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MT Team: National Care Coordination Academy

Montana Team: National Care Coordination Academy Banner also showing logos for partner agencies Rural Instiute, University of Montana, and Montana Pediatrics

Montana healthcare providers, families & caregivers, and social & human service professionals share the same on-going overall goal for at-risk children and youth: Improved health and well-being outcomes of children, youth and their families.

A Montana interdisciplinary team is participating in a unique learning community centered on implementation of care coordination. Through workshop-structured learning opportunities, regular virtual meetings, and targeted technical assistance, the National Care Coordination Academy supports Montana efforts to acquire the essential knowledge, skills, and competencies for effective care coordination in the Big Sky.

Key Montana Team Outcomes

  • Meaningful family and youth participation in healthcare decisions that impact their health and family well-being.
  • Increased healthcare literacy among families and transitioning youth.
  • Increased provider understanding of patient- and family-centered medical homes, how they function, and what is required to sustain them.
  • Enhanced communication across health centers, systems and providers.

Connect to the Montana Team

Montana Team Member Listserv: This email address is being protected from spambots. You need JavaScript enabled to view it.
Team Coordination Contact: Kelsey Christopher This email address is being protected from spambots. You need JavaScript enabled to view it.
Team Leadership Contact: Kim Brown This email address is being protected from spambots. You need JavaScript enabled to view it. , Mackenzie Petersen This email address is being protected from spambots. You need JavaScript enabled to view it.

Team Resources

Open Pediatrics Connection

Go to: https://learn.openpediatrics.org/learn

National Care Coordination Academy materials are in the “My Courses” section of Open Pediatrics.  If you are unable to connect to your Open Pediatrics account, please contact Kelsey Christopher (This email address is being protected from spambots. You need JavaScript enabled to view it.)  

Pediatric Care Coordination

The five module Pediatric Care Coordination Curriculum, 2nd Ed. (Antonelli, et al., 2020) is available on Open Pediatrics. This online video version uses a learning management system to guide learners through the content.

A hard-copy version of the Pediatric Care Coordination Curriculum, 2nd Ed. is available online at: https://medicalhomeinfo.aap.org/tools-resources/Documents/PCCC%202nd%20Edition/Full%20Pediatric%20Care%20Coordination%20Curriculum.pdf

Curriculum learning objectives

  • Discuss key components of care coordination within an integrated model of care delivery
  • Identify established tools and processes that can be used to implement key components of care coordination
  • Apply tools and processes that support key components of care coordination to a case example

Target audience

  • Physicians
  • Nurse Practitioners
  • Nurses
  • Social Workers

Related Resources

The National Care Coordination Academy is a Partnership of the Division of General Pediatrics and the Department of Accountable Care and Clinical Integration, Boston Children’s Hospital/ Harvard Medical School and the Collaborative Improvement and Innovation Network for Children with Medical Complexity at the Center for Innovation in Social Work and Health, Boston University School of Social Work, with support from the Health Resources and Services Administration, Maternal and Child Health Bureau.

Annual Review FY 2020

2020 Annual Review Cover thumbnailLetter from the director

2020 was an exceptional year -- we had our share of uncertainty, sadness and frustration. But the year also provided opportunities to demonstrate our creativity, expertise and humanity. The Rural Institute for Inclusive Communities quickly found ways to provide service, research and training activities in formats requested by community and government partners. For example, the MonTECH program developed and implemented COVID-safe practices so they could continue to provide assistive technology to Montanans; one of the first AT programs in the U.S. to do so. RTC:Rural published information briefs to help policy makers and service providers understand the economic and social impact of COVID on people with disabilities who live in rural America.

Though COVID dominated our attention, it didn't hinder our work. We set up technology in our homes so we could reach record numbers of people through video meetings and conferences. We started new projects to better understand community strengths and system barriers faced by rural Americans. We came up with innovative ways to connect with research participants and partners around the U.S.--the people who drive our efforts. We've always practiced the value that "people are at the center of our work" and 2020 provided an opportunity to once again prove that point.

Visit us on social media or our website to learn more about how we are building "collaborative community partnerships that support opportunities for all."

May you enjoy a peaceful, healthy and fulfilling 2021!

