Project Grant G2046025

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT - APPLICANT ORGANIZATION INFORMTAION: NAME TECHE ACTION BOARD, INC. (D.B.A. TECHE ACTION CLINIC) ADDRESS 1115 WEBER STREET, FRANKLIN, LA 70538 FACILITY TYPE FEDERALLY QUALIFIED HEALTH CARE CENTER WEB ADDRESS HTTPS://TABHEALTH.ORG/ GRANT NUMBER H80CS00767 DESIGNATED PROJECT DIRECTOR INFORMATION: NAME JENNIFER FABRE, DNP, ARNP, FNP-BC TITLE CHO, DIRECTOR OF QUALITY AND RISK MANAGEMENT PHONE 337-828-2550, EXT. 2116 FAX 337-828-5411 EMAIL JFABRE@TABHEALTH.ORG TITLE "IMPROVING HEALTH OUTCOMES IN RURAL POPULATION IN CHRONIC CARE MANAGEMENT: A QUALITY IMPROVEMENT INITIATIVE USING THE CHRONIC CARE MODEL" GOAL IMPROVED HEALTH OUTCOMES, EXPANDED CAPACITY FOR ESSENTIAL HEALTH CARE SERVICES, AND INCREASED FINANCIAL SUSTAINABILITY SERVICE AREA: FRANKLIN, LA; ST MARY PARISH MORGAN CITY, LA; ST. MARY PARISH PIERRE PART, LA; ST. MARY PARISH THIBODAUX, LA; LAFOURCHE PARISH EDGARD, LA; ST JOHN PARISH RESERVE, LA; ST JOHN PARISH GRAMERCY, LA; ST JAMES PARISH **(ALL FQHC, RURAL HEALTH CARE CENTERS) TARGET POPULATION: MEDICARE ENROLLED PATIENTS WITH AT LEAST TWO (2) OR MORE CHRONIC CONDITIONS, AS DEFINED BY CMS LIVING IN OUR RURAL SERVICE AREAS QUALITY IMPROVEMENT MODEL: CHRONIC CARE MODEL TO GUIDE CHRONIC CARE MANAGEMENT PROCESS, PDSA (PLAN DO STUDY ACT) MODEL TO GUIDE IMPLEMENTATION OF GOALS AND INTERVENTIONS PROJECT ACTIVITIES: 1. SELECT CHRONIC CARE MANAGEMENT IMPLEMENTATION DESIGN 2.DEVELOP CHRONIC CARE MANAGER JOB AND CARE TEAM ROLES 3. DEVELOP TRAINING FOR CHRONIC CARE MANAGEMENT IMPLEMENTATION AND MAINTENANCE 4. PATIENT IDENTIFICATION AND RISK STRATIFICATION 5. PROVIDER AND OFFICE STAFF ENGAGEMENT 6. PATIENT ENGAGEMENT AND ENROLLMENT 7. INCREASE FINANCIAL SUSTAINABILITY EXPECTED OUTCOMES: 1. PATIENT COMPLIANCE AND REDUCTION IN ER VISITS AND/OR HOSPITALIZATIONS, IMPROVING PATIENTS' HEALTH OUTCOMES 2. EXPANDING THE CCM PROGRAM THROUGHOUT ALL TAC CLINICS, TO EXPAND CAPACITY FOR ESSENTIAL HEALTH CARE SERVICES 3. ENROLL CCM ELIGIBLE PATIENTS INTO THE PROGRAM, UTILIZING CPT CODES FOR BILLING AND THUS INCREASING FINANCIAL SUSTAINABILITY FUNDING PREFERENCE: TECHE ACTION BOARD, INC. IS REQUESTING A FUNDING PREFERENCE BASED ON QUALIFICATION 1 FOR BEING A HEALTH PROFESSIONAL SHORTAGE AREA