A care coordination program that uses care facilitators has helped to improve care coordination and reduce ED use among a frontier, or very rural, population.

  • The program targets people who have healthcare barriers, mental health issues, and social determinants of health that prevent them from maintaining optimal health.
  • Local service organizations team up with grant- and Medicaid-funded providers to help people lead more stable and healthy lives.
  • Care facilitators reach out to build connections with the clinic and community providers, and help people understand what the services are.

The nation recently has focused on rural areas experiencing opioid epidemics and struggling to regain employers during the major shift from manufacturing and mining to service industry jobs. One result is that the healthcare industry now can see the major health access problems faced by rural and frontier towns and communities.

Individuals in those areas tend to be older, have lower incomes, and lack public transportation. They also have limited healthcare resources, and few local social workers and counselors to deal with mental health issues, says Pat Conway, PhD, MSW, senior research scientist at Essentia Health in Duluth, MN.

“One problem is pain. There is no local resource or treatment for pain,” Conway says.

These demographics and healthcare barriers are why researchers targeted the frontier/rural area of Ely, MN, to use case management strategies in improving patients’ health and reducing barriers and costs.

Conway and other researchers recently published a paper on healthcare innovation in frontier communities. Their project used team facilitators to help patients with social-behavioral and resource issues. They found that the project increased care coordination for people with complex needs. ED use decreased following people’s enrollment in care coordination.1

“There’s a big push in healthcare to reduce unneeded emergency department use,” Conway says. “Across the country, people with behavioral health disorders get their first level of care in the ED.”

Programs like the team facilitation approach help to decrease ED visits, lower costs, and give patients a more appropriate way of handling their problems, Conway explains.

“Care facilitators intervene early, and whatever issues patients have, they can be kept safe without going to the ED,” she adds.

“An important part of the work we’ve done is to provide care facilitation through an individual who partners with community members and identifies their needs and goals, reduces barriers, and establishes supportive services,” says Heidi Favet, CHW, community care team leader at Essentia Health–Ely Clinic in Ely, MN.

Sometimes, people in need of healthcare are labeled as noncompliant by providers. The case management approach is to learn what is going on with them to create barriers to their wellness and to help them improve their health and reduce ED visits, says Jenny Uhrich Swanson, MPA, behavioral health network director at Northern Lights Clubhouse, a program of Well Being Development in Ely. Swanson also is executive director of Well Being Development.

Swanson, Favet, and Conway explain how the program works:

  • The community has a hub-and-spoke model of care coordination.

“There’s a hub, which we have located at the clinic with Heidi, and that’s where the referrals go,” Swanson says.

“Say a doctor refers a patient for care facilitation,” she explains. “That person is referred to Heidi, and she does an initial assessment and then decides where to host the person’s care coordination.”

There also are care coordinators in clinics. At Well Being Development, a care coordinator focuses on mental health. Other coordinators work with youth services and in schools.

With the hub model, patients can enter the program from any point in the community, Swanson says.

For instance, they can be referred to care coordination from the ED, a general practitioner, or even the local housing authority. They can self-refer. Or students, identified as having issues in school, can be referred by the school. Family members can call and ask for services for a loved one, she says.

  • A community care team provides help.

“Building a community care team was a genesis project,” Favet says. “Our hope was to build a safety net for community members, starting in 2011.”

But even as the team connected services across the community, some people slipped through the cracks, she says.

“We started the care facilitation model to capture people,” she explains. “As we grew to have care facilitators in more and more settings, we grew with the hub-and-spoke model.”

Care facilitators meet regularly, encouraging cooperation between service agencies instead of competition, Conway says.

  • Care facilitators address patient needs through care coordination.

Care facilitators address the health needs of their referred patients. They look at each person’s health issues, transportation barriers, food, housing, and medicine, and assess whether there are any service gaps that can be addressed.

“They identify gaps in service and identify new ways of solving problems,” Conway says.

