Fort Drum Regional Health Planning Organization Inc

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM - APPLICANT ORGANIZATION INFORMATION: FORT DRUM REGIONAL HEALTH PLANNING ORGANIZATION (FDRHPO), A 501(C)3 NONPROFIT ENTITY LOCATED AT 120 WASHINGTON STREET, WATERTOWN NY, 13601, IS REQUESTING FUNDS OF $1,200,000 FOR THE PROPOSED 4-YEAR PROJECT. DESIGNATED STAFF INCLUDE NETWORK DIRECTOR JOANNA LOOMIS (JLOOMIS@FDRHPO.ORG), PROJECT DIRECTOR LINDSAY BALDWIN (LBALDWIN@FDRHPO.ORG), AND JEFF BAZINET DIRECTOR OF DATA ANALYTICS (JBAZINET@FDRHPO.ORG). WEBSITE ADDRESS: WWW.FDRHPO.ORG. PHONE: 315-755-2020. PROJECT TITLE: IMPROVING TRANSITIONAL AND CHRONIC CARE MANAGEMENT FOR RURAL COMMUNITIES. GOAL: INCREASE ACCESS TO EVIDENCE-BASED CARE MANAGEMENT SERVICES FOR RURAL COMMUNITIES TO IMPROVE PATIENT OUTCOMES AND ADVANCE THE DELIVERY OF VALUE-BASED HEALTHCARE SERVICES. FOCUS AREAS: PRIMARY CARE, CARE MANAGEMENT, SOCIAL DETERMINANTS OF HEALTH TARGET PATIENT POPULATION: LOCATED IN THE NORTHERN HRSA-DESIGNATED RURAL REGIONS OF NEW YORK, THE NETWORK MANAGES CLINICALLY AND SOCIALLY COMPLICATED PATIENTS ACROSS A GEOGRAPHICAL AREA SPANNING JEFFERSON, LEWIS, AND ST. LAWRENCE COUNTY AND PORTIONS OF FRANKLIN COUNTY. THE TARGET PATIENT POPULATION INCLUDES INDIVIDUALS TRANSITIONING CARE FROM A HOSPITAL SETTING TO AN OUTPATIENT SETTING (~146,000 INDIVIDUALS ANNUALLY) AND THOSE WHO REQUIRE CARE MANAGEMENT TO BETTER CONTROL THEIR CHRONIC CONDITIONS (~150,000 INDIVIDUALS ANNUALLY). NETWORK: NORTH COUNTRY INITIATIVE. MEMBERS: 52 SITES INCLUDING PRIMARY CARE, HOSPITALS, BEHAVIORAL HEALTH, AND COMMUNITY ORGANIZATIONS SERVING RURAL RESIDENTS. NETWORK PROJECT ACTIVITIES: FDRHPO WILL WORK WITH NETWORK MEMBERS TO EXPAND CAPACITY AND ACCESS TO TRANSITIONAL CARE MANAGEMENT (TCM) AND CHRONIC CARE MANAGEMENT (CCM) SERVICES. SERVICES WILL INCORPORATE FOLLOW-UP FROM HOSPITAL DISCHARGE AND DEVELOPMENT OF COMPREHENSIVE CARE PLANNING THAT INCLUDES SOCIAL DETERMINANT OF HEALTH (SDH) SCREENING AND REFERRALS TO NETWORK MEMBERS FOR IDENTIFIED SOCIAL, PHYSICAL, AND MENTAL HEALTH NEEDS. EXPECTED OUTCOMES: RHND DOMAIN 1: IMPROVE ACCESS BY INCREASING PAYOR-BILLABLE TCM & CCM SERVICES BY 10% & INCREASE SOCIAL DETERMINANT SCREENINGS BY 40%. RHND DOMAIN 2: EXPAND TCM & CCM SERVICES TO 12% OF THE MEDICAID POPULATION. RHND DOMAIN 3: ENHANCE OUTCOMES FOR THOSE ENGAGED IN TCM AND CCM BY CLOSING 35% OF OPEN CARE GAPS AND REDUCING 30-DAY POTENTIALLY PREVENTABLE ADMISSIONS & READMISSIONS BY 10%. RHND DOMAIN 4: PROMOTE SUSTAINABILITY BY ENGAGING NETWORK IN AT LEAST 3 VALUE-BASED CONTRACTS. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS: FDRHPO IS A RECOGNIZED LEADER OF REGIONAL QUALITY INITIATIVES, ADDRESSING THE COMMUNITY’S HEALTH NEEDS THROUGH PATIENT-CENTERED MEDICAL HOME TRANSFORMATION, IMPLEMENTING ELECTRONIC HEALTH RECORDS, CONNECTING PARTNERS TO THE HEALTH INFORMATION EXCHANGE, DEVELOPING A WORKFORCE PIPELINE, STRENGTHENING MENTAL HEALTH AND SUBSTANCE ABUSE INFRASTRUCTURE, AND POPULATION HEALTH MESSAGING.?FDRHPO MAINTAINS AN EXTENSIVE COMMITTEE STRUCTURE TO ENSURE REGIONAL INITIATIVES ARE ADDRESSED WITH ROBUST INPUT FROM NETWORK MEMBERS. 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 SDH, INCLUDING SUPPORTING THE DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP) PROGRAM. FDRHPO FACILITATED THE INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH, CHRONIC DISEASE MANAGEMENT IN CLINICAL AND COMMUNITY SETTINGS, AND PATIENT ENGAGEMENT, WHICH RESULTED IN REACHING NYS’S GOALS TO REDUCE PREVENTABLE HOSPITAL ADMISSIONS AND READMISSIONS. IT HAS ALSO PROMOTED TCM, CCM, & SDH SCREENING WITHIN PRIMARY CARE, WHICH THIS PROJECT SEEKS TO EXPAND. WHILE PHYSICALLY LOCATED WITHIN THE URBAN AREA OF WATERTOWN, NY, MORE THAN 67% OF NETWORK PARTNERS ARE IN SURROUNDING RURAL COMMUNITIES (SEE ATTACHMENT 3). FUNDING PREFERENCE: #1 HPSA, ENTIRE SERVICE R EGION IS LOCATED IN A PRIMARY CARE HPSA