Martin E. Blair, PhD
Executive Director


Impact

  • The Rural Institute has 55 active projects and programs
  • We mentored 43 trainees across 14 disciplines
  • 47 UM students took a class sponsored by the Rural Institute
  • We published 18 reports, articles and book chapters
  • We shared 28 conference presentations and posters
  • We trained 5,665 people in Montana and across the country
  • Rural Institute staff members participated in 48 local, state and national committees, councils and boards

Budget

13% Evaluation

15% Education

27% Service

45% Research

FY 2020 budget = $6,095,572


Projects and Programs

Evaluation

Montana Access to Pediatric Psychiatry Network (MAPPNet)
Evaluates impact of statewide pediatric telehealth program

Healthy Montana Families Home Visiting Needs Assessment
Identifies the need for home visits for pregnant women & families with children 5 and under

Montana Title V Needs Assessment
Assesses Montana’s maternal and child health population needs, and the capacity to meet those needs

Montana Obstetrics and Maternal Supports Evaluation (MOMS)
Evaluation and research for Montana Obstetrics and Maternal Support project

Montana Primary Care Office Needs Assessment
Assesses the need for and access to primary healthcare services across the state

Achieving Success by Promoting Readiness for Education and Employment (ASPIRE)
Evaluates impact of independent living and employment supports on families

School Climate Transformation: MBI in High Need Areas
Evaluates effectiveness of PBIS in high-need schools

Education

UR-LEND
Leadership training and education focused on family-centered healthcare

Egypt Disability Services Study Tour
Strengthens the capacity of Egyptian university staff to administer Disability Support Centers

Community Oriented Living Well
Expands the delivery of Living Well with a Disability curriculum to rural Montanans through CILs

UM OUTREACH
Trains speech language pathologists in rural and tribal communities

Diversity Fellowship Program
Graduate fellowship for culturally-diverse students

Service

MonTECH: Montana’s Assistive Technology Program
Supplies technology to support independence across the lifespan

Montana Family to Family Health Information Center
Provides family-focused healthcare information

Healthy Community Living
Offers independent living workshops focused on health and community living skills

Montana Disability and Health Program
Promotes health-related policy and practice initiatives

All of Us Outreach in Montana
Recruits participants for national health outcomes research

Deaf-Blind Project
Gives resources and assistance to local school systems

NCDB: Transition Outcomes for Youth with Deaf-Blindness
Provides training to improve transition outcomes for youth

Children’s Special Health Services: Montana Transition Resources
Provides transition-to-adulthood health resources for youth, families and providers

Movin’ On in Montana
Offers a college experience for high school students with disabilities

Research

Home Usability Project
Promotes community participation of adults with disabilities

Out and About
Evaluates community intervention to promote health and wellness

Partnering with Women with Disabilities to Develop a Health Information Website
Creates an online health information resource for women

Texas Model Spinal Cord Injury (SCI) Systems
Evaluates ways to improve the health of people with SCI

Loneliness and Its Relation to Health in People with Spinal Cord Injury
Identifies how loneliness impacts the health of people with SCI

Effort Capacity and Choice
Investigates the link between energy exertion and quality of life

mHealth App Development
App that features the Living Well with a Disability curriculum

Montana Pediatric Medical Passport (MP2)
Builds an app for healthcare information and decision making

Rural Community Living Development
Develops a peer-to-peer training program CILS can use to address issues and initiate change

Understanding Personal Assistance Services Experiences in Rural States
Explores barriers to PAS delivery, and designs an intervention to address rural outcomes

Rocky Mountain Region ADA Research
Researches ADA legal issues

Expanding the Availability and Quality of Rural Data
Rural analyses of existing large data sets

Exploring Rural Disability Onset
Explores how disability evolves

Rural Access to Health Insurance and Health Care
Answers questions about health care and quality of life

Rural Resource Analysis
Maps community resources and networks

Building Networks to Expand Living Well Delivery
Scales up Living Well to rural hospitals

Personal Assistance Services in Rural America
Explores and addresses rural PAS outcomes

Rural Transportation Options
Explores accessible transportation in rural communities

Rural Self-Employment
Develops and evaluates online tools for state and tribal Vocational Rehabilitation

Annual Report FY 2018

Rural Institute Cover AR FY2018DRIVING CHANGE CHANGING LIVES

Annual Report FY2018

Beginning with the first $200,000 grant in 1978, Rural Institute staff have raised over $175 million to meet the needs of people with disabilities. Dozens of education, research and service initiatives have come and gone over our 40-year history, but they have a common theme: Partnership.

Thoughtful reflection on the lessons we have learned with our partners and the good we have done over four decades demonstrates we are at our best when working side-by-side with those who benefit from our efforts. We appreciate and value people with disabilities, their families, the service providers and personal assistants who assist them, and policy makers who work closely with us. It is through our shared expertise that we achieve our most important successes—the improved quality of life and life satisfaction of people with disabilities and their families. Year 41 starts now and we look forward to working with you in the years to come!