Care facilitators use a standard workflow that begins with outreach, building connections with the clinic and community providers, and helping them to understand what the services are, Favet says.

They also provide warm handoffs to clinics and might even connect with patients in the ED. They assess care plans and patients’ mental health status and social determinants of health.

“There’s a comprehensive assessment of needs,” Favet says. “The assessment is focused on personal goals and starts with what the individual sees as a highest priority and biggest concern.”

“The care coordination workflow includes outreach, assessment, care planning, and intervention — where people are connected to services,” she says. “The other step that is very important to our model is the follow-up step.”

“We are very consistent with not just connecting someone to a therapist or giving them a phone number or sending them to a healthcare navigator,” she adds. “We call back to see if it worked: Were there any barriers to getting to the appointment? Did it work? Do you need a new therapist?”

Often, patients are referred to the program because of one glaring problem, Swanson says. “Often, when that’s resolved, you find many other things behind it, and that’s what the reassessment is.”

  • It’s funded in a variety of ways.

State grants paid for the creation of community care teams, Swanson says. “That’s where the first process started,” she says.

“Initially, Medicaid was paying for care coordination,” Favet says. “The lion’s share of people were Medicaid recipients, but we didn’t want to limit who received those services.”

Since then, various community agencies, including those committed to helping people with healthcare, housing, and employment, have been involved, often using their own resources to help the program’s patients. Those that can bill payers do so, but the others use different resources. For instance, Well Being Development pays for a care coordinator to work, long-term, with the care coordination efforts, Swanson says.

“After five years of this process, we’ve moved that care coordinator position from a grant-funded position to a clinic-funded position,” Favet says.

Federal money also supports some of the facilitator roles.

“The plan was for the service to be reimbursable and sustainable long-term,” Swanson says. “The issue we found was that small nonprofits could not be billable providers, and the service was only reimbursed for educating on diagnosis-based items, such as a new diabetes diagnosis.”

It’s a value to the community, so those involved look for alternative funding, including grants, she adds.

  • Anecdotal and other evidence demonstrate program’s benefits.

Aside from observing reduced ED visits and improved care coordination, it’s difficult to measure the program’s overall community effect, Favet notes.

“We’re so small that showing any population health prevention level impact would be very difficult in a community our size,” she says. “Our entire area is 12,000 people, spread out over nearly 100 miles.”

The town of Ely has about 4,000 permanent residents.

“We haven’t undertaken a population health study because it’s very difficult to show causation when there are so many things that happen simultaneously,” Favet says.

However, there have been plenty of anecdotal examples of the program’s success.

One person who connected with the program through Well Being Development suffered a bipolar condition and other chronic health conditions, Favet recalls.

“She had a low quality of life, living on a sofa in someone else’s home, and she reported she didn’t know what a good day looked like for her,” she says.

Four years after care facilitation help, the woman is in college, has her own apartment, is involved in creative activities, and volunteers in the community.

“The most wonderful thing is to see her smiling,” Favet says. “I think about how we helped an individual, who had struggled chronically and felt totally unsupported, meet her potential.”

Another person, whose untreated diabetes led to repeated ED visits and hospitalizations, was helped with his housing situation. This led to more stable housing, and it gave the person the self-confidence necessary to improve his medication compliance, Favet says.

“Last spring, he was trained in a chronic disease self-management model, and so that’s just another one of our many success stories,” she adds.

One of the program’s chief benefits is how it normalizes the importance of paying attention to the whole person, looking at depression, anxiety, and other issues, Conway says.

“This is a story that might happen across the country in rural areas if we can continue to focus on teams in the community and in the clinic, rather than just focusing on the individual and individual’s diagnosis,” Conway says.


  1. Conway P, Favet G, Hall L, et al. Rural health networks and care coordination: health care innovation in frontier communities to improve patient outcomes and reduce health care costs. J HC for Poor & Underserved 2015;27(4):91-115.