Partnerships for Better Health Grantees

Partnerships for Better Health Grantees

  • Barrett Hospital Foundation - +

    Southwestern Montana Rural Accountable Care

    Project Term: 24 months, Nov 1, 2015 – Oct 31, 2017
    Grant Amount: $50,000

    This grant will support the participation of Barrett Hospital in Montana’s first Rural Accountable Care Organization (RACO). Barrett Hospital and HealthCare will join a consortium of regional Critical Access Hospitals being formed to create a RACO among 12 hospitals in Montana, Idaho, and Wyoming that will collectively serve a group of more than 9,000 Medicare patients. The Centers for Medicare and Medicaid Services will track healthcare spending and measure the quality of care that is provided to these patients. Participating hospitals will have improved access to data to help measure costs, assess quality and safety.

  • Billings Clinic - +

    Transforming Primary Care to Meet the Needs of Alzheimer's Patients and Caregivers

    Project Term: 24 months; Nov 1, 2016 – Oct 31, 2018
    Grant Amount: $150,000

    This project will develop and implement a clinical care pathway to screen for and improve outcomes among Alzheimer’s patients at Billings Clinic and two rural healthcare facilities: Glendive Medical Center and Lewistown’s Central Montana Medical Center. The project will ensure that patients over the age of 65 are screened appropriately for Alzheimer’s dementia and related dementias (ADRD), and that those diagnosed with ADRD and their caregivers receive high-quality care and support. The project will also result in a detailed clinical care pathway and set of tools that address clinical care, support services, operations, and billing issues, with the goal of transforming and standardizing dementia care. The practices involved are diverse—they include a large, urban health system, a Billings Clinic-affiliated critical access hospital, and a non-affiliated critical access hospital—which will help ensure that the model created will be useful to and facilitate uptake by primary care practices across the state.

  • Cabinet Peaks Medical Center Foundation - +

    Enhanced Transition of Care Involving All Aspects of Wellness for the Residents of Lincoln County

    Project Term: 12 months; April 2017 – March 2018
    Grant Amount: $44,236

    This project will develop a new approach to discharge planning for hospitalized patients that systematically identifies and addresses the social factors that influence outcomes, such as ability to afford home heating, food, housing, and medications. The hospital will develop a discharge planning tool that identifies these needs, and will work with local clinics, and local aid and social service agencies to provide a safety net of services for patients in need at the time of discharge. The project seeks to reduce readmissions related to socioeconomic barriers to health, and to increase the acuity of patients seen in the emergency department as well as utilization of local clinics for outpatient care.

  • Community Health Partners - +

    CHP Park County Connect Program: A Community-Based Model to Reduce ER High-Utilization

    Project Term: 24 months; Jul 1, 2015 – Jun 30, 2017
    Grant Amount: $93,000

    High utilizers of the emergency department drive up costs unnecessarily and are not entering the healthcare system at an access point that is prepared to address their underlying needs. In an effort to improve care and health outcomes while lowering unnecessary costs to our healthcare system, Community Health Partners, the Park County Health Department, Livingston Mental Health Center and Livingston HealthCare have partnered to create the Park County Connect Program. Funds will support a social worker housed in the health department who will design and implement a community-based outreach program for existing emergency department high utilizers and those members of the community at risk for unnecessary utilization of the emergency department. The social worker will coordinate partner organizations to develop referral and tracking systems to ensure that interventions are documented and communicated, enhancing care coordination and improving outcomes. Performance indicators will be identified at both the patient and community level, and all partners will contribute data to the program evaluation process. This two year project aims to identify relatively simple interventions that can positively affect overall community health and well-being using a model that could be easily replicated in other rural communities.

    Promotoras de Salud: Bridging Latino Health Disparities in West Yellowstone and Belgrade

    Project Term: 24 months, Nov 1, 2015 – Oct 31, 2017
    Grant Amount: $20,000

    Community Health Partners (CHP) will develop a program in the communities of Belgrade and West Yellowstone to reach the growing, isolated communities of Latino immigrants there. Promotoras, or promoters of health, are laypersons who are trained to deliver basic health education and outreach to members of their community. An established partnership between CHP and the Montana State University INBRE Program (IDeA Network of Biomedical Research Excellence) will be leveraged to create a community-based health partnership with Latinos. The project seeks to help reduce health disparities through effective health care education and basic prevention while also empowering the community to become agents of their well-being.

