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.
