Delta health systems implementation program - urgent & primary care of clarksdale (UPC), a rural healthcare organization in coahoma county, mississippi, proposes a $399,500 project under the delta…

The Department of Health and Human Services Health Resources and Services Administration awarded Urgent & Primary Care of Clarksdale LLC $399,500 under the Delta Health Systems Implementation Program (DSIP, Assistance Listing 93.619) on September 1, 2026, to implement chronic care management and remote patient monitoring capabilities within its TEBRA electronic health record system serving Coahoma County, Mississippi.

The recipient will enroll 250 high-risk patients and integrate chronic care management workflows and remote patient monitoring devices—including glucometers and blood pressure cuffs—into TEBRA to enhance quality improvement and telehealth access. Key activities include staff training led by Dr. Mary Williams (20 percent FTE), equipment procurement, and patient education. The project targets a 15 percent reduction in complications, a 1 percent A1C decrease, and 80 percent remote patient monitoring adherence by August 31, 2027, tracked via TEBRA data and quarterly evaluations.

Coahoma County is a predominantly Black (77.2 percent) and impoverished (36 percent) population of 20,197 with a 17 percent diabetes prevalence and elevated hypertension rates. The project builds on technical assistance provided through the Delta Region Community Health Systems Development Program from 2020 to 2023.

The period of performance runs from September 1, 2025, through August 31, 2027. The obligated amount is $350,000, with sustainability planned through $126,000 in annual Medicare chronic care management reimbursement by year three.

Delta health systems implementation program - urgent & primary care of clarksdale (UPC), a rural healthcare organization in coahoma county, mississippi, proposes a $399,500 project under the delta health systems implementation program (DSIP) to implement chronic care management (CCM) and remote patient monitoring (RPM) within its tebra electronic health record (EHR) system. Serving a predominantly black (77.2%) and impoverished (36%) population of 20,197, coahoma county faces a high chronic disease burden, with a 17% diabetes prevalence and elevated hypertension rates, often leading to complications like renal failure (2023 county health rankings). Building on technical assistance from the delta region community health systems development program (2020- 2023), this 2-year initiative (9/1/2025-8/31/2027) aims to enroll 250 high-risk patients, integrating CCM workflows and RPM devices (e.g., glucometers, BP cuffs) into tebra to enhance quality improvement and telehealth access. Key activities include staff training, equipment procurement, and patient education, supported by a multidisciplinary team led by DR. Mary williams (20% FTE). The project targets a 15% reduction in complications, a 1% A1C decrease, and 80% RPM adherence by 8/31/2027, tracked via tebra data and quarterly evaluations. Sustainability will be achieved through $126,000 in annual medicare CCM reimbursement by year 3. By addressing health disparities and improving outcomes in this underserved delta region, UPC's project aligns with DSIP's mission to strengthen rural healthcare delivery and financial viability, offering a scalable model for chronic disease management in similar communities.