Initiative Two

Initiative Two: Strengthening the Continuum of Care in Rural Georgia

RHT Program Strategic Goal: Make Rural America Healthy Again
GREAT Health Vision Alignment: Needs of Rural Populations

The strategies within the Strengthening the Continuum of Care in Rural Georgia initiative are synergistic — they increase access and fill gaps in a continuum of care across:

Life stages (infants, children, pregnant women, adults, older adults)
Settings (home, school, hospitals, nursing homes, community, online)
Needs (mental health, nutrition, transportation, emergency safety)

Together, they form a holistic, wraparound approach to preventing and managing chronic illness and disease, identifying and addressing root causes of diseases, and improving physical and mental health and wellbeing for rural Georgians. Core strategies of this initiative focus on improving the overall health of children and families by strengthening integration between schools, community behavioral health, and primary care providers. Other strategies include reducing wait times, preserving availability, expanding capabilities of EMS, and improving child health outcomes through newborn screenings, prevention, and nutrition services.

The following are key outcome metrics associated with this initiative. Additional metrics are included in the Metrics and Evaluation plan section. Unless otherwise indicated, baseline measures are zero and will be established at Year 0 of the program; the proposed outcomes will be observed by FY31.

Outcomes

The outcomes of this initiative will be measured by: improved physical infrastructure for healthcare facilities at the county level (target 100%); increased referrals to behavioral health services (target 20%); increased screenings for individuals served under this initiative (target for each is 20%: behavioral, newborn, upstream drivers), and number of emergency preparedness baseline assessments completed (target is 249).

Overall Funding for this Initiative

$15,214,250 in Budget Period 1.

Table 3: Strategies of Strengthening the Continuum of Care in Rural Georgia

This table was reformatted as an ordered list for better readability.

