Community Champion Honor

Cathy Eades, Donna Dittman Hale, Christy Jensen and Rick Jackson

Bay Rivers Telehealth Alliance (BRTA) is pleased to be named a Rural Health Community Champion for innovative efforts around the use of evidence-based models from US Department of Health Resources and Services Administration (HRSA) Rural Health Care Services Outreach Grant Program. There were over 130 nominations detailing impressive work in rural communities across the country. BRTA has also been distinguished with an honorable mention in the category of creative partnerships.
The U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Rural Health Care Services Outreach program expands health care delivery in rural areas based on evidence-based or promising practice models. HRSA Administrator George Sigounas, MS, Ph.D. “These organizations are an essential part of the health care system because they understand their local communities, are able to fill significant health care gaps and ultimately improve the quality of life for those living in rural America.”
Tappahannock-based Bay Rivers Telehealth Alliance Bridges to Care Transitions project was built around a creative integration of three evidence-based models of care with Remote Patient Monitoring, in order to improve access to and quality of rural health care among an older population with chronic illness and high rates of hospital (re)admission: The Coleman Model®, The Healthy IDEAS Model, and The Stanford Model for Chronic Disease Self-Management.
The ultimate goal of the Bridges to Care Transitions project is to assist patients in developing chronic disease self-management skills to reduce unnecessary emergency department visits or hospitalizations, as well as to understand when to seek primary care. In working with its project partners, Bay Aging, which provides Care Transition Coaching and Healthy Ideas, Middle Peninsula Northern Neck Community Service Board, Professional Support and Mental Health Services, Riverside Center for Excellence in Lifelong Health – Evaluation Team, and Riverside Health System – Remote Patient Monitoring, BRTA has been exploring a number of strategies to sustain the project beyond the lifetime of the grant. BRTA has successfully integrated telehealth and face-to-face healthcare for both physical and behavioral health among our rural population in the Middle Peninsula, Northern Neck and Eastern Shore, whose access to healthcare has been severely limited by provider shortages, long travel distances, and poverty.

BRTA has created significant impact in improving health and healthcare access, quality, and affordability through its Bridges to Care Transitions project. It is estimated that at least $919,200 in net savings has been achieved when taking into considered the cost savings for in-patient care, transportation, personal care, and caregiver and community services. Remote patient monitoring and care transitions coaching, including chronic disease self-management education and behavioral health screening and treatment, have improved health care. Bay Rivers Telehealth Alliance is a non-profit network working to connect healthcare providers, patients, educators, and consumers and their families to a comprehensive continuum of care using telehealth technologies. Members of the Alliance include Riverside Health System, HCA Capital Region Hospitals, Bay Aging, Middle Peninsula Northern Neck Community Services Board, Rappahannock Community College, Bay Workforce Investment Board, and Eastern Virginia Medical School.