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.