  • Glacier County Emergency Medical Services - +

    Glacier County, Montana Integrated Mobile Health

    Project Term: 24 months, Nov 1, 2015 – Oct 31, 2017
    Grant Amount: $50,000

    Glacier County Emergency Medical Services (GCEMS) will implement a novel program in which they will provide home-based medical care in partnership with regional healthcare providers located in North Central Montana. The project seeks to improve health outcomes among medically vulnerable individuals identified by the hospital and medical providers, reduce unnecessary emergency department (ED) use and hospital readmission, and, ultimately, to save healthcare dollars by preventing unnecessary ambulance transports, emergency department visits, and hospital readmissions. The project builds on ideas from “community paramedicine” programs that are emerging in other parts of the US, and adapts them to serve the specific needs of Glacier County. The grant will fund a pilot in two communities, East Glacier Park and Babb, which include a high percentage of American Indians, elderly, at-risk children, and veterans. Services to be provided by EMS personnel include (1) home observation for ED patients judged to be at risk but too stable for admission; (2) home health services during off hours; (3) support for hospice patients to remain at home rather than going to the ED for crises; (4) home visits and calls to patients discharged from the ED or hospital and at high risk for readmission; and (5) 911 triage—establishing a call center for non-emergent, low-acuity callers to avoid unnecessary emergency transports. The proposal includes several strategies for sustainability, including intra-agency savings (reduced EMS calls), shared savings with hospitals (funding services using savings on readmission and uncompensated care), and changes that would make these services reimbursable by public and private insurance programs.

  • Hays Lodgepole School District 50 - +

    Fort Belknap Indian Community Homeless Youth Feasibility Study

    Project Term: 12 months; August 2017 – July 2018
    Grant Amount: $49,000

    The Hays Lodgepole Public School and the Fort Belknap Indian Community Council will assess the feasibility of designing, constructing, operating, and facilitating housing and supportive services to improve health and education outcomes for homeless youth on the Fort Belknap Reservation. By coordinating with other community organizations and tribal departments, this project will analyze housing and care needs, investigate successful housing and service coordination models, and identify potential funding sources for constructing and operating a shelter. With proper planning, the school and community hope to coordinate services to meet basic needs and provide a solid foundation that will improve education outcomes, personal health, and future success.

  • Healthy Mothers, Healthy Babies - +

    Montana Children's Health Data Partnership Project

    Project Term: 12 months; Dec 1, 2017 – Nov 30, 2018
    Grant Amount: $50,000

    This project seeks to advance a statewide framework to address key determinants of health for children in Montana by collaborating with public and private sector practitioners to develop benchmarks that will guide and support community coalitions around the state. Healthy Mothers Healthy Babies currently works with 20 early childhood coalitions around Montana, all of which have varying levels of capacity and often unique but related goals and strategies. This project will partner with the Montana Early Childhood Coalition to support local and regional networks and coalitions and allow them to apply a collective impact framework that relies on mutually agreed-upon priorities and metrics that can be used to jointly plan efforts to address key health determinants and to measure outcomes.

  • Human Resource Development Council of District IX, Inc. - +

    Assessment of Community Costs of Chronic Homelessness

    Project Term: 12 months; Jan 2016 – Dec 2016
    Grant Amount: $20,000

    The Human Resource Development Council (HRDC) is a leader in community efforts improving lives for low-income people and those struggling with homelessness. For this project, HRDC will develop partnerships with other community organizations on an initiative that seeks to improve health outcomes for homeless people in Gallatin County through addressing their housing needs. The project will create a framework for a coordinated community health response to chronic homelessness through a baseline assessment of the community-wide costs of homelessness and how those costs may be reduced through the implementation of the “Housing First” model in Gallatin County. The project will also determine the extent of need for Housing First units in the community to promote public and private investment in the model. Housing First is an evidence-based approach that provides stable housing as the foundation for improving treatment outcomes for those with chronic mental and physical illnesses, as well as improving participation in personal health care, financial stability, and the ability to achieve self-sufficiency.

