Rural Northern Border Region Network Planning Program - Community Health Centers of the Rutland Region (CHCRR), a Federally Qualified Health Center and the largest FQHC in Vermont, requests $97,648.05 in one-year planning funds under the Rural Northern Border Region Network Planning Program to design a structured, interoperable closed-loop referral coordination model in partnership with Rutland Regional Medical Center (RRMC) and Southwestern Vermont Council on Aging (SVCOA). This project is submitted under Legislative Aim #2 (expand access to, coordinate, and improve the quality of basic health care services and associated health outcomes), with strong secondary alignment to Aim #3 (strengthen the rural health care system as a whole). Referral operations across the CHCRR-RRMC-SVCOA service area are high-volume and increasingly strained: RRMC alone processed over 34,000 outgoing referrals in 2025. Because high-demand specialties such as orthopedics, ENT, and digestive services frequently carry appointment backlogs exceeding 12 months, referrals routinely expire before patients are seen, breaking the closed-loop referral cycle and creating gaps in continuity of care. These breakdowns are worsened by manual, non-standardized processes, including continued reliance on fax transmission with no receipt confirmation and inconsistent scheduling requirements across partner facilities. Over a 12-month period of performance, the network will conduct a joint current-state assessment of referral workflows and systems; design a future-state closed-loop referral model with defined governance and roles; identify the technology and interoperability requirements needed for real-time referral tracking; establish data-sharing and security frameworks; evaluate automation and AI-supported tools to reduce manual tracking burden; and pilot-test revised workflows with a limited referral cohort. The project will conclude with a phased implementation roadmap and sustainability plan positioning the network to pursue future implementation funding. The target rural service area is Rutland County, Vermont, a HRSA-designated rural area within the Northern Border Regional Commission service area. Rutland County is home to one of the oldest populations in the country (23% of residents age 65 and older, compared to 15% nationally) and experiences some of the highest rates of chronic illness in the state. Residents face significant barriers to specialty care, including long travel distances, limited public transportation, and constrained economic resources. By building a formal, sustainable referral-coordination network among CHCRR, RRMC, and SVCOA, this project will improve care continuity and health outcomes for Rutland County's rural, aging, and medically underserved population.
