Project Grant D0649179

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM - APPLICANT ORGANIZATION INFORMATION: BI-STATE PRIMARY CARE ASSOCIATION (WWW.BISTATEPCA.ORG) IS A RURAL PRIMARY CARE ASSOCIATION SERVING NH AND VT, LOCATED AT: CORPORATE: 525 CLINTON ST, BOW, NH 03304; PROGRAMMATIC: 61 ELM ST, MONTPELIER, VT 05602 DESIGNATED PROJECT DIRECTOR (PD) AND DESIGNATED NETWORK DIRECTOR (ND) INFORMATION: PD: KATE SIMMONS; SR. DIRECTOR, OPERATIONS; 802-229-0002 X217 KSIMMONS@BISTATEPCA.ORG ND: KRISTEN BIGELOW-TALBERT; SR. PROGRAM MANAGER, HEALTH QUALITY; 802-229-0002 X220 KBIGELOW@BISTATEPCA.ORG RURAL HEALTH NETWORK DEVELOPMENT PROJECT: THE VT FOOD ACCESS & HEALTH CARE NETWORK (FAHC NETWORK) HAS THE GOAL OF INTEGRATING FOOD ACCESS AS PART OF HEALTH CARE IN RURAL VT. FOCUS AREA(S): VALUE-BASED CARE READINESS; HEALTH EQUITY; SOCIAL DRIVERS OF HEALTH / SDOH TARGET PATIENT POPULATION: RESIDENTS IN VT'S THIRTEEN RURAL COUNTIES FACING BARRIERS TO ACCESSING A SUFFICIENT, MEDICALLY APPROPRIATE DIET. CURRENT VT HOUSEHOLD FOOD INSECURITY ESTIMATES, WITH COVID-19 & ECONOMIC DISRUPTIONS, RANGE FROM 14% TO OVER 30%. FOOD INSECURITY DISPROPORTIONATELY AFFECTS RURAL RESIDENTS, PEOPLE OF COLOR, PEOPLE LIVING WITH DISABILITIES, OLDER VERMONTERS, SINGLE PARENT HOUSEHOLDS, AND VERMONTERS WITH LOWER INCOME. POOR DIET QUALITY INCREASES RISK OF DISEASES LIKE HYPERTENSION, DIABETES, & HEART FAILURE, AND LACK OF FOOD RESOURCES ALSO IMPEDES PATIENTS' ABILITY TO MANAGE THESE CONDITIONS ONCE THEY OCCUR. OUR PROGRAMS TARGET PATIENTS ACROSS THIS CONTINUUM FROM PREVENTION TO TREATMENT, WITH A FOCUS ON HEALTH EQUITY. WE WILL SERVE VT'S ADDISON, BENNINGTON, CALEDONIA, ESSEX, FRANKLIN, GRAND ISLE, LAMOILLE, ORANGE, ORLEANS, RUTLAND, WASHINGTON, WINDHAM, WINDSOR COUNTIES. NETWORK MEMBERS (6): BI-STATE PCA; VT FOODBANK; HUNGER FREE VERMONT; VT PROGRAM FOR QUALITY IN HEALTH CARE; VT ACADEMY OF NUTRITION & DIETETICS; VT FARM TO PLATE NETWORK PROJECT ACTIVITIES/SERVICES: INTEGRATION OF FOOD ACCESS AS PART OF HEALTH CARE, EMPHASIZING: S DOH DATA COLLECTION AND STANDARDIZATION (TO ADVANCE HEALTH EQUITY, SUPPORT RESOURCE REFERRALS, AND ESTABLISH HIGH QUALITY DATA FOR VALUE-BASED CARE READINESS); CLOSED-LOOP REFERRALS IN MEDICAL AND SOCIAL SERVICES; TRAINING FOR COMMUNITY HEALTH WORKERS (CHWS) AS PART OF AN INTEGRATED CARE TEAM (AND A NEWLY RECOGNIZED WORKFORCE IN VT); EVIDENCE-BASED TAILORED FOOD OPTIONS FOR PATIENTS MANAGING SERIOUS DIET-RELATED HEALTH CONDITIONS; QUALITY IMPROVEMENT FACILITATION TO OPTIMIZE PROCESSES AND WORKFLOWS; PEER-TO-PEER LEARNING; LEARNING FROM EVIDENCE-BASED MODELS BEYOND VT; AND SUSTAINABLE PROGRAM FUNDING STREAMS. EXPECTED OUTCOMES: WE EXPECT TO SEE: AN INCREASED RATE OF PATIENTS SCREENED FOR FOOD INSECURITY; AN INCREASED RATE OF PATIENTS OFFERED A REFERRAL AFTER A POSITIVE SCREEN; DECREASED BMI (THOUGH 4 YEARS IS A SHORT HORIZON FOR THIS OUTCOME); AND AN INCREASED RATE OF "CLOSING THE LOOP" FOR NUTRITION-RELATED REFERRALS. FOR PROVIDERS (ESPECIALLY CHWS) AND FOOD PARTNERS, WE EXPECT TO SEE: INCREASED TRAINING OPPORTUNITIES; OPTIMIZED WORKFLOWS FOR SCREENINGS AND REFERRALS; AND INVESTMENTS IN PILOT INITIATIVES INTEGRATING FOOD ACCESS AND HEALTH. FOR THE FAHC NETWORK: WE EXPECT EFFECTIVE GOVERNANCE WITH A RURAL FOCUS; ENGAGEMENT OF ALL NETWORK PARTNERS; AND SUSTAINABILITY PLANNING AND THE IMPLEMENTATION OF THOSE PLANS. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS: THIS APPLICATION SUPPORTS A MAJOR EXPANSION OF TWO STRATEGIC PLANNING PROJECTS (2020 - EARLY 2023) INTO A SUSTAINED INITIATIVE TO SERVE RURAL VERMONT BY INTEGRATING FOOD ACCESS AS PART OF HEALTH CARE. WE HAVE DEMONSTRATED PARTNERSHIP VALUE & CAPACITY DURING THE STRATEGIC PLANNING PHASE. THE NETWORK PARTNERS ALL OPERATE IN VERMONT'S RURAL COMMUNITIES, HAVE DECADES OF EXPERIENCE, AND TOGETHER REACH EVERY CORNER OF THE STATE. ALL PARTNER ORGANIZATIONS HAVE MAJORITY-RURAL MEMBERSHIP STRUCTURES. FUNDING PREFERENCE: REQUESTED FOR PRIMARY CARE FOCUS & WELLNESS/PREVENTION STRATEGIES.