Rural Health Initiative Breaks Down Barriers for Plainfield Resident

I really didn’t manage [my diabetes] before. It was the Rural Health Initiative that helped me get back on track.

Matt Callies, ThedaCare and Rural Health Initiative Patient

Before Matt Callies connected with the ThedaCare Rural Health Initiative, he was in a rough place.

The 41-year-old Plainfield resident lives with multiple chronic conditions, including type 2 diabetes, sleep apnea, debilitating back pain, and anxiety.

“I wasn’t doing so great for a while,” Matt says of the state of his health before he began working with RHI. “My weight comes with its own health problems. With my diabetes, I was having a rough time with that, controlling my eating and taking my meds.”

Matt is unemployed due to his back pain, and he doesn’t have a car. His primary care physician, Dr. Zach Baeseman, practices at ThedaCare Physicians-Wild Rose — a 20-minute drive for Matt. He also has care needs at ThedaCare Medical Center-Berlin, a 45-minute trip.

“Getting to my appointments is difficult,” Matt says. “Plus, I always get nervous in medical settings, and it raised my anxiety a bit.”

Those factors led Dr. Baeseman to refer Matt to the Rural Health Initiative. The care he’s received has proved life-changing for Matt.

Answering the Call

The picture of rural health care is far from a monolith.

Someone who receives care through the ThedaCare Rural Health Initiative could be a farmer whose first priority is planting and harvesting, not managing their blood pressure. It could be a Hispanic farm worker who needs health care as well as Spanish-language educational materials. Or it could simply be someone like Matt, who’s living in a rural community and trying to manage a medical condition while also facing barriers to care.

“We really need to meet the patient where they’re at, and everyone has a different background,” says Debbie Walrath, a nurse and outreach health specialist with the Rural Health Initiative (RHI). “They have a different upbringing. They have different preferences. They’ve been taught different things. They’ve had different occupations. We really individualize care.”

RHI began in 2004 as the rural home health care pilot program, serving farmers in Shawano County. It’s since expanded and gone on to create nearly two decades of positive impact.

The initiative became a part of ThedaCare in 2021. It now operates under the umbrella of the ThedaCare Family of Foundations. It includes a fund to which people, organizations, and companies can donate to support RHI’s efforts.

Financial support from ThedaCare, a Health Equity Grant from the Centers for Disease Control and Prevention, and contributions from donors have provided RHI with the funds to offer services in seven counties that ThedaCare serves: Green Lake, Marquette, Outagamie, Shawano, Waupaca, Waushara, and Winnebago. RHI is not available to those living in metro areas in these counties, such as Appleton and Oshkosh.

RHI has an outreach health specialist in each of the seven counties. Any resident age 18 or older in a rural area can call the specialist in their county to set up an appointment for a free health screening.

Immense Impact

The Waushara County community of Plainfield is home to fewer than 1,000 residents. Living in a rural community like Plainfield brings abundant gifts. Matt, who’s lived in rural communities his whole life, says he wouldn’t choose any other way of life. He praises the kind people of his community and enjoys close connections to his friends and neighbors.

At the same time, living in a rural community can bring challenges that affect people’s health and well-being. Those may include less access to healthy foods, fewer economic opportunities, and transportation difficulties — which can worsen during winter months. RHI can help address these barriers.

Matt’s referral to RHI meant he could have health care specialists come to his home, reducing his need to travel. His first appointment included a visit with Debbie Walrath, who serves as his outreach health specialist, and Morgan Platta, a pharmacist with ThedaCare Physicians-Waupaca and -Wild Rose.

Debbie says she brings a “traveling office” to her visits. That includes a Cholestech machine for lipid panels as well as a hemoglobin A1C machine.

“Along with the medication management part of it, it’s really important that we get the diagnostic end of it to make sure that the doctor is aware of where [the patient is] at,” Debbie says. “And our pharmacists can also make those recommendations then to the providers and make adjustments.”

Morgan provided Matt with a pill container that helps him better manage his medications. She and another pharmacist also assisted him with issues he was experiencing with his glucose monitor.

“I really didn’t manage [my diabetes before],” Matt says. “Dr. Baeseman would tell me what to do at every appointment. But … [it went] in one ear and out the other. It was the Rural Health Initiative that helped me get back on track.”

Circle of Care

In addition to Walrath and Platta, Matt’s care team included Lisa Hoger, a nurse practitioner; Carter Havican, a pharmacist with ThedaCare Physicians-New London; and Kathy Brown-Miner, a registered dietitian and exercise physiologist.

In her role, Hoger serves people in rural communities through both in-person and telehealth visits. She acts as a care extender for a patient’s primary care provider.

“I think in rural communities, they have their own unique culture. Sometimes overcoming certain cultural perceptions is an important part of what we do,” she says. “It’s OK to seek help if you’re feeling anxious. It’s OK to seek help if you’re feeling depressed. I’m here to help you. I can help connect those dots for you, and we can get you what you need to live your best life.”

When it came to working with Matt, it was about providing tools to help him better manage his physical and mental health needs, as well as helping him become an advocate for himself. Doing so was a joy, Hoger says, because Matt’s gratitude was “immense.”

“We were all Team Matt,” she says. “His wins are our wins. And when he shines, we shine. That was the coolest thing to see.”

For his part, Havican visited Matt’s house to help him troubleshoot issues with his glucose monitor.

“We have some patients where if they’re having issues with those, we do device training,” he says. “A lot of times me or the other members on our team will then come out and provide that. That’s a huge barrier, because if a patient can’t regularly track their blood sugar or understand their insulin dosing, they’re not going to be able to report that back to their doctor or to the nurses on that doctor’s team.”

Havican became familiar with the concept of “cura personalis” while attending Creighton University in Nebraska. The phrase means “care for the whole person,” and the philosophy continues to guide Havican in his work.

“What I love the most is being able to talk to the patients in their home and just hear everything that they’re going through,” he says. “Is it financial reasons that they’re not able to get the medicines they need? Is there any food insecurity? And we help with that too.”

For Brown-Miner, it was also powerful to connect with Matt in his own home. When she first visited him, he was making lunch, which offered an ideal education opportunity. Matt was making chili that day, and Brown-Miner could look at how he prepared the meal and offer suggestions for making the dish healthier.

“As a dietitian in the home, I could see not only what he was preparing then, but also what else he had available, because there’s different limitations for everyone,” she says. “He had a lot of positive food habits, but there’s always obstacles, even when individuals feel like they’re doing all they can. Matt was a willing participant to make the changes he felt were achievable.”

Matt is preparing to “graduate” from the RHI program, though his team will remain there for him. He’s developed strategies for managing his physical and mental health, and it’s thanks to the dedicated team who worked with him. To them, he has a message to share.

“You’re a godsend,” he says. “You saved my life. Thank you for everything.”

If you live in a rural area and would like to connect with an outreach health specialist, call 715-524-1488.

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