Rural health care services outreach grant program - funding track: glenns ferry health center, INC

DBA desert sage health centers (DSHC) is applying for regular track funding. Focus area: DSHC is focusing on outreach and education activities targeting the unique health needs in rural idaho. Rural service area/target population: DSHC will serve two rural counties in idaho - elmore and owyhee counties. The target population includes low-income, migrant seasonal agricultural workers (MSAWS), medicaid-covered, and uninsured rural residents. The purpose of this grant is to expand access to health care in rural communities by growing DSHC's rural outreach program, improve the delivery of health care services by improving collaborations with consortium members and increasing use of DSHC's mobile medical unit, and strengthen resources and capacity in rural idaho by developing a rural health outreach consortium. Grant funds will be used to hire staff (a program coordinator, two community outreach workers (CHWS), and launch and support the consortium of rural health care providers. Service area health needs are great. Nearly 40% of the population lives below 200% FPL; 13% are uninsured, 15% are covered by medicaid, and 15% are covered by medicare. The ST. Luke's 2023 elmore community health needs assessment provides a comprehensive evaluation of residents' most important health needs. Residents reported difficulties accessing health care because of long waitlists, trouble scheduling urgent appointments, and particularly in rural areas, difficulty obtaining and getting to specialty care. These hurdles are even more challenging for people relying on medicaid or medicare. Difficulty accessing health care can lead people to neglect their health, especially preventative health, resulting in more negative outcomes and higher medical costs in the future. The goals of the rural outreach program are (1) to facilitate the development of a rural outreach consortium. (2) expand DSHC's community health worker (CHW) outreach program by hiring a 1.0 FTE CHW and expand screening for social determinants of health (SDOH) to all medicaid and high risk patients. (3) develop referral pathways to DSHC with idaho central district health's (CDH) health screening program. (4) expand dshcs mobile medical unit (MMU) reach by deploying MMU to local schools and areas identified by the CDH as high need. (5) implement community health EMS (CHEMS) BI-directional referral program by DSHC referring high risk patients with chronic illness to CHEMS for in-home follow-up care while accepting referrals from CHEMS to address non-medical SDOH needs. (6) strengthen partnership with ST. Luke's hospital for data sharing and implementing strategies to address SDOH. This will include quarterly data reports; exploring CO-located CHWS at DSHC and the hospital; implementing CHW follow-up to all DSHC patients with ED visits or indicated via SDOH screening; CO-develop and support solutions to address SDOH gaps in the community. DSHC will institute four evidence-based practices: community health workers, care coordination, patient-centered medical home, and community paramedicine. History: DSHC has provided health care in rural idaho since 1982. The organization is experienced in participating in and leading health consortiums to address community need, including the elmore health coalition which led to school-based health centers in three local schools and the local covid response. Funding preferences: DSHC qualifies for 3 funding preferences: (1) the health professional shortage area preference because DSHC has sites located in hpsas. (2) the medically underserved community/ populations preference because DSHC has sites located in mups. (3) the focus on primary care, and wellness and prevention strategies preference as a ncqa recognized patient-centered medical home.