Somewhere in Appalachia, a mother with diabetes wonders how she will afford nutritious food for her family. An older relative undergoing cancer treatment can’t find a ride to their follow-up appointments. And a retired veteran must decide between paying the mortgage and affording his medications.
These challenges exist across the country, but they can be especially difficult to overcome in the rural communities we serve at Ballad Health. In each of those situations, health care is impacted by much more than a diagnosis or treatment recommendation. It’s shaped by factors like distance, housing stability, insurance coverage and food insecurity.
Better health requires addressing needs beyond the doctor’s office
While health care leaders increasingly acknowledge the importance of addressing the nonmedical factors
that influence one's health, many providers have struggled to refer patients to local food banks, housing programs or transportation services because those support connections didn’t exist. For years, the standard was to hand patients a list of resources and hope they were able to navigate the system.
Today, technology is helping bridge that gap by enabling health care providers and community organizations to make real-time connections for people in need. Better coordination across clinical care and community support services improves health outcomes and reduces costs, a major achievement that can be replicated across Appalachia.
Connecting rural patients with community services
At Ballad Health, we’re proud to be part of a statewide partnership serving communities across the Appalachian Highlands. Together with the Virginia Department of Health, Virginia Hospital & Healthcare Association (VHHA) and Unite Us, we launched a closed-loop referral network that connects patients with a wide range of community services.
The network helps identify gaps between health care and community care while connecting tens of thousands of people with services to measurably improve their lives. This includes food assistance, transportation support, housing resources, maternal health programs, substance use treatment and more.
Having a centralized platform empowers community health workers to track services, follow up with patients and monitor outcomes. The results demonstrate what can happen when health care and community support systems work together.
The results: Fewer emergency visits and lower health care costs
In the six months following a referral, we saw an 8.5% reduction in the number of emergency department visits among patients connected to services through the network. Patients referred by a community health worker showed a25% decrease in emergency department visits, suggesting that their interactions with community health workers and support services helped them better manage their health conditions. This led to nearly $1 million in estimated annual savings per 1,000 patients.
To further test how this model was improving outcomes, we also compared health care utilization and costs one year before and one year after low-income and uninsured patients engaged with community health workers.
The results were astounding: preventable inpatient utilization declined 28%, while medically necessary outpatient utilization increased 55.5%. Costs declined 46.2% at the contribution margin level and 31.6% at the net income level, generating an estimated $2.50 to $3.40 in return for every $1 invested.
These savings translate into more resources that can be devoted to patient care, lower Medicaid costs for taxpayers, and most importantly, healthier communities.
A model for improving rural health across America
This model has produced positive changes across Appalachia and demonstrates how communities can achieve better outcomes when patients are connected to the support services. It’s also a model that can be replicated in rural communities nationwide.
To transform the health outcomes of rural Americans, we must examine the upstream factors that impact health, streamline how we distribute resources, strengthen partnerships between community organizations and providers, and track the impact of our work.
The evidence is clear: When the right systems are in place, rural communities can achieve better health outcomes and lower costs for the people they serve.
Dr. Paula Masters serves as chief health disparities officer for Ballad Health, an integrated community health improvement organization serving 29 counties of the Appalachian Highlands in Northeast Tennessee, Southwest Virginia, Northwest North Carolina and Southeast Kentucky.
This article originally appeared on Nashville Tennessean: Better rural health takes more than medical care | Opinion
