Rural Health Care Services Outreach Grant Program - Hawai‘i Island Community Health Center’s (HICHC) Pono Pulse Primary Care Project will provide an expanded and significantly enhanced comprehensive and intensive effort to address the healthcare needs of high-risk persons on Medicaid or Medicare in rural Hawai‘i County with complex and chronic health conditions. Patients will be assessed through risk stratification of payor and HICHC data and prioritized for enrollment in the project, an intensive chronic care management plan that includes dedicated nurse case managers and chronic care management clinics. The focus of the Pono Pulse program will be those patients with at least one uncontrolled medical condition (hypertension, diabetes, tobacco use disorder, high cholesterol, or congestive heart failure) and at least one other chronic medical or behavioral health condition. The primary evidence-based model is the CDC and CMC initiative Million Hearts. HICHC seeks to achieve improved health outcomes for patients with complex and chronic health conditions and reduce avoidable hospitalizations and associated costs through the following goals: ? =80% blood pressure control ? =80% statin compliance ? =80% antiplatelet compliance ? =80% smoking cessation screening in adult patients ? 10-15% reduction in uncontrolled A1c performance ? 8-10% reduction in overall hospitalizations among HICHC patients ? 8-10% reduction in inpatient 30-day rehospitalization rates among HICHC patients ? 10-15% reduction in hospital visit costs of care/member with CHF During the same period under a separate initiative, HICHC also seeks to grow its patient base 5% annually or 22% during the four-year period. HICHC serves a 20 ZIP Code region inhabited by nearly 90% of the island’s total population, has nearly 40,000 patients, and is the largest FQHC in the state. Hawai‘i Island is a rural island with a population density of 52 people per square mile over 4,000 square miles. HICHC currently has 14 community health center sites, 9 school-based center sites, and several mobile units. HICHC also has a large health equity and enabling services staff committed to alleviating if not eliminating barriers to access and the negative impacts of social determinants of health. HICHC works closely with state departments of health and education, as well as county agencies and community nonprofits. Hawai‘i’s healthcare challenges are unique and often more severe compared to other regions of the country due to its diverse patient base and isolated location. HICHC qualifies for all three funding preferences: HPSA, MUA, and Primary Care project focus.
