Rock River Health Care Network partners collaborate to bring strategies and programs to our region that increase the health equity in Jefferson and Dodge Counties in Wisconsin.
This subcommittee surveyed all area Behavioral Health Providers early in the project to assess the community capacity of behavioral health services for the medically underserved. Area capacity does not support the actual referral experience for the RRCC patient population in the RRHCN service area. The Committee mapped existing community resources to get a clear understanding of gaps in care. The Committee engaged consulting resources to better understand best practices for supporting community emotional wellbeing, asking the questions, “What best practices have been deployed in communities similar to us that have improved access to and quality of behavioral health services?” The Committee will use learnings from this journey to design more effective access systems and improve care coordination.
This subcommittee was formed to further understand the impact of the social determinants of health on the target population. Their work will include developing referral patterns for chronic disease management, behavioral health and safety net services. They will evaluate and monitor results of the utilization of a best-practice common screening tool (the PRAPARE) and determine further dissemination of the tool. Finally, their work will inform the Steering Committee as to next steps in achieving health equity in our communities.
Federally Qualified Health Center (FQHC) Status
The Rock River Community Clinic (RRCC) is in the process of applying to receive FQHC Look-Alike Status. The lengthy application process includes an exhaustive application that describes the target population in a 16 zip code area. It fully describes the staffing, costs, operational processes and governance of the RRCC. In addition to an application, a site-visit evaluation is required. If FQHC status is obtained, the RRCC will be reimbursed by the Federal government for a percentage of the costs incurred and will allow the clinic to serve the low-income, uninsured and under-insured populations. To learn more about FQHC’s visit RRCC’s FAQ page.
Care Navigation Pilot Project
The Care Navigation Pilot Project includes three Network Partners who have been utilizing an evidence-based screening tool to capture SDOH data and inform “next steps” of assistance for the patients/clients. A full-time Care Navigator is employed at RRCC to help identify barriers that patients may be experiencing and then connect them to needed services. Other Network partners implementing the tool include Fort HealthCare and Rainbow Hospice Care (Supportive Care Management Program). A Care Navigator Workgroup including area Care Navigators and area experts meet monthly to discuss referral processes and patterns as well as referral partner education.