Public Health Investments: Georgia Newborn Screening Program
- Key Metrics:
  - 35 screenings in the first few days of life for blood disorders, hearing issues, congenital heart disease and other conditions
  - 127,143 infants screened in 2024 with 545 infants diagnosed with a genetic or hearing loss condition (Georgia Department of Public Health, 2024).
- Transformative Care Solution: Proposed public health laboratory upgrades
  - Currently Atlanta is the only screening lab for the entire state; quick screening and referral is critical to improving long term health outcomes.
  - Expanding services at the laboratory in Waycross ensures faster access for rural families.
  - Ongoing costs will be covered by the newborn screening fee for sustainability.
- Key Activities:
  - Equipment purchase and installation, ramp-up operations, staff training
- Use of Funds:
  - A. Prevention and Chronic Disease
- Technical Score Factors:
  - B.1. Population health clinical infrastructure
  - B.2. Health and Lifestyle
- Key Stakeholders:
  - Georgia Department of Public Health (DPH), newborns, and families
- Measurable Outcomes:
  - Average wait times for required newborn screening test results in counties served by laboratory (desired trend decrease)
- Counties Impacted:
  - Statewide
- Estimated Funding:
  - $3,750,000 total /$2,000,000 in Budget Period 1
- Results and impact:
  - Improved wait times for rural infant screening
  - Contingency plan for statewide backup for the Atlanta lab
Public Health Investments: Inter-hospital Transportation
- Key Metrics
  - Long wait times for Emergency Medical Services (EMS) in rural Georgia put patients at risk
  - Hospital transfers of stable patients keep EMS occupied when emergencies are occurring
- Transformative Care Solution: Specialized vehicles for inter-hospital transfers
  - Provide Type 2 ambulances to hospitals to use when transferring stable rural patients between hospitals and to fill other non-emergency medical transportation gaps
  - Six rural hospitals each year will apply and be selected to receive Type 2 ambulances, for a total life-of-program impact of 30 rural hospital ambulances.
  - Hospitals will use billing to cover maintenance and other costs for sustainability
- Key Activities
  - Hiring staff, purchasing ambulances, providing training, and assisting hospitals with billing structure to ensure sustainability
- Use of Funds
  - E. Workforce
- Technical Score Factors
  - C.1. Rural Provider Strategic Partnerships
  - C.2. EMS
- Key Stakeholders
  - DPH, rural hospitals, providers, payers, ambulance providers, EMS
- Measurable Outcomes
  - Average wait times for ambulances providing emergency transport as compared to counties with and without the service (desired trend decrease)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $10,500,000 total /$2,100,000 in Budget Period 1
- Results and Impact
  - Free up hospital beds
  - Improve patient satisfaction
  - Reserve EMS Type 1 vehicles for 911 calls
Support for Acquired Brain Injury (ABI) Survivors
- Key Metrics
  - Number of ABI injuries annually: 30,000
  - Total cost (incl. medical expenses and lost wages): $1.5 billion
- Innovative Care Solution: Acquired Brain Injury (ABI) clubhouse approach to
  survivor-centered care
  - Side-By-Side (SBS) Clubhouse’s Day Program provides: Vocational training, Life skills counseling, Caregiver support, and Community support
  - Open first rural clubhouse network (currently only in metro Atlanta) to expand to statewide capacity
- Key Activities
  - Assessment, planning, and capacity building for SBS to be statewide, open the first rural ABI Clubhouse, expansion and evaluation, innovate within new and existing clubhouse
- Use of Funds
  - G. Appropriate Care Delivery
  - H. Behavioral Health
- Technical Score Factors
  - B.1. Population health clinical infrastructure
  - B.2. Health and lifestyle
- Key Stakeholders
  - Acquired brain injury survivors and their families
- Measurable Outcomes
  - Number of unique individuals in rural areas served by ABI Clubhouses (desired trend increase)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $3,475,000 total/ $257,000 in Budget Period 1
- Results and Impact
  - Reduced ER utilization
  - Lower hospital and follow up care costs
  - Improved patient safety
  - Community independence
  - Enhanced life quality
Transportation to Treatment Pilot for Mental Health Crisis
- Key Challenge
  - Individuals experiencing acute mental and behavioral crises in rural areas face significant travel distances to appropriate facilities and need safe transport to treatment, a task that often falls to law enforcement who have limited mental health training
- Innovative Care Solution: Pilot program expansion
  - A successful program in Southwest Georgia places mental health professionals in charge of transportation to Emergency Receiving Facilities (ERF)
  - Law enforcement, probate court, or private hospitals notify the provider when transportation is needed
- Key Activities
  - Develop funding model, evaluate regions and partners for expansions, expand program, and evaluate results
- Use of Funds
  - G. Appropriate Care Delivery
  - H. Behavioral Health
  - K. Fostering Collaborations
- Technical Score Factors
  - C.1. Rural Provider Strategic Partnerships
  - C.2. EMS
- Key Stakeholders
  - Individuals experiencing mental and behavior health crises; Georgia Sheriff’s Association; Georgia Crisis and Access Line; Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD); ERFs
