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

Zsolt J. Nagykaldi, PhD; Dewey Scheid, MD; Daniel Zhao, PhD; Bhawani Mishra; Tracy Greever-Rice, PhD


J Am Board Fam Med. 2017;30(5):583-591. 

In This Article

Abstract and Introduction


Objective. This quasi-experimental pilot study aimed to implement and evaluate a sustainable, rural community–based patient outreach model for preventive care provided through primary care practices (PCPs) located in a rural county in Oklahoma. A Wellness Coordinator (WC) working with PCPs, the county health department, the county hospital, and a health information exchange (HIE) organization helped county residents receive evidence-based preventive services.

Methods. The WC used a community wellness registry connected to electronic medical records via HIE and called patients at the county level based on PCP-prioritized and tailored protocols. The registry flagged patient-level preventive care gaps, tracked outreach efforts, and documented the delivery of preventive services throughout the community. Return on investment (ROI) for prioritized preventive services was estimated in participating organizations.

Results. Six of the 7 PCPs in the county expressed interest in the project. Three of these practices fully implemented the 1-year outreach program starting in mid 2015. The regional HIE supplied periodic data updates for 9138 county residents to help the coordinators address care gaps using the community registry. A total of 5034 outreach calls were made by the WC in the first year and 7776 prioritized recommendations were offered when care gaps were detected. Of the 5034 distinct patients who received a call, 1146 (22%) were up to date on all prioritized services, whereas 3888 (78%) were due for at least 1 of the selected services. Health care organizations in the county significantly improved the delivery of selected preventive services (mean increase, 35% across 10 services; P = .004; range, 3% to 215%) and realized a mean ROI of 80% for these services (range, 32% to 122%). The health system that employed the WC earned an estimated revenue of $52,000 realizing a 40% ROI for the coordinator position.

Conclusions. Although more research is needed, our pilot study suggests that it may be feasible and cost effective to implement an innovative, county-level patient outreach program for improving preventive care in rural settings.


Optimizing the delivery and receipt of 6 key preventive measures is estimated to save approximately 100,000 lives a year in the United States (aspirin prophylaxis; smoking cessation; influenza vaccination; and colorectal, breast, and cervical cancer screening).[1] However, primary care practices (PCPs) continue to fall short of providing preventive services to all patients who could benefit.[1–4] There are several reasons for this problem. Yarnall and colleagues[5,6] calculated that it would take primary care clinicians over 21 hours per day to provide high-evidence primary and secondary preventive services recommended by the US Preventive Services Task Force (USPSTF) and tertiary preventive care to patients with chronic illnesses recommended by disease-specific guidelines. The diversity of electronic health records that are not interoperable and the decreasing margin of resiliency of PCPs, especially in rural areas, may also contribute to suboptimal care delivery.[7,8]

More recently, hospitals have become more engaged in prevention, providing immunizations for patients with pneumonia, smoking cessation counseling, referrals for tobacco-related illnesses, and low-dose aspirin or β blockers for patients with heart attacks. County health departments (CHDs) are also committed, particularly to primary prevention. However, large segments of the population rarely visit hospitals or health departments and only approximately half of recommended preventive services are received by the adult population in the United States.[9]

Efforts of these 3 potential partners (PCPs, hospitals, and CHDs) are often not well aligned. For example, PCPs are frustrated by the adverse health effects of physical inactivity and obesity, perceiving that these are public health problems, which they are expected to address. They are also frustrated that when many low-income children are immunized at the CHD, they may not present to their well-child visits. A significant portion of reimbursements for the time and resources required by PCPs to make sure patients get referred screening tests go to the subspecialists and hospitals. When immunizations are given in the hospital or CHD, the information may often not make it back to the PCP records. CHDs have trouble getting practices and hospitals to use immunization registries, and they would like to see more patients referred to them for immunizations.

Rural populations suffer both from poorer health and decreased access to quality care than their urban and suburban counterparts.[10] They are older on average and have lower income, less education, and higher rates of smoking and obesity. Rates of hypertension, diabetes, and cardiovascular disease are also higher in rural counties.[11] Despite greater health care needs, fewer than half as many physicians per capita work in rural counties as in urban and suburban counties in Oklahoma.[12] Therefore, new models of health care delivery in rural America are needed.

A 2012 Institute of Medicine (IOM) report entitled, "Integrating Primary Care and Public Health," indicated renewed interest in collaborative models.[13] The IOM Committee pointed to the need for "neutral convener" organizations that bring together primary care and public health professionals. Hospitals must adjust their business plans to the changing epidemiology of illness and efforts to reduce admissions, early readmissions, and emergency department visits. Nonprofit hospitals that accept Medicare are now required to construct and carry out community health improvement plans. Accountable care organizations are forging new relationships between PCPs and hospitals.

Based on these trends and needs, we initiated a 4-year study to implement, evaluate, and disseminate a sustainable, rural community–based patient outreach model to improve preventive care provided through 20 PCPs located in 3 rural counties in Oklahoma. Wellness Coordinators (WCs) working with PCPs, CHDs, local hospitals, and Health Information Exchange (HIE) organizations helped county residents receive evidence-based preventive services. A quasi-experimental implementation pilot study that was part of the 4-year initiative and what we describe in this article evaluated the impact of the community-level preventive services outreach program in the first of the 3 consecutively engaged rural counties.