Transaction Description:
RURAL NORTHERN BORDER REGION OUTREACH PROGRAM - APPLICATION ORGANIZATION INFORMATION: FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION, INC. (FDRHPO), A 501(C)3 NONPROFIT LOCATED AT 120 WASHINGTON ST, STE 230, WATERTOWN, NY 13601. WEBSITE: WWW.FDRHPO.ORG. DESIGNATED PROJECT DIRECTOR & OTHER KEY PERSONNEL INFORMATION: PROJECT DIRECTOR: HEATHER PETRIE, PRACTICE TRANSFORMATION SPECIALIST, (315) 755-2020, HPETRIE@FDRHPO.ORG ERIKA FLINT, EXECUTIVE DIRECTOR, (315) 755-2020, EFLINT@FDRHPO.ORG LINDSAY BALDWIN, CHIEF FINANCIAL OFFICER, (315) 755-2020, LBALDWIN@FDRHPO.ORG RURAL NORTHERN BORDER REGION OUTREACH PROGRAM PROJECT TITLE: USING THE COMMUNITY HEALTH WORKER MODEL TO IMPROVE CLINICAL AND SOCIAL OUTCOMES OF RURAL HIGH-NEEDS INDIVIDUALS PROJECT GOALS: 1) PROVIDE COMMUNITY HEALTH WORKER (CHW) INTERVENTIONS TO TARGET POPULATION MEMBERS, 2) ENHANCE THE HEALTH OUTCOMES OF TARGET RURAL INDIVIDUALS, & 3) ENSURE SUSTAINABILITY OF THE CONSORTIUM & PROJECT. PROJECT OBJECTIVES: 1) CHWS ENGAGE AT LEAST 30% OF ELIGIBLE TARGET POPULATION MEMBERS BY THE END OF AWARD, 2) CLOSE AT LEAST 35% OF MEMBERS’ IDENTIFIED OPEN CARE GAPS AND 50% OF IDENTIFIED SOCIAL NEEDS, & REDUCE THEIR PREVENTABLE INPATIENT STAYS AND EMERGENCY DEPARTMENT VISITS BY AT LEAST 10%, & 3) ENGAGE PRIMARY CARE CONSORTIUM MEMBERS IN AT LEAST 2 VALUE-BASED CONTRACTS & MAXIMIZE THEIR PROJECT-RELATED BILLABLE REVENUE. PROPOSED SERVICE AREA: ST. LAWRENCE COUNTY, NY; LEWIS COUNTY, NY; RURAL CENSUS TRACTS OF ALEXANDRIA BAY, CLAYTON, AND WILNA IN JEFFERSON COUNTY, NY (36045060100, 36045060200, 36045980000). TARGET POPULATION: MEDICAID- AND/OR MEDICARE-INSURED INDIVIDUALS LIVING IN THE PROPOSED SERVICE AREA, WHO HAVE MULTIPLE CHRONIC CONDITIONS AND/OR HEALTH-RELATED SOCIAL NEEDS, HIGH HEALTHCARE COSTS, UNMET PRIMARY OR PREVENTIVE CARE NEEDS, AND/OR INPATIENT AND/OR EMERGENCY DEPARTMENT UTILIZATION. FOCUS AREAS: COMMUNITY HEALTH WORKERS; PRIMARY AND PREVENTIVE CARE; CARE MANAGEMENT; HEALTH EQUITY CONSORTIUM ME MBER PARTNERSHIPS: FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION (APPLICANT; COMMUNITY-BASED ORGANIZATION), CARTHAGE AREA HOSPITAL (PRIMARY CARE), CLIFTON-FINE HOSPITAL (PRIMARY CARE), RIVER HOSPITAL (PRIMARY CARE), SAMARITAN MEDICAL CENTER (PRIMARY CARE), NORTHERN REGIONAL CENTER FOR INDEPENDENT LIVING (COMMUNITY-BASED ORGANIZATION) PROJECT ACTIVITIES: FDRHPO WILL ENGAGE NORTHERN REGIONAL CENTER FOR INDEPENDENT LIVING TO PROVIDE 3 FTE COMMUNITY HEALTH WORKERS (CHWS) TO ENGAGE TARGET POPULATION MEMBERS IN PRIMARY AND PREVENTIVE CARE, INCLUDING WELL VISITS, CANCER SCREENINGS, IMMUNIZATIONS, TRANSITIONAL AND CHRONIC CARE MANAGEMENT, & CONNECTIONS TO OTHER CLINICAL, BEHAVIORAL, AND SOCIAL SERVICES AS NEEDED. THE CONSORTIUM WILL GATHER, TRACK, AND ANALYZE PROJECT DATA TO EVALUATE THE OUTCOMES DESCRIBED BELOW. EXPECTED OUTCOMES: 1) CHWS ENGAGE AT LEAST 30% OF ELIGIBLE TARGET POPULATION MEMBERS BY THE END OF AWARD, 2) AT LEAST 35% OF MEMBERS’ IDENTIFIED OPEN CARE GAPS AND 50% OF IDENTIFIED SOCIAL NEEDS ARE CLOSED, & THEIR PREVENTABLE INPATIENT STAYS AND EMERGENCY DEPARTMENT VISITS ARE REDUCED BY AT LEAST 10%, AND 3) PRIMARY CARE CONSORTIUM MEMBERS ARE ENGAGED IN AT LEAST 2 VALUE-BASED CONTRACTS & THEIR PROJECT-RELATED BILLABLE REVENUE INCREASED OVER THE COURSE OF THE AWARD. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS IN THE NBRC REGION: FDRHPO IS A RECOGNIZED LEADER OF REGIONAL QUALITY INITIATIVES. 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 HEALTH-RELATED SOCIAL NEEDS, INCLUDING THROUGH SEVERAL HRSA AWARDS. WHILE PHYSICALLY LOCATED WITHIN THE URBAN AREA OF WATERTOWN, NY (JEFFERSON COUNTY), MORE THAN 67% OF CONSORTIUM PARTNERS ARE LOCATED IN SURROUNDING RURAL COMMUNITIES. FUNDING OPPORTUNITY NOTIFICATION: OTHER: RURAL HEALTH REDESIGN CENT ER FUNDING PREFERENCE: QUALIFICATION #1: HPSA
