A Sustainable Model for Preventive Services in Rural Counties

The Healthier Together Study

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


J Am Board Fam Med. 2020;33(5):698-706. 

In This Article

Abstract and Introduction


Objective: The Healthier Together study aimed to implement and evaluate a sustainable, rural community-based patient outreach model for preventive care provided through primary care practices located in 3 rural counties in Oklahoma. Community-based wellness coordinators (WCs) working with primary care practitioners, county health departments, local hospitals, and health information exchange (HIE) networks helped residents receive high-priority evidence-based preventive services.

Methods: The WCs used a wellness registry connected to electronic medical records and HIEs and called patients at the county level, based on primary care practitioner–preferred protocols. The registry flagged patient-level preventive care gaps, tracked outreach efforts, and documented the delivery of services throughout the community. Return on investment (ROI) in participating organizations was estimated by the study team.

Results: Forty-four of the 59 eligible clinician practices participated in the study. Two regional HIEs supplied periodic health data updates for 71,989 patients seen in the 3 implementation counties. A total of 45,862 outreach calls were made by 6 WCs, 100,896 high-priority recommendations were offered to patients based on care gaps and 14,043 additional services were delivered. Of all the patients reached, only 1917 (4.2%) were up to date on all prioritized services. Participating primary care practices significantly improved the delivery of preventive services (mean increase: 20.2% across 12 services; P < .001; range: 7% to 43%) and realized a mean ROI of 68%. Health systems that employed the WCs earned a mean revenue of $175,000, realizing a 75% ROI for the outreach program.

Conclusions: Although health care is under-resourced and segmented in many rural counties, when stakeholder partnerships are established, they may be able to achieve and economically sustain community-wide health improvement by creating a win-win situation for all partners.


Preventing premature death and disability is among the main goals of health care. Strategies to achieve this goal include promoting wellness, preventing disease and injury, early detection of diseases by screening, and chronic disease management to prevent or delay complications. A number of evidence-based, cost-effective preventive measures have been identified, some more cost effective than others. Optimizing the delivery/receipt of 5 key preventive measures would save about 100,000 lives a year in the United States.[1]

While primary care practitioners (PCPs) make improvements to deliver these key preventive services, they continue to struggle to provide all needed services to patients who could benefit.[1–4] Well-established reasons include a continuous expansion of competing care priorities,[5] and an increasing amount of nonclinical work that burdens health care professionals on a daily basis.[6] At the same time, hospitals and county health departments (CHDs), even in rural areas, have become more engaged in prevention due to various mandates and programs. However, many of these initiatives remain uncoordinated or misaligned across local communities.

Rural health disparities are evident throughout the United States. These include poorer health and lower quality health care compared with urban and suburban populations.[7] Rural residents tend to be older, less affluent, less educated, and carry a higher disease burden, including smoking, obesity, hypertension, diabetes, and cardiovascular disease.[8] Greater health care needs are coupled with less than half per-capita physician workforce compared with urban and suburban counties.[9] It is clear that innovative health care models must be designed and implemented in rural America that can bring together rural health stakeholders and help integrate primary care and public health within a learning health system.[10–14]

Among the many components of preventive care, systematic patient outreach, which initiates the care process, is perhaps the least supported component structurally and financially. As a possible solution for establishing scalable preventive outreach, telephone-based reminders have been shown to be effective for increasing the receipt of preventive services.[15,16] It is well established that the use of patient reminders increases screening rates for breast, cervical, and colorectal cancers,[17] and computerized reminder systems are known to increase the delivery of preventive services in primary care[18] and in hospitals.[19–22] For example, we have demonstrated that a preventive services registry can increase the delivery and receipt of services by about 25% when integrated into well-resourced care settings.[23] A community-based registry is a feasible option for small rural practices; however, it requires extra investment into dedicated registry operators and connecting electronic medical record (EHR) systems to a common, regional database either directly or through a health information exchange (HIE). In a past study, we have successfully connected a community-based preventive registry to 35 practices in a rural region of Oklahoma through an HIE service.[24]

In this 4-year study, we designed, implemented, and evaluated a sustainable, rural community–based patient outreach model to improve preventive care provided through primary care practices located in 3 rural counties in Oklahoma. Six wellness coordinators (WCs) working with 44 PCPs, 3 CHDs, 3 local hospitals, and 2 HIEs helped rural residents receive evidence-based preventive services while creating a ROI for rural health stakeholders.