Improving Health and Access to Care in Rural Areas: One Pennsylvania couple’s story

The Pennsylvania Rural Health Model aims to improve rural patients’ access to care and reduce hospital admissions 

Marilyn Mong, 81, and her husband regularly enjoy fruit and yogurt smoothies, pita bread pizzas, and homemade chicken stir fry together. But Mong, who is her husband’s caretaker, said the professed “meat and potatoes kind of guy” didn’t always follow a healthy diet.

Mong said she started adjusting their diet, making new recipes, and using healthier oils and sweeteners, after participating in the Independence Health System’s Food Institute at Clarion Hospital. Mong was referred to the Institute after her husband struggled with rheumatoid arthritis and related complications resulting in several hospital visits. 

Independence Health System makes the Food Institute program available to all its community members who are food insecure. 

Clarion Hospital is part of the Pennsylvania Rural Health Model, a pilot program led by the Center for Medicare and Medicaid Innovation at CMS.

The model pays participating hospitals a fixed amount upfront, regardless of patient volume, empowering these hospitals to invest in high-quality primary and specialty care that address the specific needs of the communities they serve. Among the model benefits are better coordination and linkage of medical and social needs services, chronic disease management, preventive screenings, and substance use disorder treatment.

Carrie McHenry, a care transition navigator at Clarion Hospital, assists patients with health issues that keep sending them to the hospital by directing them to a variety of community services. She calls patients at regular intervals to make sure they’ve been able to connect with services and if needed, can help them with applications for medical assistance, transportation, or other services offered within the community.

“It’s nice to see that progression between phone calls and follow-through with suggested supports and see they are able to take that information and do something with it,” McHenry said. Part of the goal is to reduce the hospital readmission rate, change patients’ mindsets that the emergency department is their family physician, and that getting set up with primary care appointments is more consistent with and beneficial to their individual goals, she said.

Clarion Hospital’s community is rural, and many of the patients are older, McHenry said. She regularly sees patients with chronic obstructive pulmonary disease (COPD), respiratory illnesses, diabetes, or other issues and helps connects them to a range of resources, from local food pantries to county transportation programs, or mental health and substance abuse treatment. Often, she helps prepare family caregivers with resources and helps them navigate home and community supports.

Among her success stories is a veteran with COPD who struggled to get his wife, who uses a wheelchair, to her medical appointments. McHenry connected the couple to a program called Ramps for Hope, to build an outdoor wheelchair ramp so that the husband could get his wife safely out to the car by himself. McHenry also connected the couple to local transportation services for when he could not drive her.

Another woman, McHenry recalled, needed extra support at home but didn’t have family nearby to help her. McHenry connected her to LIFE Northwestern PA, a program that provides a range of services to support adults with activities of daily living so they can continue to live independently. The patient was able to access a drop-in center, where she received help washing her clothes and other services. The patient has not had a hospital visit since, McHenry said. 

“So many individuals have no idea where to go to get the help that is needed,” she said.

For Mong, she wishes there was a similar program to the Food Institute for family members who live elsewhere and struggle with diabetes.

“I think it’s a great program,” said Mong. “It’s very informative. I’ve been really pleased.” 

While her husband has been slower to embrace some of the dietary changes to support his health, he has some newfound favorites, she said.

“Smoothies, anything like greens and fruit, yogurt. My husband likes that,” she said.