SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT - UPMC KANE IS A SMALL RURAL HOSPITAL LOCATED IN KANE, PENNSYLVANIA SERVING MCKEAN, ELK, AND WARREN COUNTIES. THE TOTAL POPULATION IS 109,726 IN THE THREE-COUNTY SERVICE AREA. THE PROJECT WILL SERVE, TRACK AND IMPROVE OUTCOMES FOR APPROXIMATELY 3,000 INDIVIDUALS (THE TARGET POPULATION) WHO ARE AT-RISK FOR OR HAVE A DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), HEART DISEASE, DIABETES, AND INDIVIDUALS WITH OPIOID/SUBSTANCE. ALL ADULTS THAT ARE AT-RISK FOR HEART DISEASE, DIABETES, LUNG DISEASE AND CO-MORBID CONDITIONS WITH CHRONIC HEALTH MANAGEMENT NEEDS WILL BE TARGETED. ALL AGE GROUPS FOR INDIVIDUALS WITH OPIOID OR SUBSTANCE ABUSE WILL BE TARGETED IN THE QUALITY IMPROVEMENT INITIATIVE. THE UNDERLYING FACTORS THAT ARE DRIVING GROWING RURAL HEALTH DISPARITIES IN OUR COMMUNITY INCLUDE BARRIERS TO CARE THAT DRIVE OUR COMMUNITY'S LEADING CAUSES OF AVOIDABLE DEATH: HEART DISEASE, CHRONIC LOWER RESPIRATORY DISEASE, AND SUBSTANCE USE. THE UPMC KANE NETWORK INCLUDES FIVE RURAL PROVIDERS TO EFFECTIVELY SERVE THIS TARGET POPULATION. THE UPMC KANE RURAL HEALTH QUALITY IMPROVEMENT PROJECT GOALS ARE TO IMPROVE DELIVERY OF COST-EFFECTIVE, COORDINATED, CULTURALLY, AND LINGUISTICALLY APPROPRIATE AND EQUITABLE HEALTH CARE SERVICES, RE-DESIGNED CARE COORDINATION, ENHANCED CHRONIC DISEASE MANAGEMENT, WITH IMPROVED HEALTH OUTCOMES FOR PATIENTS WITH HEART AND LUNG DISEASE AND OPIOID/SUBSTANCE ABUSE SERVICE NEEDS. GOALS: 1) IMPROVE HEALTH OUTCOMES FOR HEART AND LUNG DISEASE AND REDUCE SUBSTANCE ABUSE (REDUCE POTENTIALLY AVOIDABLE UTILIZATION (PAUS), OR ACUTE CARE ADMISSIONS. 2) EXPAND CAPACITY FOR ESSENTIAL HEALTH CARE SERVICES FOR TARGETED CHRONIC ILLNESSES, THROUGH CARE COORDINATION, AND GREATER ACCESS TO ENHANCED CHRONIC DISEASE MANAGEMENT. PROVIDING CLINICAL HEALTH SERVICES FOR RURAL RESIDENTS THROUGH TELEHEALTH AND SCREENING PROGRAMS AND CONDUCTING COMMUNITY HEALTH AND PREVENTION EFFORTS FOR RURAL COMMUNITIES. 3) INCREASE FINANCIAL SUSTAINABILITY IN THE RURAL HEALTH MODEL BY REDUCING CHRONIC DISEASE COSTS, REDUCING HOSPITAL RE-ADMISSIONS, AND IMPROVING EFFICIENCY THROUGH GREATER ACCESS TO CLINICAL MANAGEMENT OF SERVICES WITH CARE-COORDINATION STRATEGIES. QUALITY IMPROVEMENT (MODELS) THAT WILL BE USED WITH SOME MODIFICATIONS INCLUDE: PROJECT ECHO® - EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES; AND CHRONIC DISEASE SELF-MANAGEMENT PROGRAM WHICH WILL BE ADAPTED FOR THE QUALITY INITIATIVE. EXPECTED OUTCOMES: IMPROVED HEALTH OF INDIVIDUALS WITH CHRONIC ILLNESSES, REDUCED HOSPITAL RE-ADMISSIONS, INCREASED PATIENT FOCUSED PREVENTION, INCREASED UTILIZATION OF COMMUNITY-BASED SELF-DIRECTED PREVENTION PROGRAMS, AND GREATER ACCESS TO PAIN MANAGEMENT AND REDUCED SUBSTANCE ABUSE IN TARGET POPULATION. UPMC KANE IS REQUESTING A FUNDING PREFERENCE BASED ON SEVERAL HPSA DESIGNATIONS IN THE TARGET 3 COUNTY SERVICE AREA. THE RURAL AREA HAS HISTORICALLY SUFFERED FROM POORER HEALTH OUTCOMES, HEALTH DISPARITIES, AND OTHER INEQUITIES. THE POPULATION INCLUDES LOW-INCOME INDIVIDUALS AND FAMILIES HAVE HISTORICALLY LACKED ACCESS TO HEALTH SERVICES PARTICULARLY PRIMARY CARE SERVICES. THE TARGET POPULATION IS INCLUSIVE OF THE SERVICE AREA AND TYPICALLY MUST TRAVEL OVER 1 ½ HOUR BY CARE TO SEEK REGULAR PRIMARY CARE, OR SPECIALTY CARE. THE PROPOSED PROJECT WILL IMPROVE ACCESS FOR THOSE WITH CHRONIC DISEASE MANAGEMENT NEEDS AND REDUCE TRAVEL TIMES FOR SERVICES. TELEMEDICINE AND A COLLABORATION OF FIVE LOCAL HEALTH SERVICE AGENCIES INCLUDING UPMC KANE (APPLICANT AND RURAL HOSPITAL), UPMC HOME HEALTH CARE, THE LUTHERAN HOME OF KANE, AREA AGENCY ON AGING (KANE SENIOR CITIZEN CENTER), AND ALCOHOL & DRUG ABUSE SERVICES, INC., OUR REGIONAL SCA FOR SUBSTANCE ABUSE/OPIOID ABUSE SERVICES.