Marty Blair


RESEARCH - Exploring Rural Disability

The Research and Training Center on Disability in Rural Communities (RTC:Rural) helps people with disabilities participate in their rural communities. RTC:Rural conducts research and provides training and technical assistance in the areas of health, employment, and independent living. We collaborate with individuals with disabilities, family members, and service providers to uncover personal and environmental factors that influence disability and quality of life. Together, we identify research priorities, understand findings, and develop best practices for applying research in rural communities.

Recent Research and Development activities at RTC:Rural:

  • Geography of Rural Disability analyses lay the groundwork for examining demographics of people with disabilities living in rural areas. This work has led to the creation of the Step-by-Step Guide to Accessing Disability Data that explains how to get disability data and make maps to show the data.
  • Employment research explores solutions to barriers people with disabilities face in achieving and maintaining employment. We created the Vocational Rehabilitation Self-Employment Guide, a web-based tool for individuals and VR counselors to assess self-employment readiness and develop a business plan.
  • Health and Wellness activities aim to address unique rural health challenges by developing and testing health promotion delivery models to serve people with disabilities in rural areas. Through RTC:Rural’s training and technical assistance activities, service providers share their experiences and receive support to implement the Living and Working Well with a Disability Programs.
  • Rural Community Living research focuses on how the accessibility of rural environments affects community participation and quality of life. This research led to the creation of resources available through the Rural Disability Resource Library and includes the Toolkit for Operating a Rural Transportation Voucher Program, developed with the Association of Programs for Rural Independent Living (APRIL).

A sample of upcoming Research and Development activities include the:

  • Geography of Rural Disability project which continues to study the relationships between the presence of community resources and disability rates in rural communities across the U.S.
  • Rural Self-Employment project, a collaboration with American Indian VR service providers, to adapt the VR Self-Employment Guide website for people with disabilities residing on rural American Indian Reservations.
  • Rural Community Living research initiative to explore rural-urban differences in personal assistance services (PAS) and develop an adapted PAS training for providers working in rural communities.

EDUCATION - Building the future

Utah Regional Leadership and Education in Neurodevelopmental Disabilities (UR-LEND)

The Rural Institute partners with the Utah Center for Persons with Disabilities and the University of Utah School of Medicine to train Montana graduate students to become leaders in providing family-centered care for children with special healthcare needs. Trainees from different disciplines attend weekly seminars on topics such as epidemiology of developmental disabilities, special education law, working with refugee families and financing healthcare, among many others. Family perspective is the thread that weaves through every lecture and community-based training experience. Trainees complete the program with an improved ability to collaborate with other healthcare professionals outside their discipline, an increased ability to recognize and address the complexity of disability, and a deeper understanding of the value of family input while providing evidence-based care.


SERVICE - Helping people achieve independence and self-support

MonTECH provides technology, support, and services that improve the quality of life for Montanans with disabilities. By loaning assistive technology and adaptive equipment, MonTECH helps people increase their independence. For example, screen reader software and screen magnifiers allow Montanans with low vision read books or watch sporting events. A grandfather who is hard of hearing used a Contego listening device to join conversations at his family reunion. MonTECH’s free device-loan program enabled Olivia, an 11-year-old with dyslexia and dysgraphia, explore how an iPad could help her ‘ear read,’ learn, and show others what she knows. With her new iPad, she is successful and less anxious at school.

MonTECH loans assistive technology and adaptive equipment to any Montanan with a disability. Last year, over 800 devices were borrowed by Montanans looking for tools to help them live more independently. MonTECH saved device borrowers $230,055 through open-ended loans and device reuse. In partnership with Rural Dynamics, Inc., MonTECH offered 15 financial loans to Montanans who could not otherwise afford assistive technology equipment.


A Year in Review

$6,498,767 Rural Institute FY2018 Annual Budget

18 Funding proposals submitted

37 Programs & Projects

  •  13 Community Service and Training
  •  24 Research and Evaluation

58 Trainees representing 13 disciplines

41 Seats on local, state and national committees, councils and boards

16 Reports and Monographs

115 Training activities that served 7,075 participants

42 Conference presentations and posters

10 Peer-reviewed articles submitted to scholarly journals for publication


Visit us:

Rural Institute - ruralinstitute.umt.edu

RTC:Rural - rtc.ruralinstitute.umt.edu

MonTECH - montech.ruralinstitute.umt.edu

Disability Counts - rtc.ruralinstitute.umt.edu/geography

Telecom Toolbox - telecomtoolbox.ri.umt.edu

Healthy Community Living - healthycommunityliving.com


RESEARCH

Healthy Community Living - Independent living skills and multimedia health promotion program

