Initiative Three

Initiative Three: Connecting to Care to Improve Healthcare Access in Rural Georgia 

  • RHT Program Strategic Goal: Sustainable Access

  • GREAT Health Vision Alignment: Needs in Rural Places

The galvanizing concept of the strategies in this initiative are to close geographic, economic, and systemic gaps in access to timely, high-quality healthcare by leveraging innovation, technology, and targeted investments. Each initiative contributes to building a seamless, person-centered care-delivery system that meets people where they are— whether through mobile units, virtual care platforms, or strengthened local care networks. Data flows between services, follow-up is built into the model, and support is sustained through stabilization funding and infrastructure investments. Together, these strategies form a cohesive framework for improving access, continuity, efficiencies, and outcomes, particularly in rural populations.

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: increased access to prenatal and postpartum visits (target is 25%); reduced 30-day readmission rates for inpatient visits (target is 10%); decreased non-emergent ED visits (target is 24%); and increased use of primary care services at the county level (target is 30%).

Overall Funding for this Initiative

$34,968,968 in Budget Period 1.

Table 4: Strategies of Connecting to Care to Improve Healthcare Access in Rural Georgia

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

  • Care to Consumer – Point of Care Telepods & Mobile Clinics
    • Key Challenges
      • Rural access to primary, dental, behavioral, and preventive care
      • Urgent need for services, such as substance use treatment, cancer screenings, and alternatives to emergency department overuse
    • Innovative Care Solution: Rural Mobile Health Units        
      • Mobile health units will be supported through grants administered by the Georgia Board of Health Care Workforce (GBHCW) with collaboration between local clinics, hospitals, and academic institutions
      • Tailored to specific needs with follow-up systems and opportunities for undergraduate and graduate medical education clinical rotations
    • Innovative Care Solution: Point-of-Care Telepods
      • Deployed through a vendor selection process by the SORH and staffed by/connected to regional hospitals for follow up
      • Located in community areas, such as libraries and workplaces
      • Will offer rural residents 24/7 access to providers
    • Key Activities
      • Develop grant funding proposal with key stakeholders
      • Award grants to rural hospitals and clinics
      • Design mobile units and develop system for clinical rotations
      • Ensure interoperability for pods
      • Evaluate outcomes
    • Use of Funds        
      • A. Prevention and Chronic Disease, 
      • D. Training and Technical Assistance, 
      • E. Workforce,
      • G. Appropriate Care Availability, 
      • H. Behavioral Health
    • Technical Score Factors        
      • B.1. Population health clinical infrastructure
      • C.1. Rural provider strategic partnerships
      • F.1. Remote care services
    • Key Stakeholders        
      • Free and charitable clinics, rural hospitals, schools of medicine/nursing/allied health, AHECs, DPH, FQHCs, CCBHCs, SORH, EMS, community-based partners
    • Measurable Outcomes
      • Number of unique individuals served by mobile units (desired trend increase)
      • Number of unique individuals served by point-of-care pods (desired trend increase)
      • Number of pods and mobile units placed in rural areas (desired trend increase) (baseline FY25 = zero)
    • Counties Impacted        
      • 126 HRSA-rural counties/portions of counties
    • Estimated Funding        
      • $17,180,000 total/ $7,371,401 in Budget Period 1
    • Results and impact        
      • Meet care needs closer to home
      • Reduce strain on rural emergency departments for non-emergencies
      • Supports rural workforce development
      • Supports rural transformation for success under AHEAD by providing additional and alternative primary care access points
      • Sustainability through billable services, continuity of care and improved health data collection to demonstrate impact and drive future improvements
         
