Tahoe Forest Health System Foundation

RURAL COMMUNITIES OPIOID RESPONSE PROGRAM ? MENTAL AND BEHAVIORAL HEALTH - 1. PROJECT TITLE: TAHOE FOREST HEALTH SYSTEM BEHAVIORAL HEALTH AND SUBSTANCE USE TREATMENT EXPANSION 2. REQUESTED AWARD AMOUNT: $489,839 PER YEAR 3. APPLICANT ORGANIZATION NAME: TAHOE FOREST HEALTH SYSTEM FOUNDATION 4. APPLICANT ORGANIZATION ADDRESS 11075 DONNER PASS ROAD, TRUCKEE, CA 96161-0442 5. APPLICANT ORGANIZATION FACILITY TYPE (E.G., RURAL HEALTH CLINIC, CRITICAL ACCESS HOSPITAL, TRIBE/TRIBAL ORGANIZATION, HEALTH SYSTEM, INSTITUTE OF HIGHER LEARNING, COMMUNITY-BASED ORGANIZATION, FOUNDATION, RURAL HEALTH NETWORK, ETC.): HEALTH SYSTEM INCLUDING TWO CRITICAL ACCESS HOSPITALS, AND RURAL HEALTH CLINICS SPANNING TWO STATES 6. PROJECT DIRECTOR NAME AND TITLE (SHOULD BE THE SAME INDIVIDUAL DESIGNATED IN BOX8F OF THE SF-424 APPLICATION FORM) CLAIRE DA LUZ, SUBSTANCE USE NAVIGATOR 7. PROJECT DIRECTOR CONTACT INFORMATION (PHONE AND EMAIL) 530-582-3298, CDALUZ@THFD.COM 8. DATA COORDINATOR NAME AND TITLE: ASHLEY VIGANO, GRANTS BILLING COORDINATOR 9. DATA COORDINATOR CONTACT INFORMATION (PHONE AND EMAIL) 530-582-6496 AVIGANO@TFHD.COM 10. EIN/DUNS NUMBER EXCEPTION REQUEST IN ATTACHMENT 8? (Y/N) - NOTE: HRSA RESERVES THE RIGHT TO DEEM APPLICATIONS THAT PROVIDE INSUFFICIENT INFORMATION IN ATTACHMENT 8, OR ARE NEARLY IDENTICAL IN CONTENT, TO BE INELIGIBLE. IN THIS INSTANCE, ASSUMING ALL OTHER ELIGIBILITY CRITERIA ARE MET, HRSA WILL ONLY ACCEPT THE LAST SUBMITTED APPLICATION ASSOCIATED WITH THE EIN OR DUNS NUMBER. NO 11. HOW THE APPLICANT FIRST LEARNED ABOUT THE FUNDING OPPORTUNITY HRSA-22-061 10 (SELECT ONE: STATE OFFICE OF RURAL HEALTH, HRSA NEWS RELEASE, GRANTS.GOV, HRSA PROJECT OFFICER, HRSA WEBSITE, TECHNICAL ASSISTANCE PROVIDER, STATE/LOCAL HEALTH DEPARTMENT) WWW.GRANTS.GOV 12. NUMBER OF CONSORTIUM MEMBERS & LIST OF CONSORTIUM MEMBERS (INCLUDING THE APPLICANT ORGANIZATION) : 4 MEMBERS; TAHOE FOREST HEALTH SYSTEM, SIERRA COMMUNITY HOUSE, PLACER AND NEVADA COUNTIES, GATEWAY MOUNTAIN CENTER 13. IS THE APPLICANT ORGANIZATION A PREVIOUS OR CURRENT RCORP AWARD RECIPIENT OR CONSORTIUM MEMBER? IF YES, SPECIFY: FY18, FY19, AND/OR FY20 RCORP- PLANNING; FY19 RCORP-MAT EXPANSION; FY19, FY20, FY21 RCORP- IMPLEMENTATION, FY20 RCORP-NEONATAL ABSTINENCE PROGRAM, FY21 RCORP- PSYCHOSTIMULANT SUPPORT NO 14. INDICATE IF APPLICANT ORGANIZATION INTENDS TO APPLY FOR FY22 RCORP- IMPLEMENTATION? (Y/N) NO 15. DOES THE TARGET SERVICE AREA OVERLAP WITH THE SERVICE AREAS OF THE NORTHERN BORDER REGIONAL COMMISSION, THE DELTA REGIONAL AUTHORITY, OR THE APPALACHIAN REGIONAL COMMISSION? (INDICATE Y/N AND SPECIFY) NO 16. RCORP-BHS TARGET SERVICE AREA (MUST BE EXCLUSIVELY RURAL, AS DEFINED BY THE RURAL HEALTH GRANTS ELIGIBILITY ANALYZER): A. FULLY RURAL COUNTIES: PROVIDE THE COUNTY NAME AND STATE: NEVADA COUNTY, CALIFORNIA B. PARTIALLY-RURAL COUNTIES: PROVIDE COUNTY NAME, STATE, AND THE RURAL CENSUS TRACT (LIST OF RURAL CENSUS TRACTS) PLACER COUNTY, CA CENSUS TRACTS 06122011, 06122014, 06120107, 06120106, 06120105, 06120104, 061222, 061221, 061223, 061202. WASHOE COUNTY, NEVADA CENSUS TRACTS 0313308, 0313306, 0313305, 0313307. 17. BRIEF DESCRIPTION OF THE TARGET POPULATION. INDICATE APPROXIMATELY WHAT PERCENTAGE (IF ANY) OF THE TARGET POPULATION IS NATIVE AMERICAN, AND, IF APPLICABLE, PROVIDE 2-3 SENTENCES REGARDING HOW THIS PROJECT SPECIFICALLY TARGETS TRIBAL POPULATIONS THE TARGET POPULATION IS EXCLUSIVELY RURAL IN THE SIERRA NEVADA MOUNTAINS AND SPAN A 3,500 MILE REMOTE AND ISOLATED SERVICE AREA. THE MAJORITY OF THE TARGET POPULATION IS WHITE WITH THE NEXT MOST POPULOUS ETHNICITY HISPANIC/LATINO. THE ETHNIC BREAKDOWN OF THE TARGET POPULATION IS 9.8% HISPANIC/LATINO AND 90.2% NON-HISPANIC/LATINO. APPROXIMATELY 1.3% OF OUR POPULATION IS AMERICAN INDIAN/ALASKAN NATIVE. BRIEF PROJECT DESCRIPTION: THIS PROPOSED PROJECT WOULD INCREASE COMMUNITY MEMBERS’ ACCESS TO SUBSTANCE USE TREATMENT, BEHAVIORAL HEALTH TREATMENT, AND GROUP THERAPY SUPPORT. A LICENSED CLINICAL SOCIAL WORKER

SMALL HEALTH CARE PROVIDER QUALITY IMPROVEMENT

RURAL HEALTH NETWORK DEVELOPMENT PLANNING GRANT PROGRAM