An Innovative Community-based Model for Improving Preventive Care in Rural Counties

Area of Science:

• Public Health
• Health Services Research
• Rural Health

Background:

• Rural communities face unique challenges in accessing preventive care.
• Primary care practices (PCPs) in rural areas often lack resources for proactive patient outreach.
• Innovative models are needed to bridge the gap in preventive service delivery for rural populations.

Purpose of the Study:

• To implement and evaluate a sustainable, rural community-based patient outreach model for preventive care.
• To assess the feasibility and cost-effectiveness of a Wellness Coordinator (WC)-led program integrated with PCPs, health departments, and health information exchange (HIE).
• To improve the delivery of evidence-based preventive services in a rural Oklahoma county.

Main Methods:

• A quasi-experimental pilot study involving a WC who utilized a community wellness registry connected to electronic medical records via HIE.
• The WC prioritized and contacted patients based on identified preventive care gaps.
• Return on investment (ROI) for prioritized preventive services and the WC position was estimated.

Main Results:

• Three of seven PCPs fully implemented the 1-year outreach program.
• A total of 5034 outreach calls were made, identifying care gaps in 78% of contacted patients.
• Significant improvements in preventive service delivery (mean increase of 35%) and a mean ROI of 80% were observed for participating organizations.

Conclusions:

• A county-level patient outreach program is feasible and cost-effective for enhancing preventive care in rural settings.
• The integration of a WC with PCPs and HIE facilitates proactive care and addresses service gaps.
• Further research is warranted to validate these findings in broader rural contexts.