Organizing Complex Care for Rural Populations: A Case Study of Three MT Communities

Mountain-Pacific Quality Health, a nonprofit quality improvement network/quality improvement organization, developed and tested “ReSource Teams” in three rural Montana communities in Kalispell, Billings, and Helena. The ReSource teams consist of community health workers and volunteers who visit patients in their homes, and consult remotely (either by phone or iPad) with registered nurses, pharmacists, and behavioral health providers.

In this report, ReSource Team members were interviewed on their methods for addressing the needs of extremely medically complex and socially vulnerable individuals. Additionally, the interviewees shared their perspectives on accessing and combining data sources to track patients’ hospital and social services needs and utilization; using ICD-10 Z-codes to monitor and respond to patients’ social determinants of health needs; and connecting patients to care in the context of limited and highly fragmented community resources.