- Measurable Outcomes
  - Percent of all law enforcement calls in counties used to provide emergency transport to mental health crisis facility (desired trend decrease)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $3,750,000 total/ $750,000 in Budget Period 1
- Results and impact
  - Faster access to appropriate care
  - Less diversion of law enforcement from primary duties
Building Bridges (School-Based Health Care Services Infrastructure)
- Key Challenge
  - Barriers to accessing quality healthcare in rural areas
- Transformative Care Solution: Multistakeholder Cooperative utilizing schools as entry-point
  - Leverage proven frameworks such as the Pediatric Collaborative Care Model and existing state-funded programs, Georgia Apex (mental health resource), and School-based Health Centers
  - Create a customized health information exchange (HIE) for each collaborative to support communication and referrals
  - Utilize a multi-generation approach focused on the behavioral health needs of students in pre-K through 5th grade as entry point
- Key Activities
  - Form program cooperative to leverage infrastructure
  - Integrate care across multiple sectors
  - Develop HIE
- Use of Funds
  - A. Prevention and Chronic Disease,
  - D. Training and Technical Assistance,
  - E. Workforce,
  - F. IT Advances,
  - H. Behavioral Health,
  - K. Fostering Collaboration
- Technical Score Factors
  - B.1. Population Health Clinical Infrastructure
  - C.1. Rural provider strategic partnerships
  - F.2. Data infrastructure
- Key Stakeholders
  - Public elementary schools, primary care clinics, community health clinics, certified community behavioral health clinics (CCBHCs), safety net mental health providers,
    community-based organizations, nonprofits, state agencies (DOE, DPH, DECAL, DBHDD)
- Measurable Outcomes
  - Number of referrals of students to mental health, physical health, or social services (desired trend increase)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $30,000,000 total/ $5,000,000 in Budget Period 1
- Results and Impact
  - Faster access to appropriate care
Emergency Preparedness — Shelter-in-Place
- Key Challenges
  - Georgia’s prevalence of severe weather and disasters leaves patients especially vulnerable when they are unable to relocate.
  - High cost, risk, and logistical complexity of relocating vulnerable patients and residents during disaster situations
  - Interruptions in dialysis or oxygen therapy
  - Heightened risk of falls or pressure injuries
  - Increased hospitalizations and double the probability of death (Dosa, 2012)
  - High relocation costs (as much as $600,000 for a 100-bed facility) (Desai, 2019).
- Transformative Care Solution: Improved Disaster Resilience for SIP and Receiving Facility Capacity
  - Establish a comprehensive infrastructure assessment and strengthening program that enhances the capacity of rural hospitals and skilled nursing facilities (SNFs) to either safely shelter-in-place (SIP) or act as designated receiving facilities for evacuees from other locations
- Key Activities
  - Planning and assessment of rural facilities
  - Grant administration with metrics tied to safe SIP capacity
  - Implementation of assessment findings, including electrical grid enhancements, generator purchases, roof repairs and environmental improvements (water and air quality reviews)
    - Note: While such work may lead to unexpected infrastructure areas of concern and improvements, no new construction or patient care-related footprint expansions are authorized.
  - Follow up assessments and demonstration of sustainability
- Use of Funds
  - J. Capital Expenditures & Infrastructure,
  - K. Fostering Collaboration
- Technical Score Factors
  - C.1. Rural Provider Strategic Partnerships
  - E.2. Individuals dually-eligible for Medicare and Medicaid
- Key Stakeholders
  - Healthcare facilities, DCH, UGA Institute of Disaster Management, Georgia Emergency Management Agency, DPH, State Fire Marshal’s Office, DCH Healthcare Facility Regulation, Georgia’s Healthcare Coalitions, SORH
- Measurable Outcomes
  - Percent of rural facilities completing infrastructure enhancements to become eligible shelter-in-place facilities (desired trend increase)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $3,000,000 in Budget Period 1
- Results and impact
  - Reduction in unnecessary patient/resident transfers, while evacuee-receiving facilities expand surge capacity across county and state lines, allowing for more efficient, regionally-based disaster response
Regional Nursing Home Transportation Enhancement
- Key Challenges and Metrics
  - Traditional Medicaid non-emergency medical transportation (NEMT) service is not designed for frail, compromised nursing home residents who require support with activities of daily living
  - Georgia has over 21,000 residents in skilled nursing facilities who require NEMT for dialysis, consultations, imaging, and specialty appointments
  - Typical NEMT limitations on wait times and assistance into physician offices or diagnostic settings are problematic, leading to delayed or missed appointments and challenges with drop-off and pick-up of potentially confused and dependent residents
- Innovative Care Solution: Regional hubs
  - Leverage community partners to establish regional transportation hubs to coordinate with NEMT brokers
- Key Activities
  - Assessment, policy and contract review, program design, education and training, purchase vehicles, regional pilot implementation, expansion, sustain, evaluate
