Rural health care services outreach grant program - the rural heart and lung tele-care collaborative will begin in three rural counties in maine, one of our nation's most rural states comprised of the…

Rural health care services outreach grant program - the rural heart and lung tele-care collaborative will begin in three rural counties in maine, one of our nation's most rural states comprised of the oldest residents. These counties span from northern "downeast" (washington and hancock county) and far western maine (oxford county). Rural and remote residents of these rural counties are among the most underserved in healthcare and suffer disproportionate rates of disease. The project goal is to increase timely access to specialty care for patients at rural health centers across maine. Process objectives: 1. By 10/31/25, put in place a mechanism to use claims data (a) to identify all patients eligible for peer-to-peer consults for heart disease and for copd at each participating member site and (b) to create a referral process to proactively recommend peer-to-peer consults for these patients (project cohort). 2. By 10/31/27, increase by at least 5% from the prior year rate the peer-to-peer consults (reactive and proactive) for eligible patients for heart disease and copd. 3. By 10/31/26, at least four rural ccpm members will have clinical staff trained to facilitate patient telehealth encounters with remote medical specialists. By 4/30/29, at least 50% of rural members will have > one trained telehealth facilitator on staff. OBJ. 4. By october 31, 2027, have in place a process whereby a participating rural health center can perform a facilitated telehealth "coordinated care model" of care for an eligible patient with diagnosed heart disease or copd. Outcome objectives: 5. By 10/31/27, decrease by at least 10% from the prior year rate the referral rate patients with heart disease and copd. Note: each subsequent year, increase by 10% from the year prior. 6. By 10/31/27, decrease the number of 30-day heart disease or copd related emergency department or hospital readmissions for patients recently hospitalized for heart disease or copd by at least 5% from prior year. (note: each subsequent year, decrease by 5% from the prior year) the collaborative will use picassomd which has a growing evidence-base. Picassomd connects primary care providers (PCP) with specialists (peer-to-peer) for feedback on a patient's case. Based on the strategic plan developed, the plan is to implement picassomd to address the limited access to specialty services in rural maine. Then move forward with a stepwise plan to improve health care access and outcomes for rural mainers suffering from a variety of specific diseases within the realm of picasso MD (e.g., cardiology, pulmonology). We simultaneously offer training to medical assistants and nurses in the field of telehealth facilitation. While our consortium will begin with four rural clinics, we expect these services to be available to all 18 rural health centers within ccpm by april 30, 2029. The hrsa forhp funded facilitated surgical telehealth network planning grant was successfully administered by SJH over the past year. We worked with four rural health centers and the local community college, which resulted in the creation of the facilitated telehealth certificate course now available to medical staff. And resulted in a strategic plan that pointed to ccpm as the central structure for administration and to broader scope of specialty care and to focus on those conditions with the highest prevalence; hence health disease and chronic lower respiratory disease (copd) - thus applying for the specialty track. We are requesting a funding preference as we meet the medically underserved population (qualification #2) by governor's exception, 1995 (please see attachment 11); our four rural health centers also qualify for hpsa and MUA/p.