaged Ingenium to conduct Telehealth Program Assessments for the region’s interested health centers, critical access hospitals, rural health clinics, and behavioral health agencies. In 2022, this evolved into a multi-year program to improve access to care through an innovative, multi-pronged systems approach.

A Community-Focused Systems Approach

Thriving Together NCW’s declared goal is to significantly improve access to health and human services across a vast, four-county, rural region, especially for those facing barriers to needed care. Fostering equity, both health equity and digital equity.

While many individual organizations around the world are pursuing similar goals on behalf of their individual organizations and communities, the endeavor in North Central Washington is distinctive in its breadth, depth, and collaborative approach — working across traditional boundaries. Setting a model that others can learn from, and perhaps even champion and adopt.

As Thriving Together’s Executive Director, John Schapman, describes it: “We are bringing together unlikely partners — creating bridges between organizations that would not otherwise be working together — to make an impact in the lives of those who live here.”

The innovative interventions we continue to work on implementing since 2022 bring together a variety of community partners:

• Over 15 Clinical Partners ranging from Behavioral Health Agencies and Addiction Treatment Services to Community Health Centers (FQHCs), Rural Health Clinics (RHCs), and Critical Access Hospitals (CAHs).
• Three types of community access points including schools, libraries, and fire stations.
• Social service partners to complement the clinical services offered in libraries and fire stations.
• Plus a Technology Alliance with a digital navigator program to complement the approach.

The interventions for the clinical partners include an assessment of their current telehealth maturity and optimization of their telehealth services, coupled with customized expansion and growth of their telehealth utilization – e.g, through no-show and cancellation conversation, TeleCrisis services in Emergency Rooms, or TeleSUD services, etc.

In addition, we have launched school-based telehealth services through a technology and provider-agnostic approach that allows multiple clinical providers to serve students in the school using the same processes and computer system — but still their own preferred telehealth solution.

Similarly, access to care can be provided to adults and adolescents through telehealth access points in libraries and fire stations. In addition, this is augmented by access to regional social services, such as energy assistance, tax filing help, or English language learning programs.

The Why

Any successful program starts with clarity of purpose. For the Thriving Together Program this purpose was developed early on and documented in a mission and vision:

Mission: Improving health & wellness in the Thriving Together NCW community through telehealth.

Vision: Every resident can easily access ALL* the care they need — Where they need it, when they need it.

*ALL: primary, behavioral, dental, chronic, rehab, specialty care, etc. To support the realization of this vision, the Governing Board of Thriving Together NCW committed in 2022 the funding to invest in this approach.

The Who

Across the region there are over 25 independent, clinical organizations ranging from community health centers and rural health clinics to community and critical access hospitals and ERs to mental health and addiction treatment facilities. Together, but primarily independently, they serve the residents of four counties that sit half-way between Seattle and Spokane and from the Canadian border down to the Columbia River.

In this same region, the NCW Libraries has close to 30 library branches and the North Central Educational Services District (NCESD) provides supportive services to approximately 30 school districts serving 150 schools.

Over the past two years, both the libraries and the schools have stepped up, defined their unique contributions to this effort, and are eager partners in bringing services closer to where residents live, work and go to school. They are strengthening their communities by providing ready access to health, human and social services, especially for those individuals and families with the biggest challenges and needs.

In addition, as the program has gained traction, some communities without a school or library are exploring fire stations or community halls as a possible access point to care and social services for those who do not have the technology, digital literacy, or connectivity at home.

Increasingly we are also complementing the access to care with the equally important access to key vital social services that support housing, learning, and other basic services of modern living.

The How

While other regions around the US have undertaken school-based or library-based virtual care initiatives, the unique approach here is that the community-based telehealth access points do not “belong” to any one clinical organization. Rather they are provider-agnostic and thereby deemed a more valuable and versatile resource that many can use, thereby improving impact, stretching resources, and reducing duplication of efforts.

The coordinated, regional approach has several strategies which are well-synchronized and made available to interested participants:

Wendy Brzezny, Director of Clinical Integration at Thriving Together, recently shared at a state-wide Telehealth Collaborative meeting that she is especially proud of the digital equity focus within this effort. With our multi-pronged approach, our focus on improving digital equity is ever present throughout the initiative. Using library and school-based access points to provide easier access for those lacking transportation, time, or the digital means to do a telehealth visit from home. In addition, digital navigation has been a distinctive element of the program with devices and navigators deployed throughout the region.

As mentioned above, we are also experimenting with enabling social service agencies to provide their services virtually (tele-social services), tapping into library and fire station access points to provide tele-services such as language learning and energy assistance. We envision this aspect of the program to grow further, to include other types of agencies and social service offerings, once the concept has been proven with some early adopters.

The Impact

Early on in the program, we realized that while this approach has the great potential to improve access to care and social services that should drive improved health outcomes, we would not know unless we systematically measured the impact of our interventions.

Early on, we invited our colleagues Jason Goldwater and Yael Harris of Laurel Health Advisors to lead a two-year effort to measure the impact and, most importantly, to guide our work by pointing us into the direction of the highest need.

To date, numerous clinical organizations have assessed their telehealth capacities, strengthened their internal capabilities, and expanded their virtual care reach through over 60 tele-services projects. Various school districts and libraries have demonstrated the ease and elegant simplicity of provider-agnostic access points. Students, residents, patients, and clients are accessing needed care more readily.

One success story from the region is Renew, a behavioral health agency whose leader Dell Anderson provided an update about his organization’s success with “connected care” at Ingenium’s inaugural Telehealth T-Time event, where the presentation by Dell and my colleague Kathy Letendre was recorded.

As we are winding down the current scope of work we are documenting our approach and lessons learned in reusable playbooks, to ensure the sustainability of the program beyond the current work and so that the ecosystem and infrastructure can grow in the coming years.

Ultimately, it’s about using today’s technology innovation in the right way to give those who do not have access to modern digital technologies an equal opportunity to receive the services they need.

Because what good is innovation if it is not accessible?

Portions of this article were previously published by my colleague and partner in this endeavor, Kathy Letendre in her newsletter.

Would you like to explore how your region can benefit from a multi-pronged systems approach like the one described in the article, connect with me and my colleague Kathy for a conversation.