- Use of Funds
  - A. Prevention and Chronic Disease,
  - K. Fostering Collaboration
- Technical Score Factors
  - B.1. Population health clinical infrastructure
  - B.2. Health and lifestyle
- Key Stakeholders
  - Skilled nursing facilities, Georgia Health Care Association, Nursing facility residents
- Measurable Outcomes
  - Average wait times for skilled nursing facility patients to be transported to non-emergency services (desired trend decrease)
- Counties Impacted
  - 126 HRSA-rural Georgia counties/portions of counties
- Estimated Funding
  - $7,500,000 total/ $1,500,000 in Budget Period 1
- Results and impact
  - Improved continuity of care
  - Reductions in hospitalizations and adverse outcomes
Rural Provider Nutrition Training for Autism Spectrum Disorder (ASD)
- Key Challenges
  - Need for long-distance specialist referrals to address feeding issues and nutrition management in children with ASD
  - Children with ASD have special nutritional challenges that affect their health and treatment. This service is not available in most rural communities without long wait times and travel.
- Transformative Care Solution: Nutrition training for rural physicians to support children with ASD
  - Centralized training platform delivering accredited continuing medical education modules with online toolkits and clinical resources
  - Tele-consults with registered dieticians and therapists
- Key Activities
  - Curriculum development, training and implementation
  - Planning, patient and provider marketing
  - Referral network expansion
  - Evaluation and monitoring
- Use of Funds
  - A. Prevention and Chronic Disease,
  - C. Consumer Tech Solutions,
  - D. Training and Technical Assistance,
  - E. Workforce
- Technical Score Factors
  - B. 4. Nutrition Continuing Medical Education
  - D. 1. Talent recruitment
  - F. 3. Consumer-facing tech
- Key Stakeholders
  - Pediatricians, dietitians, patient advocacy groups, GA-AAP
- Measurable Outcomes
  - Number of rural providers participating in training (desired trend increase)
- Counties Impacted
  - Statewide
- Estimated Funding
  - $279,250 total/ $107,250 in Budget Period 1
- Results and impact
  - Reduction of gastrointestinal issues and behavioral challenges
  - Improved developmental outcomes
  - Sustainability based on billing uptake, utilization of codes and provider feedback
Planning for Healthy Babies: Nutrition & Weight Management Eligibility Category
- Key Challenges
  - Prenatal and interpregnancy health is an important and significant determinant of pregnancy and birth outcomes
  - State agencies and legislature have maternal mortality prevention as top priorities
- Innovative Care Solution: New Eligibility Category for 1115 Demonstration Waiver- Planning for Health Babies (P4HB)
  - Adding fourth category of eligibility for women between ages 19-44 who meet certain clinical requirements (e.g. over a certain weight/BMI threshold) to qualify for additional services to decrease likelihood for dangerous pregnancy complications
  - Services will include, but are not limited to, dietician/nutritionist support, primary healthcare case management, and weight loss drugs (e.g.GLP-1s)
- Key Activities
  - Waiver planning and policy development
  - Actuarial development of the proposed waiver changes
- Use of Funds
  - A. Prevention and Chronic Disease
- Technical Score Factors
  - B.2. Health and Lifestyle
- Key Stakeholders
  - Women 19-44 who meet clinical guidelines and have income up to 211% of the FPL, OBGYNs, primary care physicians, dietitians, patient advocacy groups
- Measurable Outcomes
  - Number of referrals for the service (desired trend increase)
- Counties Impacted
  - Statewide
- Estimated Funding
  - $500,0002 in Budget Period 1. Note: While this coverage change will be cost-neutral as mandated for 1115 demonstration waivers, costs associated with actuarial development of the proposed changes will be funded by the GREAT Health Program.
- Results and impact
  - Reduction of maternal mortality
  - Better overall health for women in Georgia

Sustainability Efforts

There are a variety of sustainability efforts for the strategies included in the Strengthening the Continuum of Care in Rural Georgia initiative. Examples include user fees and private donations for the SBS Clubhouse, which, once operational, is a self-sustaining model, and payer reimbursable services for newborn screenings, school-based health and behavioral health services, and nutrition therapy training and services. In addition, there are sustained impacts from the investment of funding to improve infrastructure and remove upstream barriers, such as transportation concerns. The legacy of these impacts is future cost avoidance from preventive care, early identification of need, and quicker access to treatment, thus avoiding more complex, long-term illness and disease. Similarly, infrastructure improvements remain in the rural community long past the funding cycle and are expected to reduce illness, injury, and trauma from disasters, resulting in long-term savings for patients and the system.

The strategies of the GREAT Health Program Strengthening the Continuum of Care in Rural Georgia initiative support Georgia’s objective of ensuring a future in which all rural Georgians benefit from a focus on root causes of disease to prevent illness and coordinated care for enhanced chronic disease management, as well as the RHT Program goal of Make Rural America Healthy Again.