  • Telehealth Enhancements
    • Innovative Care Solution: Rural Health Digital Transformation through multi-hub design
      • DCH will form a statewide network through a multi-hub architecture
        • 1st hub: Local hospital as primary anchor for patient care
        • 2nd hub: Interconnected network of rural hospitals
        • 3rd hub: Digital ecosystem provides framework for patient placement, clinician education and training for scalability
      • Rural hospitals, universities, public health, and rural service providers will be connected into a coordinated system of care
      • Digital infrastructure of rural facilities, including servers, storage and networks will be modernized
    • Special Features
      • Subspecialty telemedicine consults
      • Remote Patient Monitoring (RPM) for chronic disease management
      • 24/7 patient-facing digital platform
      • AI integration for real-time advanced analytics
      • Workforce development and education, including virtual mentorships and use of the Extension of Community Healthcare Outcomes (ECHO) model to facilitate case-based learning in virtual clinics
    • Key Activities
      • Assessment and workforce preparation
      • Initiation of remote specialty care
      • Cohort implementation and equipment placement
      • Capacity expansion and scaling
      • Evaluation
    • Use of Funds        
      • A. Prevention and Chronic Disease, 
      • C. Consumer Tech Solutions,
      • D. Training and Technical Assistance, 
      • E. Workforce, 
      • F. IT Advances,
      • G. Appropriate Care Availability, 
      • H. Behavioral Health
    • Technical Score Factors        
      • C.1. Rural Provider Strategic Partnerships
      • F.1. Remote Care Services
    • Key Stakeholders        
      • Rural hospitals, rural clinics, academic medical centers, county health departments, primary care, specialty care, and behavioral health providers
    • Measurable Outcomes
      • Percent of rural hospitals connected to digital access for remote specialty care (desired trend increase)
      • Rate of county residents accessing digital specialty care stated as number per 1,000 residents/month (desired trend increase)
    • Counties Impacted        
      • 126 HRSA-rural counties/portions of counties
    • Estimated Funding        
      • $10,000,000 in Budget Period 1
    • Results and impact
      • Expansion of medical services available within rural communities
      • Allows clinicians to manage more complex cases at the local level
      • Supports workforce development and education for rural physicians, nurses, and advance practice providers
      • Provides rural hospitals with data analytics on capacity, population health and patient risk
         
  • Rural Stabilization Grants (RSG)
    • Key Context: Current Program
      • Per state statute, the State Office of Rural Health (SORH) created a grant program to provide resources for rural hospital stabilization.
      • Due to the increasing pressures on rural hospitals, the state received more applications than funds available in recent years.
      • The current program has four goals, pursuant to priorities identified under state law: increase access to care, increase market share, reduce inpatient readmissions, and decrease inappropriate emergency department utilization.
    • Transformative Care Solution: RSG Dual-track program
      • SORH will add a second track of grants focused exclusively on preparing rural hospitals and primary care for transitioning to the AHEAD model
    • Key Activities        
      • Develop new stream and align grants with AHEAD strategies, launch funding opportunity, fund hospitals, collect/monitor data, scale program
    • Use of Funds        
      • A. Prevention and Chronic Disease,
      • D. Training and Technical Assistance, 
      • G. Appropriate Care Availability, 
      • K. Fostering Collaboration
    • Technical Score Factors        
      • B.1. Population health clinical infrastructure
    • Key Stakeholders        
      • Rural hospitals, rural health clinics, FQHCs, SORH, community-based organizations
    • Measurable Outcomes
      • ED 30-day readmission rates for inappropriate utilization (desired trend decrease)
      • Percent hospital inpatient 30-day readmission rate (desired trend decrease)
    • Counties Impacted        
      • 126 HRSA-rural counties/portions of counties
    • Estimated Funding        
      • $9,540,817 in Budget Period 1
    • Results and impact
      • Hospital flexibility to align needs with AHEAD transition
      • Cross-sector collaboration to resolve upstream barriers to care, improve quality metrics, and enhance care coordination.
         
  • Strengthening Perinatal Systems of Care
    • Key Challenges
      • Critical gaps in maternal healthcare in rural communities due to continued closure of labor and delivery units
      • 108 counties in Georgia lack a birthing facility (Georgia Department of Public Health, 2025)
    • Transformative Care Solution: Non-delivering hospitals Strategy
      • Provide fully stocked, mobile, color-coded obstetrical emergency carts to aid in urgent or unexpected delivery needs. Carts will include essential medications and supplies for hemorrhage management and preeclampsia/eclampsia treatment, neonatal resuscitation equipment, and visual job aids
    • Transformative Care Solution: Birthing hospitals Strategy
      • Standardized, evidence-based patient safety bundles will be distributed and implemented in all 66 birthing hospitals, with emphasis on 15 rural hospitals each year
      • Bundles will provide structured protocols and practice changes to improve early recognition and treatment of OB emergencies
    • Key Activities        
      • Assess existing efforts at non-delivering hospitals
      • Deploy mobile carts
      • Develop standard operating procedures, train staff, run drills, and implement bundles
      • Collect and evaluate data with coordination from DPH and DPH perinatal nurse educators
    • Use of Funds        
      • D. Training and technical assistance, 
      • G. Appropriate care availability
    • Technical Score Factors        
      • C.1. Rural provider strategic partnerships
      • D.1. Talent Recruitment
    • Key Stakeholders        
      • DPH, rural non-delivering hospitals, EDs, regional perinatal centers, local health departments, FQHCs, EMS
    • Measurable Outcomes        
      • Percent targeted rural EDs equipped with OB emergency carts within first six months (desired trend increase)
    • Counties Impacted        
      • 126 HRSA-rural Georgia counties/portions of counties
    • Estimated Funding        
      • $12,606,750 total / $3,606,750 in Budget Period 1
    • Results and impact        
      • Reduction in risk of severe maternal morbidity and mortality
         
