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Survey Request! What care coordination services are available for children?

Care Coordination in Montana Logo

The Montana Team of the National Care Coordination Academy partners with The Rural Institute for Inclusive Communities.  Please help us compile information about care coordination services available for children with complex care needs by completing the Care Coordination in Montana survey.

Our goal is to develop a resource guide for in-state service providers and enable them to provide their patients with seamless care throughout Montana. This survey also serves as a platform for clarification of terms and definitions surrounding "care coordination", "case management" and "targeted case management" for children with complex care needs.

Please take the survey on or before March 18th

Hearts of Glass: A Conversation About Cultivating Inclusion, Employment and Opportunity

Hearts of Glass event info graphic for joining the conversation about the project showing three young peole smiling and hold produce grown in their project building in the background and sponsor logos for programing presented by Montana DPHHS (tagline healthy people, healthy communities,department of public health & human services), Montana VRBS (tagline vocational rehabilitation & blind services, ready, willing, able), and American Job Center.

Montana Department of Public Health and Human Services, Vocational Rehabilitation and Blind Services and the Rural Institute are excited to bring you the award-winning Hearts of Glass documentary and an engaging panel discussion!

The documentary is a story of employment possibilities and community impact that is resonating with employers, job seekers, family members and service providers.

The event will open with a special welcome by the Montana Director of the Department of Public Health and Human Services (DPHHS) Adam Meier, and then there will be an interactive panel featuring speakers from the film, presenting organizations, and community partners.

Hearts of Glass follows the first 15 months of operation of Vertical Harvest (VH) based in Jackson, Wyoming — a state-of-the-art hydroponic greenhouse that provides meaningful, inclusive employment for people with disabilities. The documentary weaves the story of VH’s launch with the personal journeys of employees with intellectual and developmental disabilities. Plants and people grow together in this intimate portrait of innovation, inclusion and impact.

Learn more about the Hearts of Glass Documentary

View the Live Panel Discussion

Hosted by:
Montana Department of Public Health and Human Services
Vocational Rehabilitation and Blind Services
Rural Institute – University of Montana

MT Team: National Care Coordination Academy

Montana Team: National Care Coordination Academy Banner also showing logos for partner agencies Rural Instiute, University of Montana, and Montana Pediatrics

Montana healthcare providers, families & caregivers, and social & human service professionals share the same on-going overall goal for at-risk children and youth: Improved health and well-being outcomes of children, youth and their families.

A Montana interdisciplinary team is participating in a unique learning community centered on implementation of care coordination. Through workshop-structured learning opportunities, regular virtual meetings, and targeted technical assistance, the National Care Coordination Academy supports Montana efforts to acquire the essential knowledge, skills, and competencies for effective care coordination in the Big Sky.

Key Montana Team Outcomes

  • Meaningful family and youth participation in healthcare decisions that impact their health and family well-being.
  • Increased healthcare literacy among families and transitioning youth.
  • Increased provider understanding of patient- and family-centered medical homes, how they function, and what is required to sustain them.
  • Enhanced communication across health centers, systems and providers.

Connect to the Montana Team

Montana Team Member Listserv: This email address is being protected from spambots. You need JavaScript enabled to view it.

Team Leadership Contacts:

  • Kim Brown This email address is being protected from spambots. You need JavaScript enabled to view it.
  • Mackenzie Petersen This email address is being protected from spambots. You need JavaScript enabled to view it.

Team Resources

Open Pediatrics Connection

Go to:

National Care Coordination Academy materials are in the “My Courses” section of Open Pediatrics.  If you are unable to connect to your Open Pediatrics account, please contact Kim Brown This email address is being protected from spambots. You need JavaScript enabled to view it.

Pediatric Care Coordination

The five module Pediatric Care Coordination Curriculum, 2nd Ed. (Antonelli, et al., 2020) is available on Open Pediatrics. This online video version uses a learning management system to guide learners through the content.

A hard-copy version of the Pediatric Care Coordination Curriculum, 2nd Ed. is available online at:

Curriculum learning objectives

  • Discuss key components of care coordination within an integrated model of care delivery
  • Identify established tools and processes that can be used to implement key components of care coordination
  • Apply tools and processes that support key components of care coordination to a case example

Target audience

  • Physicians
  • Nurse Practitioners
  • Nurses
  • Social Workers

Related Resources

The National Care Coordination Academy is a Partnership of the Division of General Pediatrics and the Department of Accountable Care and Clinical Integration, Boston Children’s Hospital/ Harvard Medical School and the Collaborative Improvement and Innovation Network for Children with Medical Complexity at the Center for Innovation in Social Work and Health, Boston University School of Social Work, with support from the Health Resources and Services Administration, Maternal and Child Health Bureau.

Annual Review FY 2020

2020 Annual Review Cover thumbnailLetter from the director

2020 was an exceptional year -- we had our share of uncertainty, sadness and frustration. But the year also provided opportunities to demonstrate our creativity, expertise and humanity. The Rural Institute for Inclusive Communities quickly found ways to provide service, research and training activities in formats requested by community and government partners. For example, the MonTECH program developed and implemented COVID-safe practices so they could continue to provide assistive technology to Montanans; one of the first AT programs in the U.S. to do so. RTC:Rural published information briefs to help policy makers and service providers understand the economic and social impact of COVID on people with disabilities who live in rural America.

Though COVID dominated our attention, it didn't hinder our work. We set up technology in our homes so we could reach record numbers of people through video meetings and conferences. We started new projects to better understand community strengths and system barriers faced by rural Americans. We came up with innovative ways to connect with research participants and partners around the U.S.--the people who drive our efforts. We've always practiced the value that "people are at the center of our work" and 2020 provided an opportunity to once again prove that point.

Visit us on social media or our website to learn more about how we are building "collaborative community partnerships that support opportunities for all."

May you enjoy a peaceful, healthy and fulfilling 2021!

Martin E. Blair, PhD
Executive Director


  • The Rural Institute has 55 active projects and programs
  • We mentored 43 trainees across 14 disciplines
  • 47 UM students took a class sponsored by the Rural Institute
  • We published 18 reports, articles and book chapters
  • We shared 28 conference presentations and posters
  • We trained 5,665 people in Montana and across the country
  • Rural Institute staff members participated in 48 local, state and national committees, councils and boards


13% Evaluation

15% Education

27% Service

45% Research

FY 2020 budget = $6,095,572

Projects and Programs


Montana Access to Pediatric Psychiatry Network (MAPPNet)
Evaluates impact of statewide pediatric telehealth program

Healthy Montana Families Home Visiting Needs Assessment
Identifies the need for home visits for pregnant women & families with children 5 and under

Montana Title V Needs Assessment
Assesses Montana’s maternal and child health population needs, and the capacity to meet those needs

Montana Obstetrics and Maternal Supports Evaluation (MOMS)
Evaluation and research for Montana Obstetrics and Maternal Support project

Montana Primary Care Office Needs Assessment
Assesses the need for and access to primary healthcare services across the state

Achieving Success by Promoting Readiness for Education and Employment (ASPIRE)
Evaluates impact of independent living and employment supports on families

School Climate Transformation: MBI in High Need Areas
Evaluates effectiveness of PBIS in high-need schools


Leadership training and education focused on family-centered healthcare

Egypt Disability Services Study Tour
Strengthens the capacity of Egyptian university staff to administer Disability Support Centers

Community Oriented Living Well
Expands the delivery of Living Well with a Disability curriculum to rural Montanans through CILs

Trains speech language pathologists in rural and tribal communities

Diversity Fellowship Program
Graduate fellowship for culturally-diverse students


MonTECH: Montana’s Assistive Technology Program
Supplies technology to support independence across the lifespan

Montana Family to Family Health Information Center
Provides family-focused healthcare information

Healthy Community Living
Offers independent living workshops focused on health and community living skills

Montana Disability and Health Program
Promotes health-related policy and practice initiatives

All of Us Outreach in Montana
Recruits participants for national health outcomes research

Deaf-Blind Project
Gives resources and assistance to local school systems

NCDB: Transition Outcomes for Youth with Deaf-Blindness
Provides training to improve transition outcomes for youth

Children’s Special Health Services: Montana Transition Resources
Provides transition-to-adulthood health resources for youth, families and providers

Movin’ On in Montana
Offers a college experience for high school students with disabilities


Home Usability Project
Promotes community participation of adults with disabilities

Out and About
Evaluates community intervention to promote health and wellness

Partnering with Women with Disabilities to Develop a Health Information Website
Creates an online health information resource for women

Texas Model Spinal Cord Injury (SCI) Systems
Evaluates ways to improve the health of people with SCI

Loneliness and Its Relation to Health in People with Spinal Cord Injury
Identifies how loneliness impacts the health of people with SCI

Effort Capacity and Choice
Investigates the link between energy exertion and quality of life

mHealth App Development
App that features the Living Well with a Disability curriculum

Montana Pediatric Medical Passport (MP2)
Builds an app for healthcare information and decision making

Rural Community Living Development
Develops a peer-to-peer training program CILS can use to address issues and initiate change

Understanding Personal Assistance Services Experiences in Rural States
Explores barriers to PAS delivery, and designs an intervention to address rural outcomes

Rocky Mountain Region ADA Research
Researches ADA legal issues

Expanding the Availability and Quality of Rural Data
Rural analyses of existing large data sets

Exploring Rural Disability Onset
Explores how disability evolves

Rural Access to Health Insurance and Health Care
Answers questions about health care and quality of life

Rural Resource Analysis
Maps community resources and networks

Building Networks to Expand Living Well Delivery
Scales up Living Well to rural hospitals

Personal Assistance Services in Rural America
Explores and addresses rural PAS outcomes

Rural Transportation Options
Explores accessible transportation in rural communities

Rural Self-Employment
Develops and evaluates online tools for state and tribal Vocational Rehabilitation

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