Rural health care services outreach grant program - project title: expanding chronic care management to improve rural health outcomes self regional healthcare (SRH) is leading the lakelands…

Rural health care services outreach grant program - project title: expanding chronic care management to improve rural health outcomes self regional healthcare (SRH) is leading the lakelands collaborative care initiative to expand chronic care management (CCM) services for rural residents in south carolina's lakelands region. This project focuses on improving outcomes for patients with heart failure and diabetes, conditions that are major contributors to hospital readmissions and mortality in the region. By enhancing care coordination and addressing social determinants of health (sdoh), the project will create a more sustainable healthcare system that meets the unique needs of rural communities. The initiative aims to reduce hospital readmissions for heart failure and diabetes by 15% over four years and improve clinical outcomes, including better control of diabetes and improved functional status for heart failure patients, by 10% within three years. At least 75% of enrolled patients will receive non-clinical support to address barriers like transportation, food insecurity, and housing. The project will expand CCM services to three new physician practices, including two rural health clinics (rhcs), by the second year and prepare for sustainability through medicare reimbursement strategies. Key activities include developing a centralized CCM team, implementing remote patient monitoring tools, and collaborating with consortium partners such as the abbeville area healthcare center, community initiatives, the food bank of greenwood county, and the south carolina department of public health. These partnerships will ensure a comprehensive approach to care, combining clinical and community resources. The project will serve communities in the lakelands region, including greenwood, abbeville, laurens, edgefield, and saluda counties. These rural areas face significant challenges, including high rates of chronic disease and limited access to care. This initiative will improve quality of life, reduce healthcare costs, and promote health equity by addressing the root causes of health disparities.