Tri-County Health Network

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT

CONNECTING KIDS TO COVERAGE HEALTHY KIDS 2019 OUTREACH AND ENROLLMENT COOPERATIVE AGREEMENTS PROGRAM

ACHIEVING NEW HEIGHTS: A COALITION APPROACH TO REDUCING YOUTH SUBSTANCE USE IN THE TELLURIDE SCHOOL DISTRICT

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM - SPECIAL TRACK. FOCUS AREAS: STROKE, HEART DISEASE, CANCER, CHRONIC LOWER RESPIRATORY DISEASE, UNINTENTIONAL INJURY, CANCER, AND MATERNAL HEALTH. TRI-COUNTY HEALTH NETWORK (TCHNETWORK) WILL OFFER SERVICES IN THE CITY OF MONTROSE AND TOWN OF OLATHE IN MONTROSE COUNTY AND THE CITY OF DELTA IN DELTA COUNTY IN RURAL SOUTHWESTERN COLORADO. WE WILL PROVIDE SERVICES TO PATIENTS WITH A SOCIAL DETERMINANT OF HEALTH (SDOH) NEED SEEKING CARE AT THE EMERGENCY ROOM FOR STROKE, HEART DISEASE, CANCER, CHRONIC LOWER RESPIRATORY DISEASE, UNINTENTIONAL INJURY AND/OR CANCER, OR THOSE ACCESSING MATERNAL HEALTH CARE SERVICES AT MONTROSE REGIONAL HEALTH AND DELTA HEALTH, THE ONLY TWO HOSPITALS IN OUR RURAL REGION. WE WILL WORK WITH HOSPITALS TO IDENTIFY AND PRIORITIZE PATIENTS WHO ARE MOST AT-RISK OF POOR HEALTH OUTCOMES DUE TO HEALTH INEQUITIES, INCLUDING LATINE AND OLDER ADULT COMMUNITY MEMBERS; PEOPLE WITH LOW INCOMES; AND PEOPLE WHO DO NOT HAVE ACCESS TO OTHER CARE COORDINATION SERVICES. COMMUNITY CARE COORDINATION SERVICES ARE SCARCE IN OUR RURAL REGION, AS ARE SERVICES AVAILABLE IN SPANISH. OUR PROGRAM WILL HELP FILL THIS GAP. GOALS AND OBJECTIVES INCLUDE: • GOAL 1: COLLABORATE WITH COMMUNITY AND CONSORTIUM MEMBERS TO EXPAND HEALTH CARE SERVICES IN OUR RURAL REGION BY OFFERING AN ADAPTATION OF THE EVIDENCE-BASED PATHWAYS HUB CARE COORDINATION (PCC) PROGRAM, WHICH WILL IMPROVE HEALTH OUTCOMES, BUILD HEALTH EQUITY, AND ADDRESS THE UNDERLYING RISK FACTORS THAT DRIVE HEALTH DISPARITIES FOR UP TO 715 COMMUNITY MEMBERS OVER THE 4-YEAR GRANT PERIOD. OBJECTIVES INCLUDE: CONVENE A PLANNING GROUP WITH 5 PARTNERS INCLUDING NETWORK MEMBERS, HOSPITALS, COMMUNITY MEMBERS, AND OTHER STAKEHOLDERS TO DETERMINE INITIAL FOCUS OUTCOMES AND PATHWAYS RELEVANT FOR OUR COMMUNITY MEMBERS BY THE END OF YEAR 1; PARTNER WITH CONSORTIUM