• Zsolt Nagykaldi, Dewey Scheid, Yan D Zhao, Bhawani Mishra, and Tracy Greever-Rice.
• From the College of Medicine, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK (ZN, DS); College of Public Health, Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK (YDZ); Institute of Public Policy, Harry S. Truman School of Public Affairs, University of Missouri, Columbia, MO (BM); School of Medicine, Center for Health Policy, University of Missouri, Columbia, MO (TGR). znagykal@ouhsc.edu.
• J Am Board Fam Med. 2020 Sep 1; 33 (5): 698-706.

ObjectiveThe 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.MethodsThe 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.ResultsForty-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.ConclusionsAlthough 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.© Copyright 2020 by the American Board of Family Medicine.

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