Enhancing a Culture of Health
Project Period: Ongoing
The Upper Midlands Rural Health Network is working to strengthen the local healthcare environment by building internal capacity and expanding reach. During the last few years, the Upper Midlands Rural Health Network has hired a full-time Executive Director, expanded to Lancaster County, updated bylaws, and developed a sustainability plan. The Network continuously facilitates work around priority health issues, seeks evidence based policies and programs relevant to the local needs, and identifies funding sources for implementation. Other priorities for 2021 include:
- Holding our annual School Health Workshop for school nurses. More details below and on the Education tab.
- Strengthening our Community Health Worker program to help patients with their social determinants of health.
- Expanding FoodShare in Lancaster County with our partner HOPE in Lancaster, Inc.
- Building on the tobacco-free policies recently adopted through the work of the Lancaster County Health & Wellness Commission.
Continuing Education for School Nurses
Project Period: May 2007 – present
The Network continues to build upon its longest running program by offering educational workshops for school nurses. This began in 2007 for the 14 school nurses in our two counties and has grown significantly, now attracting 80-90 nurses from 12-15 counties each year. School nurses play a key role in community safety, social support, and resources to children who might not receive care anywhere else. Topics have included physical assessments, diabetes, asthma, obesity, substance abuse, gangs, and mental health. Please see the Events page for information about the next workshop or the Education page to see more details about past workshops.
Community Health Worker in Two Rural Practices
Project Period: July 2020 – present
This project targets adults with chronic conditions receiving health care services at two locations in Chester; the Good Samaritan Free Medical Clinic (GSFMC) and North Central Family Medicine (NCFM). The overall goal is to implement a community health worker program into a free clinic and a federally qualified health center. The outcome of this project will be to implement a new program that integrates health care and community programs to improve health, access, and delivery. This will be addressed by one Community Health Worker operating in a shared capacity among two agencies in Chester County.
Transitional Care / Chronic Care Management
Project Period: July 2017 – December 2020
UMRHN expanded the Care Transition Intervention® (CTI®) program at MUSC Health-Lancaster Medical Center, which began in June 2016 (see below). This project improved quality and health care delivery in rural Lancaster County through improved coordination of services; reduced hospital readmissions; and increased access and improved care to patients. This project expanded the program by 1) teaching the Transition Coach® how to engage the caregivers through the Advanced CTI® training, 2) involving the providers and future medical professionals with the CTI® components, 3) expanding the program to the Emergency Department, 4) connecting the patients to existing social service agencies in the community, and 5) ensuring the program meets the CMS requirements for Transitional Care or Chronic Care Management for future sustainability.
Preventing Avoidable Readmissions
Project Period: January 2015 – July 2017
The Upper Midlands Rural Health Network helped three local hospitals prevent avoidable readmissions by helping patients take more control of their health. The Care Transitions Intervention® program is an evidence-based model developed by Dr. Eric A. Coleman, MD, MPH. During a 4-week program, patients and family caregivers work with a “Transitions Coach®” to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This program results in better coordination among health care providers and measurable improvements for the patient as they become empowered to manage their chronic health condition(s). http://caretransitions.org/
Rural Health Information Technology
Project Period: September 2011 – August 2014
The Upper Midlands Rural Health Network received a Federal grant to assist its members in meeting Meaningful Use standards by 2014 and connecting to the SC Health Information Exchange (SCHIEx). Technical assistance, equipment maintenance, and training was provided to health care providers in Fairfield and Chester Counties. A fully operational electronic health record system connected to SCHIEx results in a more cost effective system improving efficiency of communication, information sharing, staff time, use of supplies, and reducing unnecessary duplication. Patient outcomes for chronic conditions like cardiovascular disease and diabetes will be better managed. Without this funding, it would have been impossible for small rural Critical Access Hospitals, like Fairfield Memorial, and rural primary health care providers in South Carolina to adopt electronic health records in time to meet Meaningful Use standards. This would have resulted in reduction of payments from Medicare and Medicaid, leading to the closing of many of these important local providers. This project helped to increase health care provider revenue and improve patient outcomes.
Small Health Provider Quality Improvement
Project Period: August 2010 – July 2013
This program assisted Fairfield Memorial Hospital in the implementation of quality improvement initiatives designed to improve patient care delivery to those with diabetes and cardiovascular disease. In 2007, two of the leading causes of death among South Carolinians were cardiovascular disease (CVD) and diabetes mellitus (DM). South Carolina ranks first in stroke deaths nationally. Diseases of the heart were the leading cause of death in Fairfield County and diabetes mellitus was ranked the 7th cause of death in the county. An estimated 1,746 adults or approximately 10% of adults in Fairfield County suffer annually from diabetes. This federal funding helped purchase a new, state-of-the-art electronic patient records that vastly improved capabilities to provide excellent and complete health care services to diabetes and cardiovascular patients. This system enabled the hospital to capture data regarding selected performance measures pertaining to evaluation and treatment of patients with DM and CVD. The implementation of a visit/appointment tracking system with alerts, reminders, follow-up notifications, and recalls relating to ongoing treatment assures that our patients get all of the care and treatment that they should receive, thus improving their overall health and reducing the cost and health impact of ongoing treatment.
Helping Students Manage Chronic Conditions
Project Period: May 2008 – April 2010
This project addressed planning for appropriate services for network residents including children with diabetes or at risk for developing it. The primary goals of this project were 1) to strengthen the Network and its effectiveness in improving the system of health care in the Network region, 2) to reduce absenteeism of middle school students with the chronic conditions of asthma and diabetes, and 3) to increase community knowledge of the risk factors for diabetes and asthma and how to manage them. Two school nurses were hired to case manage children with the chronic conditions of asthma and diabetes in Chester and Fairfield school districts. An electronic school health record system was implemented to help the school nurses effectively track and manage these students.
Rural Health Network Development Planning
Project Period: March 2006 – February 2007
This grant provided the necessary funding for the Upper Midlands Rural Health Network (UMRHN) to become fully operational in Chester and Fairfield counties. Founding partners included Chester Regional Medical Center, Fairfield Memorial Hospital, the John A. Martin Primary Health Care Center, and the SC Department of Health and Environmental Control. The SC Office of Rural Health serves in an Ex-Officio capacity on the Network Board. The Upper Midlands Rural Health Network successfully completed several steps in the formative network process such as establishing a regular meeting schedule, electing officers, identifying a Network Coordinator, and entering into a formal Memorandum of Agreement.