    Final Report: Assessing Community Costs of Chronic Homelessness in the Gallatin Valley

  • Kalispell Regional Healthcare - +

    Post-Delivery Support for Neonatal Abstinence Syndrome Infants and Their Parents in Rural Montana

    Project Term: 24 months, Nov 1, 2015 – Oct 31, 2017
    Grant Amount: $50,000

    Through this grant, Kalispell Regional Healthcare’s (KRH) neonatal intensive care unit staff will work with Montana hospitals to develop and implement a standardized protocol to screen for and manage drug withdrawal in newborns.  Neonatal Abstinence Syndrome (NAS) is a drug withdrawal syndrome that sometimes occurs when infants exposed to opioids and other potentially harmful drugs in utero are delivered. This project will help to establish a strong, consistent approach to NAS among the hospitals that deliver babies in Montana. To accomplish this, KRH will work with other tertiary care hospitals to develop a standardized screening protocol, and then train staff in rural hospitals and work with them to develop and implement consistent policies and procedures for NAS. Second, KRH will develop and pilot a collaborative, multidisciplinary program to provide parents of infants with NAS with support and drug and alcohol counseling while their newborns are hospitalized.

  • Missoula Aging Services - +

    Care Transitions Achieving Better Health Outcomes

    Project Term: 24 months; Nov 1, 2016 – Oct 31, 2018
    Grant Amount: $135,250

    This grant will support a care coordination position to help older adults transition successfully from hospitals back to their homes, with a focus on dual-eligible Medicare and Medicaid patients. This group of patients tends to utilize high-cost services such as inpatient care more frequently than the general population, and social risk factors such as poor housing and social isolation often lead to poor clinical outcomes. The project will use an established model that involves home visiting followed by frequent phone or in-person contacts during the month after a hospital stay. The program will also identify social risks and help coordinate appropriate referrals as needed. This project builds on a current effort funded by the Center for Medicare and Medicaid Services which has been shown to reduce hospital re-admissions and reduce healthcare spending.

  • Montana Budget and Policy Center - +

    Researching and Implementing Effective Strategies to Help Enroll Low-Income Montanans in Health Care Coverage

    Project Term: 12 months, Nov 1, 2015 – Oct 31, 2016 (COMPLETE)
    Grant Amount: $10,000

    This project will develop and disseminate (via accompanying proposal from Montana Women Vote) two reports that will guide efforts to enroll newly eligible people in Medicaid and help them use healthcare effectively.

    Final Summary:

    The Medicaid Expansion in Indian Country report was presented to the HELP Oversight Committee, which resulted in inclusion of a recommendation to the Governor and Legislative Finance Committee to develop and implement coordinated and expanded efforts to enroll American Indians in the Medicaid expansion.

    1. Medicaid Expansion Outreach and Enrollment: Effective Strategies to Expanding Access to Coverage (March 2016)
    2. Medicaid Expansion in Indian Country: Effective Strategies for Outreach and Enrollment (September 2016)
  • Montana Department of Public Health and Human Services - +

    Improving the Health of Montanans through Local and Tribal Public Health

    Project Term: 24 months; Dec 1, 2014 – Nov 30, 2016
    Grant Amount: $1,344,740

    This project will supported county and tribal health department strategic planning and programming through a collaboration with the Montana Department of Public Health and Human Services (DPHHS). As part of its efforts to support health departments around the state, DPHHS undertook a department-wide effort to provide counties with County Health Profiles, which are specific, county-level health data. This data offers an important new tool to help communities in Montana identify health needs and make plans to address them. County Health Profiles are now available to the public via DPHHS’ portal for the county health departments.

  • Montana Legal Services Association - +

    Montana Health Justice Partnership

    Project Term: 24 months, Nov 1, 2015 – Oct 31, 2017
    Grant Amount: $100,000

    The Montana Health Justice Partnership (MHJP), a collaboration between the Montana Legal Services Association (MLSA) and the Montana Primary Care Association, will provide legal assistance to patients in several rural community health centers. Such “Medical-Legal Partnerships for health” (MLP) are active in nearly 40 states. In this model, an attorney works as part of a clinical team to address issues such as housing in disrepair, medical debt, family violence, denial of senior benefits, employment problems, health care access, and other issues that can have direct and indirect impacts on health. Through this grant, an attorney will provide services for patients in community health centers in Havre, Libby, Great Falls, Billings, Dillon, Fairview, and Lolo. The Montana Primary Care Association will provide the networks, relationships, trust, and project management needed to make this project successful.