SAFETY Project - Self-advocacy training to prevent interpersonal violence

Concerns Report Method: A Family-Centered Approach to Quality Services - Family and provider input on children’s health services

Effort Capacity and Choice: Investigating a Dynamic Model of Participation - Investigates link between personal exertion and impact on choices

School Climate Transformation: MBI in High Need Areas - Evaluation of PBIS in high-need schools

Partnering with Women with Disabilities to Develop a Health Information Website - Creating an online information resource on women’s health

Texas Model Spinal Cord Injury (SCI) Systems - Evaluating ways to improve the health of people with SCI

Pain, Depression, and Resilience and their Prediction of Life Satisfaction in people with SCI - Identifies impact on life satisfaction

Achieving Success by Promoting Readiness for Education and Employment (ASPIRE) - Evaluation of comprehensive independent living and employment supports

Rocky Mountain Region ADA Research - Partnership to research ADA policy issues

All of Us - Collection of health data to improve outcomes

Home Usability Project - Promoting community participation of adults with disabilities

Out and About - Intervention to promote wellness, goal-setting and self-advocacy skills

RTC: Rural RESEARCH

Monitoring and Managing Community Accessibility

Ecological Decision Support for Health Promotion

Geography & Rural Disability

The Ecology of Rural Community Participation

Resilience in Rural Community Participation

Person - Environment Fit in Rural Communities

Measuring Opportunities in Rural Events

Rural Contracted Services

The Use of Social Media for Employment

Rural Self Employment Opportunities

Funded for 2018-2023

Building Networks to Expand Living Well Delivery

Personal Assistance Services (PAS) in Rural America

Rural Transportation Options

Rural Self-Employment

Expanding the Availability and Quality of Rural Data

Rural Resource Analysis

Rural Communication Strategies


SERVICE / EDUCATION

Living Well / Working Well with a Disability - Peer-led health and wellness training and support

Healthy Communities for People with Disabilities - Supporting accessible community health initiatives

Montana Disability and Health Program - Policy and practice initiatives to promote health and wellbeing

Inclusive Healthy Communities - Promoting community health initiatives

MonTECH: Montana’s Assistive Technology Program -Technology for independence across the lifespan

Wheels Across Montana - Free access to adaptive trikes

Children’s Special Health Services: Montana Transition Resources - Transition-to-adulthood resources for youth, families and providers

National Disability Navigator Resource Collaborative (NDNRC) - Resources to ensure accurate ACA Marketplace information

Montana Early Diagnosis - Developmental milestone resources for families and providers

Deaf-Blind Project - Assistance to school systems

Pre-Employment Transition Services Technical Assistance Center - Training and assistance to schools and employment providers

UR-LEND - Leadership education in family-centered healthcare services

Movin’ On in Montana - College experience for high school students with disabilities

UM OUTREACH - Training speech language pathologists in rural and tribal communities


Spotlight on RIIC projects:

Addressing Abuse Against People with Intellectual Disabilities

The Rural Institute is a national leader on research and training to prevent abuse of people with disabilities. Recently, Rural Institute researchers and colleagues partnered with people with intellectual disabilities and staff from 13 Centers for Independent Living across the U.S. to create The Safety Class, an eight week safety awareness program for people with intellectual disabilities. Initial feedback shows that the program is an effective way to teach safety skills and awareness. Participants stated:

“I liked learning about how to be independent, the types of abuse, how to be assertive.”

“[I liked] listening, hearing about abuse and how to talk about relationships. If you have something to say about abuse, tell someone.”

“[I] Learned about boundaries, being assertive, saying no in a difficult situation, telling someone I trust my story so they can help me.”

The Safety Class is the first known violence prevention group program designed for people with disabilities that has undergone a rigorous evaluation by 170 people with intellectual disabilities. National partners are working with us to make this program available across the U.S.

Healthy Community Living (HCL)

RTC:Rural brought together Centers for Independent Living (CIL) staff and consumers, the Association of Programs for Rural Independent Living (APRIL), and researchers to create Healthy Community Living (HCL). HCL is an inclusive health, wellbeing and independent living skills program. HCL includes two workshops (Community Living Skills and Living Well in the Community) designed to accommodate the diverse learning styles and needs of participants. Both workshops are delivered via multi-media websites that feature images and videos created and collected by project partners. HCL was created and piloted with more than 20 staff members at 12 CILs across the U.S.; the full program launch is expected in 2019.


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