Rural Health Care Services Outreach Grant Program - The proposed project (Advancing Health in Rural Michigan) establishes a new consortium of local, state, and national healthcare partners to expand high-quality rural post-acute recovery options via Critical Access Hospital (CAH) Transitional Care (TC) and increase access to MENDS® wellness and advanced care planning (ACP) education and resources in the inpatient, primary care, and community settings across rural Southwest Lower and North Central Lower Michigan communities. Efforts will address the lack of locally available healthcare and accessible wellness and advance care planning information, tools, and support. The target population for the proposed project is adults 18 and older, with a target sub-population of Medicare beneficiaries of 65 years of age and above. Individuals in the 5-county Southwest Lower & North Central Lower Michigan service area (Allegan, Arenac, Cass, Gladwin, Iosco Counties) struggle with preventable poor health behaviors and outcomes and high rates of chronic disease. Goals: Develop a strong multi-regional consortium to meet the unique needs of target rural communities through new and expanded services; Enhance care delivery, support, and enabling services across 5 counties of rural Michigan (Southwest Lower Michigan and North Central Lower Michigan regions) by implementing hospital-based post-acute CAH TC at 4 CAH partners; Support the health and wellness of rural Michigan communities through community-driven education and outreach. Objectives: Engage consortium members & rural communities to guide & support efforts; Equip, educate, and support hospital leaders, providers, and staff to provide high-quality, post-acute TC within the rural CAH setting; Enhance collaboration between rural hospitals; launch hospital-based post-acute TC services within 4 CAH partners in order to reduce health access and outcomes disparities and improve the health outcomes and quality of life of rural Medicare beneficiaries (age 65 and above) in the service area; Establish the needed infrastructure and tools to successfully implement education and outreach efforts; Launch MENDS® (an evidence-informed model) to support the improvement of health behaviors and health outcomes in rural adults (age 18 and above); and increase access for rural community members (adults age 18 and above) to advanced care planning (ACP) tools and one-on-one support. Outcomes: Increase in post-acute CAH TC admissions, bed days, and revenue; Fewer discharges directly back to acute care from post-acute care and more to home; Shorter post-acute stays; Increased patient & care team satisfaction; Increase in healthcare staff, patients, and community members with personal wellness goals, healthy behaviors, and advanced care plans. Funding Track: Regular Focus Area: Hospital-based Transitional Care & Prevention/Wellness Evidence-based/Evidence-Informed Model. The proposed project will utilize the evidence-informed hospital-based Transitional Care with MENDS® model. The Michigan Center for Rural Health (MCRH) has served as the State Office of Rural Health, serving all 57 rural Michigan counties since 1991. The MCRH has a long history in implementing rural health programs, including, but not limited to the following: Medicare Rural Hospital Flexibility Grant Program, State Office of Rural Health, Small Hospital Improvement Program, Rural Communities Opioid Response Programs (planning and implementation), and Rural Health Care Services Outreach Program. Funding Preference. The Michigan Center for Rural Health qualifies for the primary care, wellness and prevention strategies funding preference (qualification 3). The proposed project will focus on primary care, and wellness and prevention strategies. For supporting documentation, see Attachment 11.