    Montana Health Justice Partnership Project Materials:

    MLSA Referral Process
    MLSA and Montana Primary Care Association MOU
    MHJP Health Harming Legal Needs and Social Determinants of Health Training
    MHJP Authorization for Uses and Disclosures of Protected Health Information
    MHJP Authorization to Release Case-Related Information
    MHJP Screening Tool

  • Montana Medical Association Foundation - +

    Montana Health Information Exchange Feasibility Development Plan

    Project Term: 18 months; Aug 1, 2016 – Jan 31, 2018
    Grant Amount: $50,000

    Through this grant the Montana Medical Association Foundation and partners will explore the potential for creating a health information exchange for Montana. The grant will support creation of a governing board structure and workgroups that will be utilized to determine state needs and to hear reports on a pilot Health Information Exchange project existing in Montana. This private-public partnership is intended to explore the viability of a health information exchange while working under a clearly designed governance structure to develop an infrastructure and path forward to implementation. A consultant will assist to drive the completion of this effort within a defined timeframe. There are many partners for this project including the Office of the Governor, the Montana Department of Public Health and Human Services, Montana Hospital Association, health insurance providers, and the Montana Primary Care Association, among others.

  • Montana Public Radio - University of Montana - +

    Montana Care Issue Reporting

    Project Term: 12 months, Nov 2015 – Oct 2016 (COMPLETE)
    Grant Amount: $20,000

    Montana Public Radio will collaborate with Yellowstone Public Radio to research, produce, and broadcast statewide 16 in-depth stories on current health and healthcare issues in Montana. This funding would allow reporters to travel to remote parts of the state to research and cover issues relevant to rural Montanans and tribes.


    1. Montana Legislature Questions Cost of Air Ambulance Services (Dec 1, 2015)
    2. Montana Healthcare Leaders Aiming for Reform, Innovation (Jan 20, 2016)
    3. Montana Primed for Growth in Healthcare Spending, Jobs (Jan 27, 2016)
    4. Montana’s Growing Demand for Health Professionals Spurs Education Initiatives (Feb 22, 2016)
    5. Tester: ‘Veterans Choice Managers Inept,’ New Law Needed (Mar 3, 2016)
    6. Chronic Pain Patients Propose Policy Changes (Mar 10, 2016)
    7. Chronic Pain Patients Lobby For ‘Bill of Rights’ (Mar 11, 2016)
    8. Veterans Health Fix Failing in Montana (Apr 18, 2016)
    9. Montana’s ‘Pain Refugees’ Leave State for Treatment (Apr 25, 2016)
    10. Pain Helped Him Pull the Trigger (Apr 26, 2016)
    11. State Medical Board Examines Pain Treatment, Opioid Abuse Questions (May 23, 2016)
    12. Montana’s Medicaid Expansion Jobs Program Facing Scrutiny (Nov 21, 2016)
    13. Montana Healthcare Leaders Want to Ditch Fax Machines, Build An ‘Information Utility’ (Dec 8, 2016)
    14. Tester: Obamacare Repeal Has ‘Real World Impacts’ (Jan 8, 2017)
    15. Obamacare Brings Insurance, Jobs to Montana’s Indian Reservations (Jan 12, 2017)
    16. Montana Healthcare Employment Up in 2016, Future Uncertain (Jan 25, 2017)

    *Disclaimer: The statements and conclusions of these articles are those of the Grantee and not necessarily those of the Montana Healthcare Foundation.