  • Public Health Telehealth Infrastructure
    • Key Challenge        
      • Statewide technology assessment found that 162 of 167 health department offices and clinical sites lacked sufficient infrastructure to host telehealth services (National Institute of Standards and Technology, 2024)
      • Telehealth services in most rural county health departments across Georgia are either limited or non-existent due to the absence of start-up resources.
    • Transformative Care Solution: Telehealth for PH        
      • As a crucial provider in many counties, outfitting these facilities with telehealth capabilities can greatly expand coverage.
    • Key Activities        
      • Launch competitive application process, baseline assessment, procure equipment, expand infrastructure in all rural health departments, communicate with public, evaluate, integrate billing
    • Use of Funds        
      • A. Prevention and Chronic Disease, 
      • C. Consumer Tech Solutions,
      • D. Training and Technical Assistance, 
      • K. Fostering Collaboration
    • Technical Score Factors        
      • C.1. Rural provider strategic partnerships
      • F.1. Remote care services
    • Key Stakeholders        
      • DPH, local health departments, Georgia Technology Authority, patients, providers
    • Measurable Outcomes
      • Number of county health department offices and clinic sites equipped with telehealth-ready infrastructure (desired trend increase)
      • Number of trained workforce capable of delivering and billing for telehealth services (desired trend increase)
    • 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
      • Increased access in high-touch point, familiar location
         

  • Rural Telepsychiatry: Consultations and Primary Care Provider Training

    • Key Challenge

      • Due to the lack of access to psychiatrists, rural primary care providers, including pediatricians and obstetricians (OBs), are often the front-line for detecting and treating behavioral health conditions, though they have limited training in the conditions.

    • Innovative Care Solution: Ped. Psychiatry ECHO Model

      • Begin pediatric telepsychiatry training program through DBHDD

      • Project ECHO model in partnership with pediatric psychiatrists to train rural physicians and advanced practice providers via telehealth on treating complicated cases, including medication management and linkage to patient-centered resources

    • Innovative Care Solution: PEACE for Moms

      • Scale DPH’s existing Perinatal Psychiatry, Education, Access, and Community Engagement (PEACE) for Moms program of provider-to-provider consultations for OBs around treating pregnant and post-partum women who are experiencing mental health and/or substance use concerns, with on-demand consultations within a 30-minute response time

      • Expand program to include enhanced access to providers through building telehealth infrastructure for tele-psychiatry directly to patients

    • Key Activities        

      • Implement Project ECHO model with DBHDD and pediatric psychiatrists, communicate to provider for training opportunity, scale PEACE for Moms with DPH, communicate to providers across state

    • Use of Funds        

      • E. Workforce, 

      • G. Appropriate Care Availability, 

      • H. Behavioral Health, 

      • K. Fostering Collaboration

    • Technical Score Factors        

      • F.1. Remote care services

    • Key Stakeholders        

      • Rural providers, psychiatrists, youth, parents, pregnant women, DPH, DBHDD

    • Measurable Outcomes

      • Number unique providers participating in Project ECHO trainings (desired trend increase)

      • Number of providers that access PEACE for Moms telepsychiatry consultations (desired trend increase)

    • Counties Impacted        

      • 126 HRSA- rural Georgia counties/portions of counties

    • Estimated Funding        

      • $14,750,000 total /$2,950,000 in Budget Period 1

    • Results and impact        

      • Increased PCP comfort in treatment of mental health conditions

      • Increased access to psychiatry care in rural areas

Sustainability Efforts

The Connecting to Care to Improve Healthcare Access in Rural Georgia initiative is focused on increasing access and efficiencies through the implementation of technology, the integration of telehealth services, and system shifts and practices to improve workflows, partner collaborations, and quality efforts. Once the telehealth infrastructure is established and equipment is installed, each facility will develop sustainability plans for equipment maintenance and updates. The initial funding will assist facilities and partners to collaborate and develop sustainable workflows for referrals, communication, and provider-to-provider consultations and training. Aligning the Rural Stabilization Grants with local hospital, clinic, community need, and AHEAD priorities ensures readiness for moving facilities towards the AHEAD model, which is focused on value-based care and global payments to stabilize rural hospitals and clinics.

The combined strategies of the GREAT Health Program Connecting to Care to Improve Healthcare Access in Rural Georgia initiative will support Georgia’s objective of ensuring a future in which all rural Georgians will benefit from a focus on sustainable access to healthcare, as well as the RHT Program Sustainable Access strategic goal.