MEMBERS AND OTHER REGIONAL PROVIDERS TO CREATE THE TOOLS AND RESOURCES NEEDED TO DEVELOP AND/OR ADAPT 20 PATHWAYS RESPONSIVE TO THE NEEDS OF OUR COMMUNITY MEMBERS BY THE END OF YEAR 3; AND BUILD HEALTH EQUITY, IMPROVE HEALTH OUTCOMES, AND IMPROVE THE QUALITY OF HEALTH CARE SERVICES IN OUR REGION BY PROVIDING PATHWAYS CARE COORDINATION (PCC) FOR UP TO 715 CLIENTS THROUGH 20 PATHWAYS THROUGHOUT THE 4-YEAR GRANT PERIOD. • GOAL 2: STRENGTHEN OUR LOCAL HEALTH CARE SYSTEM BY CREATING A SUSTAINABLE INITIATIVE AND CONSORTIUM THAT CONTINUES BEYOND THE 4-YEAR GRANT PERIOD. OBJECTIVES INCLUDE: FACILITATE QUARTERLY MEETINGS WITH HOSPITALS, CLINICS, AND OTHER COMMUNITY-BASED ORGANIZATIONS TO INCREASE COLLABORATION AND BETTER UNDERSTAND AND ADDRESS LOCAL SDOH NEEDS AND RESOURCES TO ADDRESS THOSE NEEDS WITH UP TO 10 MEMBERS; IF PCC IS SHOWN TO BE SUCCESSFUL IN OUR RURAL REGION, DEVELOP AND IMPLEMENT A PLAN TO ENSURE FINANCIAL SUSTAINABILITY OF PCC SERVICES, AS DEMONSTRATED BY PCC SERVICES CONTINUING AFTER THE GRANT ENDS. EXPECTED OUTCOMES ARE: IMPROVED HEALTH OUTCOMES AND POPULATION HEALTH, REDUCED BARRIERS TO SERVICES, COST SAVINGS FOR PROVIDERS, AND A SUSTAINED AND STRONG CONSORTIUM. WE WILL ADAPT THE EVIDENCE-BASED PATHWAYS HUB CARE COORDINATION MODEL. TCHNETWORK HAS THE CAPACITY AND EXPERIENCE TO SERVE RURAL, UNDERSERVED POPULATIONS. WE HAVE PROVIDED SERVICES IN OUR RURAL REGION SINCE 2010 AND WE CURRENTLY OFFER 25 COMMUNITY OUTREACH PROGRAMS AND INITIATIVES THAT WORK TO ELIMINATE HEALTH DISPARITIES AND IMPROVE HEALTH. WE OFFER SERVICES SIMILAR TO THOSE IN THIS PROJECT THROUGHOUT OUR REGION, INCLUDING CARE COORDINATION TO MEDICAID PATIENTS, INSURANCE AND PUBLIC ASSISTANCE ENROLLMENT, OLDER ADULT OPTIONS COUNSELING, LATINE ADVOCACY SUPPORT, AND PCC IN A DIFFERENT PART OF OUR RURAL REGION. TCHNETWORK HAS DEVELOPED COLLABORATIVE WORKING RELATIONSHIPS WITH CONSORTIUM MEMBERS, HOSPITALS, COMMUNITY-BASED ORGANIZATIONS, SCHOOLS, GOVERNMENTAL AGENCIES, AND COMMUNITY MEMBERS TO IMPROVE HEALTH OUTCOMES IN OUR REGION. WE ARE REQUESTING FUNDING PREFERENCE BASED ON QUALIFICATION 1. DELTA, MONTROSE, AND OLATHE ARE IN HEALTH PROFESSIONAL SHORTAGE AREAS.

ACHIEVING NEW HEIGHTS: A COALITION APPROACH TO REDUCING YOUTH SUBSTANCE USE IN THE TELLURIDE SCHOOL DISTRICT

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

RURAL HEALTH NETWORK DEVELOPMENT PROGRAM

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT - TRI-COUNTY HEALTH NETWORK, DOING BUSINESS AS THRIVE COMMUNITY HEALTH NETWORK, IS REQUESTING FUNDING TO LAUNCH THE CRITICAL TIME INTERVENTION (CTI) PROJECT IN MONTROSE AND DELTA COUNTIES IN RURAL COLORADO. OUR PROPOSED CLINICAL SERVICE AREA IS CARE COORDINATION. THROUGH CTI, THRIVE WILL REPLICATE THE EVIDENCE-BASED CRITICAL TIME INTERVENTION MODEL. THE PROJECT WILL ADDRESS THE NEED FOR INTENSIVE, TARGETED, CARE COORDINATION SUPPORT SERVICES FOR PEOPLE NAVIGATING A CRISIS WHO ARE HIGH UTILIZERS OF MEDICAL CARE. MANY COMMUNITY MEMBERS IN OUR REGION STRUGGLE WITH CHRONIC DISEASE, MENTAL HEALTH DISORDER, AND SUBSTANCE USE DISORDER SELF-MANAGEMENT DUE TO A LACK OF PROVIDERS, DISPARATE COMMUNITY RESOURCES THAT ARE CHALLENGING TO NAVIGATE, LIMITED TRANSPORTATION OPTIONS, AND A RURAL CULTURE OF SELF-RELIANCE. WHILE SOME CARE COORDINATION SERVICES ARE AVAILABLE IN OUR REGION, THEY ARE ALL DESIGNED FOR PEOPLE WITH A BASELINE LEVEL OF STABILITY. CTI WILL ALLOW US TO SUPPORT 100 HIGH-RISK CLIENTS ACROSS THE THREE CORE CTI PHASES: TRANSITION, TRY-OUT, AND TRANSFER OF CARE. AT THE END OF THE PROVISION OF SERVICES, WE ANTICIPATE IMPROVED MENTAL HEALTH DISORDER MANAGEMENT, REDUCED SEVERITY OF SUBSTANCE USE, IMPROVED CHRONIC DISEASE SELF-MANAGEMENT, REDUCED RELIANCE ON THE EMERGENCY ROOM, AND IMPROVED QUALITY OF LIFE FOR PARTICIPANTS. WITH CTI, WE WILL SERVE PATIENTS ACCESSING CARE WITH TWO OF OUR NETWORK MEMBERS (MONTROSE REGIONAL HEALTH AND RIVER VALLEY FAMILY HEALTH CENTER). THESE CLINICAL PARTNERS WILL SCREEN PATIENTS FOR CHRONIC DISEASE, MENTAL HEALTH DISORDER, AND SUBSTANCE USE DISORDER; SOCIAL DRIVER OF HEALTH NEEDS; AND 2 OR MORE EMERGENCY ROOM OR URGENT CARE FACILITY VISITS IN THE PREVIOUS 12 MONTHS OR 2 OF MORE MISSED APPOINTMENTS IN THE PREVIOUS 6 MONTHS. WE WILL IMPLEMENT THREE QUALITY IMPROVEMENT STRATEGIES WITH THE CTI PROJECT. THRIVE WILL CONVENE A MULTIDISCIPLINARY QUALITY IMPROVEMENT (QI) TEAM WITH PARTNER CLINIC, COMMUNITY-BASED ORGANIZATION, AND THRIVE STAFF TO CONDUCT RAPID-CYCLE PLAN-DO-STUDY-ACT TESTS USING THE EVIDENCE-BASED MODEL FOR IMPROVEMENT (MFI). QI TEAM MEMBERS WILL BE TRAINED ON MFI AND ACT AS ACCOUNTABILITY PARTNERS SO WE CAN BUILD A SHARED REGIONAL QI CULTURE AND STREAMLINE REFERRAL WORKFLOWS. THRIVE AND OUR PARTNERS WILL ALSO STRENGTHEN DATA COLLECTION USING HEALTH INFORMATION TECHNOLOGY (HIT). DURING THE FIRST 6 MONTHS OF THE PROJECT, THRIVE WILL SELECT AND IMPLEMENT A HIT PLATFORM WITH ARTIFICIAL INTELLIGENCE PREDICTIVE FUNCTIONALITY. THIS TOOL WILL STANDARDIZE MONTHLY DATA INTEGRATION WITH CLINICAL ELECTRONIC MEDICAL RECORDS AND THE REGIONAL HEALTH INFORMATION EXCHANGE, MONITOR QUALITY MEASURES (SUCH AS HBA1C, BLOOD PRESSURE, AND EMERGENCY ROOM UTILIZATION), MAINTAIN A DIGITAL MAP OF COMMUNITY RESOURCES, AND SUPPORT OUR EFFORTS TO BILL MEDICAID AND MEDICARE FOR SERVICES. TO SUPPORT THE SUSTAINABILITY OF SERVICES BEYOND THE 4-YEAR GRANT PERIOD, THRIVE WILL OPERATIONALIZE MEDICAID AND MEDICARE BILLING FOR CTI CLIENT SERVICES. SYSTEMS AND TRAINING WILL BE IMPLEMENTED TO LEVERAGE COLORADO'S MEDICAID STATE PLAN AMENDMENT FOR HEALTH SYSTEM NAVIGATION AND MEDICARE PRINCIPAL ILLNESS NAVIGATION (AND COMMUNITY HEALTH INTEGRATION CODES. DURING THE FINAL YEAR OF THE CTI PROJECT, WE WILL CONDUCT A FORMAL REVENUE OPTIMIZATION ANALYSIS TO ENSURE WE CAN MAXIMIZE MEDICAID AND MEDICARE BILLING AND THAT SERVICES WILL SUSTAIN AFTER THE GRANT ENDS. THE QUALITY IMPROVEMENT COMPONENTS OF CTI WILL ALLOW US TO ADDRESS THE FOLLOWING NEEDS: NO CURRENT HIT RESOURCE USED BY CLINICS OR COMMUNITY-BASED ORGANIZATIONS THAT CAN SUPPORT NEEDED FOR PROJECT MANAGEMENT, EVALUATION, QUALITY IMPROVEMENT, AND BILLING; A LACK OF KNOWLEDGE AND SYSTEMS IN PLACE TO BILL MEDICAID AND MEDICARE FOR CHW SERVICES; AND NO MULTIDISCIPLINARY QUALITY IMPROVEMENT EFFORTS IN OUR REGION.

RURAL BENEFITS COUNSELING PROGRAM

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM

RURAL BENEFITS COUNSELING PROGRAM

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM