Bi-State Primary Care Assoc Inc

STATE AND REGIONAL PRIMARY CARE ASSOCIATIONS

STATE AND REGIONAL PRIMARY CARE ASSOCIATIONS

ARRA - HEALTH INFORMATION TECHNOLOGY IMPLEMENTATION

EMERGENCY FUNDS TO ELEVEN (11) NH COMMUNITY HEALTH CENTERS TO ADDRESS THE PROVISION OF MEDICAL SERVICES TO INDIGENT PATI

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM - APPLICANT ORGANIZATION INFORMATION: BI-STATE PRIMARY CARE ASSOCIATION (WWW.BISTATEPCA.ORG) IS A RURAL PRIMARY CARE ASSOCIATION SERVING NH AND VT, LOCATED AT: CORPORATE: 525 CLINTON ST, BOW, NH 03304; PROGRAMMATIC: 61 ELM ST, MONTPELIER, VT 05602 DESIGNATED PROJECT DIRECTOR (PD) AND DESIGNATED NETWORK DIRECTOR (ND) INFORMATION: PD: KATE SIMMONS; SR. DIRECTOR, OPERATIONS; 802-229-0002 X217 KSIMMONS@BISTATEPCA.ORG ND: KRISTEN BIGELOW-TALBERT; SR. PROGRAM MANAGER, HEALTH QUALITY; 802-229-0002 X220 KBIGELOW@BISTATEPCA.ORG RURAL HEALTH NETWORK DEVELOPMENT PROJECT: THE VT FOOD ACCESS & HEALTH CARE NETWORK (FAHC NETWORK) HAS THE GOAL OF INTEGRATING FOOD ACCESS AS PART OF HEALTH CARE IN RURAL VT. FOCUS AREA(S): VALUE-BASED CARE READINESS; HEALTH EQUITY; SOCIAL DRIVERS OF HEALTH / SDOH TARGET PATIENT POPULATION: RESIDENTS IN VT'S THIRTEEN RURAL COUNTIES FACING BARRIERS TO ACCESSING A SUFFICIENT, MEDICALLY APPROPRIATE DIET. CURRENT VT HOUSEHOLD FOOD INSECURITY ESTIMATES, WITH COVID-19 & ECONOMIC DISRUPTIONS, RANGE FROM 14% TO OVER 30%. FOOD INSECURITY DISPROPORTIONATELY AFFECTS RURAL RESIDENTS, PEOPLE OF COLOR, PEOPLE LIVING WITH DISABILITIES, OLDER VERMONTERS, SINGLE PARENT HOUSEHOLDS, AND VERMONTERS WITH LOWER INCOME. POOR DIET QUALITY INCREASES RISK OF DISEASES LIKE HYPERTENSION, DIABETES, & HEART FAILURE, AND LACK OF FOOD RESOURCES ALSO IMPEDES PATIENTS' ABILITY TO MANAGE THESE CONDITIONS ONCE THEY OCCUR. OUR PROGRAMS TARGET PATIENTS ACROSS THIS CONTINUUM FROM PREVENTION TO TREATMENT, WITH A FOCUS ON HEALTH EQUITY. WE WILL SERVE VT’S ADDISON, BENNINGTON, CALEDONIA, ESSEX, FRANKLIN, GRAND ISLE, LAMOILLE, ORANGE, ORLEANS, RUTLAND, WASHINGTON, WINDHAM, WINDSOR COUNTIES. NETWORK MEMBERS (6): BI-STATE PCA; VT FOODBANK; HUNGER FREE VERMONT; VT PROGRAM FOR QUALITY IN HEALTH CARE; VT ACADEMY OF NUTRITION & DIETETICS; VT FARM TO PLATE NETWORK PROJECT ACTIVITIES/SERVICES: INTEGRATION OF FOOD ACCESS AS PART OF HEALTH CARE, EMPHASIZING: S DOH DATA COLLECTION AND STANDARDIZATION (TO ADVANCE HEALTH EQUITY, SUPPORT RESOURCE REFERRALS, AND ESTABLISH HIGH QUALITY DATA FOR VALUE-BASED CARE READINESS); CLOSED-LOOP REFERRALS IN MEDICAL AND SOCIAL SERVICES; TRAINING FOR COMMUNITY HEALTH WORKERS (CHWS) AS PART OF AN INTEGRATED CARE TEAM (AND A NEWLY RECOGNIZED WORKFORCE IN VT); EVIDENCE-BASED TAILORED FOOD OPTIONS FOR PATIENTS MANAGING SERIOUS DIET-RELATED HEALTH CONDITIONS; QUALITY IMPROVEMENT FACILITATION TO OPTIMIZE PROCESSES AND WORKFLOWS; PEER-TO-PEER LEARNING; LEARNING FROM EVIDENCE-BASED MODELS BEYOND VT; AND SUSTAINABLE PROGRAM FUNDING STREAMS. EXPECTED OUTCOMES: WE EXPECT TO SEE: AN INCREASED RATE OF PATIENTS SCREENED FOR FOOD INSECURITY; AN INCREASED RATE OF PATIENTS OFFERED A REFERRAL AFTER A POSITIVE SCREEN; DECREASED BMI (THOUGH 4 YEARS IS A SHORT HORIZON FOR THIS OUTCOME); AND AN INCREASED RATE OF “CLOSING THE LOOP” FOR NUTRITION-RELATED REFERRALS. FOR PROVIDERS (ESPECIALLY CHWS) AND FOOD PARTNERS, WE EXPECT TO SEE: INCREASED TRAINING OPPORTUNITIES; OPTIMIZED WORKFLOWS FOR SCREENINGS AND REFERRALS; AND INVESTMENTS IN PILOT INITIATIVES INTEGRATING FOOD ACCESS AND HEALTH. FOR THE FAHC NETWORK: WE EXPECT EFFECTIVE GOVERNANCE WITH A RURAL FOCUS; ENGAGEMENT OF ALL NETWORK PARTNERS; AND SUSTAINABILITY PLANNING AND THE IMPLEMENTATION OF THOSE PLANS. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS: THIS APPLICATION SUPPORTS A MAJOR EXPANSION OF TWO STRATEGIC PLANNING PROJECTS (2020 – EARLY 2023) INTO A SUSTAINED INITIATIVE TO SERVE RURAL VERMONT BY INTEGRATING FOOD ACCESS AS PART OF HEALTH CARE. WE HAVE DEMONSTRATED PARTNERSHIP VALUE & CAPACITY DURING THE STRATEGIC PLANNING PHASE. THE NETWORK PARTNERS ALL OPERATE IN VERMONT’S RURAL COMMUNITIES, HAVE DECADES OF EXPERIENCE, AND TOGETHER REACH EVERY CORNER OF THE STATE. ALL PARTNER ORGANIZATIONS HAVE MAJORITY-RURAL MEMBERSHIP STRUCTURES. FUNDING PREFERENCE: REQUESTED FOR PRIMARY CARE FOCUS & WELLNESS/PREVENTION STRATEGIES.

COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED AND STATE PARTNERSHIP MARKETPLACES

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

TELEHEALTH NETWORK GRANT PROGRAM

PRIMARY CARE WORKFORCE RECRUITMENT IN NEW HAMPSHIRE

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM

HEALTH CARE AND OTHER FACILITIES

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

AMERICAN RESCUE PLAN ACT FUNDING FOR PCAS

PPHF ? 2013 - COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED AND STATE PARTNERSHIP EXCHANGES

COOPERATIVE AGREEMENT TO SUPPORT NAVIGATORS IN FEDERALLY-FACILITATED AND STATE PARTNERSHIP MARKETPLACES

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

HEALTH CARE AND OTHER FACILITIES

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM - APPLICANT ORGANIZATION INFORMATION: BI-STATE PRIMARY CARE ASSOCIATION (WWW.BISTATEPCA.ORG) IS A RURAL PRIMARY CARE ASSOCIATION SERVING NH AND VT LOCATED AT: CORPORATE: 525 CLINTON ST; BOW, NH 03304; PROGRAMMATIC: 61 ELM ST; MONTPELIER, VT 05602 PD: JAMIE RAINVILLE, MANAGER, SPECIAL PROJECTS; 802-229-0002; JRAINVILLE@BISTATEPCA.ORG RURAL HEALTH CARE SERVICES OUTREACH PROJECT: THE VT FOOD ACCESS & HEALTH CARE CONSORTIUM (FAHC CONSORTIUM – SPECIAL TRACK) HAS THE GOAL OF ASSESSING NUTRITION INSECURITY (NI) AND PILOTING INNOVATIVE FOOD ACCESS SOLUTIONS FOR RURAL VERMONTERS. TRACK: SPECIAL TRACK (FOCUSING ON HEART DISEASE AND MATERNAL HEALTH) TARGET POPULATION: RESIDENTS IN VT'S RURAL “NORTHEAST KINGDOM” (CALEDONIA, ESSEX, LAMOILLE, ORANGE, ORLEANS COUNTIES) WITH OR AT RISK FOR HEART DISEASE AND/OR PREGNANT OR BREASTFEEDING MOTHERS WHO FACING BARRIERS TO ACCESSING A SUFFICIENT, NUTRITIOUS, MEDICALLY APPROPRIATE DIET. IN 2024 HUNGER FREE VERMONT ESTIMATED THAT 2 IN 5 VT HOUSEHOLDS FACE FOOD INSECURITY (FI). POOR DIET QUALITY INCREASES RISK OF DISEASES LIKE HYPERTENSION, DIABETES, & HEART FAILURE, AND LACK OF FOOD RESOURCES ALSO IMPEDES PATIENTS' ABILITY TO MANAGE THESE CONDITIONS ONCE THEY OCCUR. POOR NUTRITION FOR PREGNANT MOTHERS LEADS TO WORSE BIRTH OUTCOMES, AND POOR NUTRITION DURING BREASTFEEDING DECREASES MILK SUPPLY AND BREASTFEEDING SUCCESS. CONSORTIUM MEMBERS: BI-STATE; 4 FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS): (1) LAMOILLE HEALTH PARTNERS (LHC); (2) LITTLE RIVERS HEALTH CARE (LRHC), AND (3) NORTHERN COUNTIES HEALTH CARE (NCHC); (4) BATTENKILL VALLY HEALTH CENTER (BVHC) PROJECT GOALS/OBJECTIVES: BI-STATE WILL COORDINATE THE ADOPTION OF NUTRITION SECURITY SCREENING TOOL; THE IMPROVEMENT OF WIC REFERRAL PROCESSES; AND ENHANCED FQHC KNOWLEDGE RE: MEDICAL NUTRITION THERAPY. THREE FQHCS WILL EACH CREATE / EXPAND NUTRITIOUS