Project Grant D0649162

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM - APPLICANT ORGANIZATION INFORMATION: FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION (FDRHPO), A 501(C)3 NONPROFIT ENTITY LOCATED AT 120 WASHINGTON STREET, WATERTOWN NY, 13601, IS REQUESTING FUNDS OF $1,200,000 FOR THE PROPOSED 4-YEAR PROJECT. DESIGNATED STAFF INCLUDE NETWORK DIRECTOR JOANNA LOOMIS (JLOOMIS@FDRHPO.ORG), PROJECT DIRECTOR LINDSAY BALDWIN (LBALDWIN@FDRHPO.ORG), AND JEFF BAZINET DIRECTOR OF DATA ANALYTICS (JBAZINET@FDRHPO.ORG). WEBSITE ADDRESS: WWW.FDRHPO.ORG. PHONE: 315-755-2020. PROJECT TITLE: IMPROVING TRANSITIONAL AND CHRONIC CARE MANAGEMENT FOR RURAL COMMUNITIES. GOAL: INCREASE ACCESS TO EVIDENCE-BASED CARE MANAGEMENT SERVICES FOR RURAL COMMUNITIES TO IMPROVE PATIENT OUTCOMES AND ADVANCE THE DELIVERY OF VALUE-BASED HEALTHCARE SERVICES. FOCUS AREAS: PRIMARY CARE, CARE MANAGEMENT, SOCIAL DETERMINANTS OF HEALTH TARGET PATIENT POPULATION: LOCATED IN THE NORTHERN HRSA-DESIGNATED RURAL REGIONS OF NEW YORK, THE NETWORK MANAGES CLINICALLY AND SOCIALLY COMPLICATED PATIENTS ACROSS A GEOGRAPHICAL AREA SPANNING JEFFERSON, LEWIS, AND ST. LAWRENCE COUNTY AND PORTIONS OF FRANKLIN COUNTY. THE TARGET PATIENT POPULATION INCLUDES INDIVIDUALS TRANSITIONING CARE FROM A HOSPITAL SETTING TO AN OUTPATIENT SETTING (~146,000 INDIVIDUALS ANNUALLY) AND THOSE WHO REQUIRE CARE MANAGEMENT TO BETTER CONTROL THEIR CHRONIC CONDITIONS (~150,000 INDIVIDUALS ANNUALLY). NETWORK: NORTH COUNTRY INITIATIVE. MEMBERS: 52 SITES INCLUDING PRIMARY CARE, HOSPITALS, BEHAVIORAL HEALTH, AND COMMUNITY ORGANIZATIONS SERVING RURAL RESIDENTS. NETWORK PROJECT ACTIVITIES: FDRHPO WILL WORK WITH NETWORK MEMBERS TO EXPAND CAPACITY AND ACCESS TO TRANSITIONAL CARE MANAGEMENT (TCM) AND CHRONIC CARE MANAGEMENT (CCM) SERVICES. SERVICES WILL INCORPORATE FOLLOW-UP FROM HOSPITAL DISCHARGE AND DEVELOPMENT OF COMPREHENSIVE CARE PLANNING THAT INCLUDES SOCIAL DETERMINANT OF HEALTH (SDH) SCREENING AND REFERRALS TO NETWORK MEMBERS FOR IDENTIFIED SOCIAL, PHYSICAL, AND MENTAL HEALTH NEEDS. EXPECTED OUTCOMES: RHND DOMAIN 1: IMPROVE ACCESS BY INCREASING PAYOR-BILLABLE TCM & CCM SERVICES BY 10% & INCREASE SOCIAL DETERMINANT SCREENINGS BY 40%. RHND DOMAIN 2: EXPAND TCM & CCM SERVICES TO 12% OF THE MEDICAID POPULATION. RHND DOMAIN 3: ENHANCE OUTCOMES FOR THOSE ENGAGED IN TCM AND CCM BY CLOSING 35% OF OPEN CARE GAPS AND REDUCING 30-DAY POTENTIALLY PREVENTABLE ADMISSIONS & READMISSIONS BY 10%. RHND DOMAIN 4: PROMOTE SUSTAINABILITY BY ENGAGING NETWORK IN AT LEAST 3 VALUE-BASED CONTRACTS. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS: FDRHPO IS A RECOGNIZED LEADER OF REGIONAL QUALITY INITIATIVES, ADDRESSING THE COMMUNITY'S HEALTH NEEDS THROUGH PATIENT-CENTERED MEDICAL HOME TRANSFORMATION, IMPLEMENTING ELECTRONIC HEALTH RECORDS, CONNECTING PARTNERS TO THE HEALTH INFORMATION EXCHANGE, DEVELOPING A WORKFORCE PIPELINE, STRENGTHENING MENTAL HEALTH AND SUBSTANCE ABUSE INFRASTRUCTURE, AND POPULATION HEALTH MESSAGING.?FDRHPO MAINTAINS AN EXTENSIVE COMMITTEE STRUCTURE TO ENSURE REGIONAL INITIATIVES ARE ADDRESSED WITH ROBUST INPUT FROM NETWORK MEMBERS. FDRHPO IS IDEALLY POSITIONED TO CARRY OUT THE PROJECT BECAUSE OF ITS WELL-ESTABLISHED RELATIONSHIPS WITH CLINICAL AND NON-CLINICAL ORGANIZATIONS SERVING RURAL TARGET POPULATION MEMBERS, AND ITS WORK TO-DATE IN PROMOTING PRIMARY CARE, CARE MANAGEMENT, AND SDH, INCLUDING SUPPORTING THE DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM. FDRHPO FACILITATED THE INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH, CHRONIC DISEASE MANAGEMENT IN CLINICAL AND COMMUNITY SETTINGS, AND PATIENT ENGAGEMENT, WHICH RESULTED IN REACHING NYS'S GOALS TO REDUCE PREVENTABLE HOSPITAL ADMISSIONS AND READMISSIONS. IT HAS ALSO PROMOTED TCM, CCM, & SDH SCREENING WITHIN PRIMARY CARE, WHICH THIS PROJECT SEEKS TO EXPAND. WHILE PHYSICALLY LOCATED WITHIN THE URBAN AREA OF WATERTOWN, NY, MORE THAN 67% OF NETWORK PARTNERS ARE IN SURROUNDING RURAL COMMUNITIES (SEE ATTACHMENT 3). FUNDING PREFERENCE: #1 HPSA, ENTIRE SERVICE R EGION IS LOCATED IN A PRIMARY CARE HPSA