Mountain Pacific Quality Health's ReSource Teams

Montana

Mountain Pacific Quality Health Foundation is a nonprofit quality improvement organization serving patients in hard-to-reach rural and frontier areas in Montana. Its “ReSource Teams” (operating in the rural communities of Kalispell, Billings and Helena) work with high healthcare-utilizing patients struggling with complex combinations of health and social challenges. ReSource Team members include community health workers and volunteers who visit patients in their homes and consult remotely (either by phone or iPad) with registered nurses, pharmacists, and behavioral health providers. In addition, they connect patients to highly fragmented resources that involve health services, social services and “as-needed” charitable contributions from individuals or community groups. This project is part of the Robert Wood Johnson Foundation's Transforming Complex Care initiative. The Camden Coalition of Healthcare Providers provides technical assistance for hotspotting.

Partner Organizations

• Mountain Pacific Quality Health
• University of Wyoming

Target Population

People who have:

Two or more inpatient admissions in six months AND/OR

Two or more ED visits AND:

• Chronic disease
• Assessed need for additional primary care
• Assessed needs related to social determinants of health

Care Team

Community health worker, volunteers, Registered Nurse, behavioral health provider, pharmacist

Timeframe

2012 - present

Results/ Studies

N/A

Funding

Health system

Resources

Program description

Organizing Complex Care for Rural Populations: A Case Study of Three Montana Communities (March 2019)

Profile by the Center for Health Care Strategies, Inc. (October 2017)