FOOD PROGRAMMING TAILORED TO THEIR COMMUNITY NEEDS (E.G., THROUGH LHP’S “HEART HEALTHY FOOD PROGRAMMING,” LRHC’S “FOOD FARMACY,” AND NCHC’S “KINGDOM KITCHEN NUTRITION NETWORK”); BVHC, WILL PARTICIPATE IN MEETINGS/TRAININGS TO LEARN FROM THE CONSORTIUM’S WORK. EVIDENCE-INFORMED MODEL: TAKING A MULTI-FACETED APPROACH, THE CONSORTIUM WILL BE UTILIZING TWO VALIDATED SCREENING TOOLS FOR FI AND NI AND IMPLEMENTING FOOD PROGRAMMING PROVEN TO IMPROVE BP (P=0.009), AND CHOLESTEROL (P=0.025), WHICH ALSO INTEGRATES ELEMENTS OF TWO EVIDENCE-BASED MODELS: (1) MEDICALLY TAILORED MEALS AND (2) PRODUCE PRESCRIPTIONS. EXPECTED OUTCOMES: PROCESS: FQHC SCREENINGS FOR NUTRITION INSECURITY WILL INCREASE; TARGETED HEART DISEASE AND MATERNAL HEALTH PATIENTS WILL UTILIZE RESOURCES PROVIDED (MULTIPLE METRICS); INCREASED REFERRALS TO WIC; OUTCOME: TARGETED PATIENTS WILL SHOW IMPROVEMENTS IN BP AND CHOLESTEROL CONTROL; PREGNANT MOTHERS WILL HAVE REDUCED RATES OF LOW TO VERY LOW BIRTH WEIGHTS; AND INCREASED RATES OF BREASTFEEDING. CAPACITY TO SERVE RURAL UNDERSERVED POPULATIONS: BI-STATE HAS A 39-YEAR HISTORY OF ADVANCING ACCESS TO COMPREHENSIVE PRIMARY CARE SERVICES FOR ALL, WITH SPECIAL EMPHASIS ON THOSE MOST IN NEED IN VT AND NH. BI-STATE HAS IMPLEMENTED RECENT PROJECTS TO SUPPORT RURAL VT FQHCS IN FOOD INSECURITY SCREENING, QUALITY IMPROVEMENT, DATA INFRASTRUCTURE, AND ACCESS TO CARE FOR SPECIAL POPULATIONS. ALL 4 FQHCS HAVE SERVED THEIR RURAL COMMUNITIES FOR 15+ YEARS, EXPANDING THEIR PATIENT BASES, IMPROVING QUALITY OF CARE, PROVIDING HEALTH EDUCATION, AND WORKING TO ADDRESS THE SOCIAL RISK FACTORS. THIS APPLICATION IS AN EXPANSION OF A PREVIOUS FORHP RHC OUTREACH SERVICES PROJECT (WHICH INCLUDED BI-STATE PCA, LHP, AND LRHC); THIS APPLICATION EXPANDS THE WORK TO A NEW REGION (WITH THE INCLUSION OF NCHC); TO A NEW TARGET POPULATION (MATERNAL HEALTH); AND TO A NEW SERVICE (NUTRITION INSECURITY SCREENING). FUNDING PREFERENCE: WE QUALIFY UNDER QUALIFICATION 3. OUR MODEL TO SCREEN FOR NI AND PROMOTE ACCESS TO NUTRITIOUS FOOD IS A STRATEGY OF PRIMARY CARE & WELLNESS/PREVENTION.

UNCOMPENSATED CARE FOR VULNERABLE POPULATIONS

HEALTH CARE AND OTHER FACILITIES

INTEGRATED COMMUNITY SYSTEMS FOR CSHCN

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

TELEMEDICINE GRANT

RURAL NORTHERN BORDER REGIONAL PLANNING

HEALTH CARE AND OTHER FACILITIES

RURAL HEALTH NETWORK DEVELOPMENT PLANNING GRANT PROGRAM

RURAL HEALTH NETWORK DEVELOPMENT PLANNING GRANT PROGRAM

RURAL HEALTH NETWORK DEVELOPMENT PLANNING GRANT PROGRAM

RURAL HEALTH NETWORK DEVELOPMENT PLANNING GRANT PROGRAM

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM