Memorial Regional Health Population Health Management enhances local care |

Memorial Regional Health Population Health Management enhances local care

Memorial Regional Health
Memorial Regional Health at Craig
Sheli Steele / Craig Press

Population Health Management is a relatively new department at Memorial Regional Health (MRH), having launched in 2018. In general, population health refers to an approach that has made recent gains across the nation, improving patient outcomes through disease prevention, identifying and closing gaps in treatment, and saving costs for patients and medical providers.

Healthcare experts often refer to the social determinants of health as the basic core of population health management. These determinants consist of social and economic conditions that shape our health status, including work and unemployment, social support, food, transportation, addiction, stress, early life experiences, and other associated factors. Like a single thread that connects the patterns that make us all unique, the social determinants are interwoven throughout our lives.

MRH’s Population Health Management department serves a variety of functions within the organization and in the community. Team members administer MRH’s state grant awards through the Cancer Prevention and Early Detection (CPED) Women’s Wellness Connection (WWC) and WISEWOMAN programs, both of which provide services for underserved women including free breast and cervical cancer screenings, as well as chronic disease prevention and management for eligible women. The department’s two care coordinators, Shannon Fatjo and Deanna Rowley, provide direct case management for patients throughout the region. They strive to improve patients’ well-being with the following resources: educational tools and referrals to community organizations; coordinating healthcare services and developing care plans, including for chronic care; serving as a centralized contact point between patients and providers; assisting with medical and other paperwork; locating medical equipment; and facilitating transportation arrangements. Their work extends to services for diabetes management, cancer prevention and women’s wellness screenings, food assistance through MRH’s Supplemental Nutrition Assistance Program (SNAP) grant, and other resources.

Additionally, the Population Health team currently manages MRH’s implementation grant awarded through the Rural Communities Opioid Response Program (RCORP). This program, which will fund MRH and its seven Consortium partners $1 million over three years, is an extension of MRH’s 2018 – 2019 RCORP-Planning grant award ($200,000 for one year) to address substance use disorder (SUD), including opioid use disorder (OUD), across Jackson, Moffat, Rio Blanco, and Routt counties. The Consortium functions to enhance existing and develop new prevention, treatment, and recovery services for people with SUD/OUD. Population Health team member Krystal Baker has taken a lead role in facilitating grant coordination activities for the RCORP-Implementation grant and providing administrative support for the WWC, WISEWOMAN, and SNAP grants.

MRH’s grant writer, Ryan Lucas, writes grant proposals for federal, state, and private funding for large regional projects as aforementioned, as well as proposals to help fund MRH Home Health and Hospice, Open Heart Advocates, and other MRH services. In addition, Ryan has provided support to community organizations and agencies by helping write proposals for the Senior Social Center of Craig and other local partners.

Population Health’s department director, Paula Belcher, serves to help develop and provide oversight to the growing myriad of Population Health programs and services. She is also responsible for overseeing MRH’s mandatory participation in the five-year Colorado Hospital Transformation Program (HTP), a value-based care initiative aiming to improve patient outcomes and reduce costs statewide with quality and value metrics.

“One of the greatest challenges in healthcare and in small communities is a lack of resources, and connecting people to the limited resources that are available,” Belcher said. “The Population Health team serves to help fill that gap, as well as bring much needed funding to our community to support programs and services. It takes time, but our team is committed to helping our community in whatever way we can.”

For more information about MRH’s Population Health programs and services, contact Paula Belcher at or 970-826-3113.

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