  • Montana State University - Office of Rural Health - +

    Montana Community Health Worker Stakeholder Project

    Project Term: 24 months; Nov 1, 2016 – Oct 31, 2018
    Grant Amount: $140,772

    This grant will create a plan to support the broader use of community health workers (CHWs) in Montana. CHWs are frontline public health workers who are trusted members of the communities they serve. They are intended to serve as a liaison between community members and health and social service providers in order to facilitate access to care, transportation, appropriate follow-up, and continuity of services. Strong evidence demonstrates that CHWs can improve health outcomes in a cost-effective way. While CHWs and CHW-like roles are becoming more common in the U.S. and Montana, there is little consistency in how the role is defined, or in the training, employment, and funding of these positions. This plan will include standardized training curriculum for CHWs, identification of payment models to support policy-level changes needed to sustain these positions, and education for providers on how to utilize them. A stakeholder group comprising payers, providers, and health departments will provide broad-based perspective; and focused work groups will develop a model curriculum, training delivery models, and address policy issues related to scope, credentials, payment models, and sustainability.

    Montana Graduate Medical Education Council Rural Residency Sustainability Initiative

    Project Term: 12 months, Nov 1, 2015 – Oct 31, 2016
    Grant Amount: $25,000

    The project will address the need to provide rural training opportunities for medical residents in Montana. The project will develop a toolkit to help rural practices become effective training sites for medical residents, nurse practitioners, and physician assistant students, and develop a sustainable financial model for rural graduate medical education in Montana.

  • Montana Women Vote - +

    Researching and Implementing Effective Strategies to Enroll Low-Income Montanans in Health Care Coverage

    Project Term: 12 months, Nov 1, 2015 – Oct 31, 2016
    Grant Amount: $25,000

    Together with Montana Budget and Policy Center, Montana Women Vote will conduct a campaign to enroll newly eligible people in Medicaid. As a grassroots organization (with partner the Montana Human Rights Network), the grant will support 25,000 contacts with newly eligible people, via a huge network on local volunteers.

  • NeighborWorks Great Falls - +

    Home Matters – Linking Homes and Health Outcomes

    Project Term: 18 months; May 1, 2016 – Oct 31, 2017
    Grant Amount: $10,000

    This grantee will evaluate changes in health status and health-related behaviors among low-income first time homebuyers, using a set of measures developed by NeighborWorks America’s Healthy Homes & Communities program. The project would be carried out in partnership with the local health department, Benefis Healthcare, and the Great Falls Clinic, with the intent of engaging these health system partners in a longer-term discussion of how they might partner with housing and community development organizations to address the health risks of substandard housing.

  • NeighborWorks Montana - +

    Manufactured Housing Rehabilitation and Replacement Collaboration

    Project Term: 18 months, Nov 1, 2015 – Apr 30, 2017
    Grant Amount: $20,000

    Substandard housing creates risks for health problems such as asthma and hip fractures, among others. This project seeks to identify new partners and collaborative, scalable solutions to repair and replace old and poorly maintained manufactured homes in western Montana, with an initial focus on Pablo and Missoula. Manufactured housing is an important form of affordable housing in Montana, but upwards of 30,000 homes are in need of repair or replacement. This project will explore shared interests with the healthcare and energy sectors, and create a task force in western Montana to identify collaborative solutions to make manufactured home repair and replacement accessible and affordable – leading to improved health outcomes for low-income people.

  • Partnership Health Center - +

    Partnership Health Center’s Care Management for Super-Utilizers Program

    Project Term: 24 months; Aug 1, 2016 – Jul 31, 2018
    Grant Amount: $148,183

    This project will employ a targeted approach to treating so-called “super-utilizers,” the approximately one percent of patients accounting for 22 percent of total healthcare expenditures. Super-utilizers often suffer from multiple chronic conditions, mental health concerns, and myriad socioeconomic barriers to care, contributing to multiple ER visits and hospital admissions. Partnership Health Center’s Super-Utilizer Care Management teams will, through home visits and a partnership of community resources, deliver comprehensive care to these patients with the goals of reducing emergency department use, hospital admissions and healthcare costs; increasing patient health and satisfaction; and transitioning patients to primary-care settings.

