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Rural Health Care Coordination Program
PROGRAM OVERVIEW |
Louisiana Rural Health Association has partnered with Louisiana Department of Health CHWays Program, Opelousas General Hospital, Louisiana Tech, and PeLEX Health Information Exchange to develop a Rural Health Network to support leveraging of Health Information Exchange (HIE) engagement, Community Health Worker (CHW) engagement, and utilization of the Chronic Care Model (CCM) to build and maintain a strategy and framework to support better health outcomes and to provide whole-person care and wraparound services to rural residents with heart failure. The Network aims to address the overarching chronic health issues for this patient population by providing more seamless avenues of care continuity and coordination. |
GOALS |
Learn more about the HRSA Rural Health Care Coordination Program |
PROGRAM SERVICE AREAS |
Saint Landry Parish |
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PelEX is a health information exchange network that has served Louisiana’s Medicaid population for over ten years. PelEX serves as a trusted health data steward for hospitals, community health centers, and behavioral health organizations through community-driven data sharing and meaningful collaboration. They provide timely, actionable data to empower care teams to deliver the best care possible, supporting care coordination following hospitalization, patient outreach, and care quality improvement. Project Role: PelEX facilitates a centralized data exchange between partners; convenes a network of providers for data sharing; identifies use cases for cross-sector collaborations and provides onboarding support for new participants. Leads:
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The Community HealthWays (CHWays) program is housed within the Office of Public Health’s Bureau of Regional and Clinical Operations (BRCO). CHWays is designed to improve the quality of life for Louisiana residents by helping to address individuals’ health-related social needs and the community factors, commonly referred to as social determinants of health (SDOH), that drive them. The program starts with a Community Health Worker (CHW) as the Frontline Public Health Worker. This individual is a trusted member of the local community and/or possesses a vested interest and understanding of the community served and resources available. The Community Health Worker assists individuals in addressing social problems that lead to poor health with increased attention on food insecurity, housing, transportation, utility assistance, furthering education, mental health connections, and education related to chronic conditions. Project Role: Community HealthWays Program provides Community Health Workers to facilitate care coordination and chronic care management as well as assess and navigate social determinants of health for participants. Leads:
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Louisiana Tech University (LaTech) is a Top Tier National University with more than 135-degree programs to align with individuals’ interests and aspirations. LaTech faculty are on the cutting-edge of research and innovation which provides students with ample opportunity to engage in hands-on learning experiences that lead to post-graduation marketability. Project Role: Louisiana Tech serves as the data management and analytics powerhouse of the project. This includes leveraging the resources of the LaTech Computer Science Department to document the patient outcomes and cost savings and conduct independent research to secure sustainability funding and support. Lead: Pradeep Chowriappa, Asst. Professor and Graduate Coordinator of Computer Science
Clinical Partners Opelousas General Health System (OGHS) has a rich and vibrant history dating back to the 1950s. The heath system is governed under the leadership of a five-member Service District Board, and a nine-member Board of Trustees. The Board is dedicated to providing OGHS patients with state-of-the-art medical care. Achieving this requires constant improvement of medical services and a commitment to the acquisition and implementation of new technology and services. This acquisition of technology, combined with continuing education relative to advanced medical techniques, provides a healing environment typically found in much larger metropolitan areas. Project Role: OGHS utilizes data collected by a patient navigator via initial screenings to define and identify the populations cohort in St. Landry Parish. Leads:
***Opelousas General Health System served as a clinical partner during years one and two of the grant cycle*** Savoy Family Care is a community-focused rural health clinic in Eunice, St. Landry Parish, that provides integrated primary and behavioral health services in one location. The care team includes a family nurse practitioner for comprehensive primary care, a psychiatric mental health nurse practitioner for conditions such as anxiety, depression, and ADHD, and a licensed clinical social worker who provides counseling and therapy. Working together, they deliver coordinated, patient-centered care to improve access and health outcomes for residents of Eunice, St. Landry Parish, and surrounding rural communities. Leads:
***Savoy Family Care officially came aboard to serve as a clinical partner for project year three and four of the grant cycle***
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