Population Health Geospatial Mapping Transforms Reno-Sparks Tribal Health Center’s Approach to Vital Care

Reno-Sparks Tribal Health Center (RSTHC) is a tribally owned and operated clinic of the Reno Colony, Reno Nevada. The health center is committed to enhancing the quality of life of all American Indian and Alaskan Native patients by providing a culturally competent and patient-centered continuum of care. Reno-Sparks Tribal Health Center has been on a mission to improve the physical, mental, social, and spiritual health of American Indians and Alaska Natives to unparalleled heights.

In the fall of 2024, South Reno, Nevada was impacted by a forest fire that triggered evacuations across the region. More than 200 Reno-Sparks Tribal Health Center (RSTHC) patients were affected and evacuated from their homes. This inspired the team at RSTHC to question how they could identify impacted patients and implement an emergency response that would address patient needs and minimize gaps in ongoing care.

By utilizing the geospatial features of the NextGen® Population Health tool, the team at RSTHC was able to map the fire alongside their patient population, giving them clear data on specific patients who were in current, and potentially future, evacuation zones. Once the impacted patients were identified, RSTHC mobilized their community health workers, public health nursing team, pharmacy team, and mobile medical and dental units to reach out to individuals and provide on-the-ground resources.

The precise data pulled from NextGen Population Health helped the team identify individual patients with complex needs, such as daily medications, referral appointments, and vital treatments. Additionally, the health center’s pharmacy team was able to complete pharmacy reviews for evacuated patients who needed medications filled. Non-emergency medical transport was dispatched for patients who needed to receive clinic services or attend referral appointments. Some evacuated patients were also on dialysis at the time, so the RSTHC team communicated with these individuals, assuring them that transport would be provided so they could attend their treatments without any gaps in care.

“There was a lot happening during the active fire, a lot of information coming in and out in the local area. And so, we said, ‘Can we use Population Health to better define our patients impacted? And if so, how can we look at an emergency response?’ The really beautiful thing is, Population Health has geospatial abilities, making our immediate response effective and targeted.”
Angie Wilson
Executive Director
Reno-Sparks Tribal Health Center

RSTHC is unique in how they leverage NextGen Population Health, gaining increasing value from it in their efforts for organizational change management and the drive to adopt it operationally on a larger scale. Here are some other opportunities they leverage NextGen Population Health:

Pre-visit planning 
Pre-visit planning has significantly improved daily workflows—a key advantage offered by NextGen Population Health. Integrated with NextGen® Enterprise EHR, providers receive a red stoplight notification when a measure hasn’t been documented. If a provider knows they can complete the measure within that visit, they try their best to do so. If not, they reschedule for a follow-up. Pre-visit planning enables the team to prepare for these instances, triaging what can be done during that day's encounter.

Outreach
Depending on the month, such as Colon Cancer Awareness or Breast Cancer Awareness Month, the team at RSTHC use NextGen Population Health to target patients and encourage them to come in for screenings with enticing activities like raffles and prizes. For example, they planned a “Back to School” initiative to reach out to parents or guardians of children within a certain age range and inspire them to schedule appointments for physicals, immunizations, and other care services. The draw: the children received back-to-school supplies, such as a backpack.

The ease of accessing information offers opportunities for RSTHC to better engage in their prevention and intervention activities. They can reference critical information to align with targeted approaches and increase effectiveness. One example, being able to reference the crossover of their diabetic patients with hypertension and depression allows them to target key patient activities that are meaningful to specific patients while also assisting with meeting funding requirements. They use the system to help drive key planning initiatives that result in strengthening tribal health care delivery overall.

RSTHC was recently recognized by the Northern Nevada Public Health Department on the significant increases in youth vaccinations including a 19% increase of Dtap, 23% increase in Tdap, 26% increase in Menveo, and a 49% increase in HPV vaccination rates. This effort was achieved through improved patient campaign, utilizing Population Health.

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