  • Poverello Center - +

    Medical Respite Shelter for Homeless Patients in Missoula, Montana

    Project Term: 24 months; May 1, 2016 – Apr 30, 2018
    Grant Amount: $50,000

    The Poverello Center Medical Respite Program partners with St. Patrick Hospital, Community Medical Center, and other Missoula area providers to provide rooms and care coordination for homeless individuals who are recovering from illness, injury or acute medical conditions and require privacy, rest and additional care for full recovery. This proposal will expand on the existing medical respite program by supporting more robust care coordination by the Center; evaluate the health outcomes achieved by the program; and strengthen and formalize partnerships and funding agreements with the hospitals that refer to the center. The long term goal is to decrease medical costs, and to improve the overall health of homeless individuals in Missoula and the surrounding communities.

  • Richland County Health Department - Mental Health Local Advisory Council - +

    Connecting Resources for Emotional Wellness

    Project Term: 12 months; August 2017 – July 2018
    Grant Amount: $28,328

    This project will use an innovative strategy to address the upstream risk factors contributing to poor emotional health and the consequent occurrence of mental health crises. Using an Emergency Preparedness Tabletop Exercise Model, Richland County will bring together multiple agency stakeholders to identify resources and gaps in support services. A map identifying “opportunities of interception” will be created and processes will be developed to intervene and improve individual emotional wellness. Also, areas or services that could be supported by partners to reduce the overall cost of mental health crisis will be identified. This project will initiate the creation of a toolbox that will allow the project to be replicated easily in other communities.

  • RiverStone Health - +

    Integrated Clinical Pharmacy Services Best Practices

    Project Term: 12 months; May 1, 2016 – Apr 30, 2017
    Grant Amount: $25,000

    This project focuses on supporting the integration of clinical pharmacists into primary care practice to improve health outcomes. Studies on incorporating pharmacists into the health care teams consistently show improved outcomes and a decrease in overall healthcare costs. This project will identify the core elements of successful health care teams, develop solutions to identified barriers, and develop resources to facilitate the cost-effective scaling up of partnerships between small and rural practices across the state with clinical pharmacists in these communities. Partners will include RiverStone Health, Montana Pharmacy Association (MPA), the University of Montana Skaggs School of Pharmacy (UM SOP), and the Montana Medical Association (MMA). Other interested payers and policymakers will be invited to participate as well.

    Payer Panel Discussion Slides

    Integrated Clinical Pharmacy Services: Best Practices Toolkit

  • Rocky Mountain Development Council, Inc.'s RSVP (Retired Senior Volunteer Program) - +

    Tri-County RSVP Keeping You Home Project

    Project Term: 12 months, Nov 1, 2015 – Oct 31, 2016
    Grant Amount: $25,000

    This project focuses on reducing the risk of readmission for seniors and disabled individuals judged to be at high risk at the time of discharge from the hospital. The grantee will extend Helena’s RSVP program to rural towns in three counties. Volunteers in the RSVP program provide resource coordination, peer support, and assistance with issues such as taking medications correctly. The RSVP program has been credited with helping to reduce readmissions in St. Peter Hospital in Helena.

  • Sprout Oral Health - +

    School Nurse Fluoride Varnish Programs in Montana Elementary Schools

    Project Term: 24 months; May 1, 2016 – Apr 30, 2018
    Grant Amount: $50,000

    This project will develop and make sustainable statewide School Nurse Fluoride Varnish Programs in elementary schools across Montana to address oral health disparities in vulnerable child populations. The project will recruit school nurses in underserved and frontier areas of Montana to apply tooth-decay preventing fluoride varnish to eligible children’s teeth under standing orders of a physician or dentist as appropriate. Additional program components will include coordination of care for children with treatment needs and assistance to families in enrolling in Medicaid/CHIP. The project would also produce a reimbursement toolkit to allow school-based programs to become sustainable. Partners include the Montana State University College of Nursing and the Montana Association of School Nurses.

  • University of Montana - +

    Effective Integrated Behavioral Health Partnerships for Rural Montana – A Collaborative Training Proposal

    Project Term: 12 months, Nov 1, 2015 – Oct 31, 2016
    Grant Amount: $50,000

    The University of Montana will develop and implement an integrated behavioral health curriculum for its psychology, social work, and counseling students, as well as the Western Montana Family Medicine Residency.  This curriculum will ultimately be used to train and certify integrated behavioral health providers across the state.