RURAL HIT NETWORK PROGRAM

RURAL HEALTH INFORMATION TECHNOLOGY WORKFORCE PROGRAM

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

TUG HILL SEAWAY MENTAL HEALTH AWARENESS TRAINING PROGRAM - THE TUG HILL SEAWAY MENTAL HEALTH AWARENESS TRAINING PROGRAM WILL AIM TO ENHANCE THE MENTAL HEALTH OF ITS LOCAL POPULATIONS BY PROVIDING MENTAL HEALTH EDUCATION AND LINKAGE RESOURCES TO INDIVIDUALS WHO SERVE AND SUPPORT COMMUNITY RESIDENTS SUFFERING FROM A MENTAL ILLNESS. NORTHERN NY FACES CHALLENGES COMMON TO RURAL AREAS, INCLUDING INCREASED POVERTY AND LIMITED ACCESS TO CARE. WHILE MUCH OF THE SERVICE REGION DOES HAVE A CHARACTERISTICALLY HIGHER PERCENTAGE OF OLDER ADULTS, THIS IS CONTRASTED BY THE DISTINCTIVE AND PARTICULARLY YOUNG POPULATIONS OF MILITARY PERSONNEL AND THEIR FAMILIES, AS WELL AS COLLEGE STUDENTS. FDRHPO WILL COLLABORATE WITH EXISTING PARTNERING PROVIDERS TO INCREASE THE NUMBER OF INDIVIDUALS TRAINED TO RECOGNIZE THE SIGNS AND SYMPTOMS OF MENTAL DISORDERS IN THEIR SERVICE POPULATIONS, EMPLOY CRISIS DE-ESCALATION TECHNIQUES, AND PROVIDE CRITICAL LINKAGE SUPPORT TO MENTAL HEALTH SERVICES. ACTIVITIES WILL INCLUDE: (1) ADULT MENTAL HEALTH FIRST AID (AMHFA) TRAINING TO INDIVIDUALS AND FIRST RESPONDERS WHO SERVE, SUPPORT, AND INTERACT WITH VETERANS, ACTIVE DUTY SOLDIERS, AND INDIVIDUALS IN THE CIVILIAN COMMUNITY WITH SERIOUS MENTAL ILLNESSES (SMI) AND/OR SERIOUS EMOTIONAL DISTURBANCES (SED); (2) YOUTH MENTAL HEALTH FIRST AID (YMHFA) TRAINING TO SCHOOL PERSONNEL AND FAMILY MEMBERS WHO SERVE, SUPPORT, AND INTERACT WITH SCHOOL-AGED CHILDREN IMPACTED BY SMI AND/OR SED; AND (3) CRISIS INTERVENTION TRAINING (CIT) OR MENTAL HEALTH FIRST AID-PUBLIC SAFETY (MHFA-PS) TRAININGS ENABLING LAW ENFORCEMENT OFFICERS TO ADDRESS THE NEEDS OF INDIVIDUALS WITH SMI AND/OR SED. TRAINEES WHO INTERACT, SERVE, AND SUPPORT THE MOST VULNERABLE POPULATIONS IN THE TUG HILL SEAWAY REGION WILL BE THE PROJECT’S PRIMARY TARGET GROUP. REGIONAL POPULATIONS OF FOCUS FOR WHICH THE PROJECT WILL BE DEVELOPED ARE ADULTS AND YOUTHS WITH SED AND/OR SMI, ESPECIALLY VETERANS, ACTIVE DUTY SOLDIERS, FARMERS, AND INDIVIDUALS LIVING IN POVERTY. TRAININGS WILL BE DELIVERED IN JEFFERSON, LEWIS, AND ST. LAWRENCE COUNTIES IN NORTHERN NY. THE FOLLOWING TRAINING OBJECTIVES WILL BE CONDUCTED PER GRANT YEAR: (1) 100 INDIVIDUALS TRAINED ACROSS 4 YMHFA SESSIONS; (2) 70 INDIVIDUALS TRAINED ACROSS 3 AMHFA SESSIONS; (3) 20 LAW ENFORCEMENT OFFICERS TRAINED IN 1 ANNUAL CIT AND/OR MHFA-PS SESSION; (4) DEVELOPMENT OF A PUBLIC DIRECTORY OF REGIONAL MENTAL HEALTH SERVICES; AND (5) IMPLEMENTATION OF AT LEAST 2 MARKETING CAMPAIGNS TO RAISE AWARENESS AND REDUCE THE STIGMA OF MENTAL HEALTH DISORDERS USING CULTURALLY COMPETENT AND DEVELOPMENTALLY APPROPRIATE MATERIALS. TO INCREASE THE LIKELIHOOD OF SUSTAINABILITY, FDRHPO INTENDS TO SEEK AND IDENTIFY ALTERNATIVE SOURCES OF FUNDING AND LEVERAGE EXISTING GRANT FUNDS, WHERE FEASIBLE AND APPROPRIATE.

RURAL NORTHERN BORDER REGIONAL PLANNING