Organization Name: Delta Health Alliance, Inc. Address: 435 Stoneville Rd., Stoneville, MS, 38776 Entity Type: Non-profit 501c3 Website: www.deltahealthalliance.org Project Director: Bria Beal, Director of Programs; (662) 686-7004; bbeal@deltahealthalliance.org Project Title: The NEW YOU (Nutrition, Exercise and Wellness for You) Collaborative Goal: Improve efficiencies, increase access to care, and strengthen rural health systems to reduce disparities among racial and ethnic minorities living in the Mississippi Delta who have been diagnosed with obesity and/or cardiovascular disease Service Region: Mississippi Service Region A Target Population: Low-income, rural residents of the Mississippi Delta. Of 481,596 residents, 50.0% are Black/African American, only 81.4% of adults have a high school degree, 25.2% live in poverty, 42.6% of adults are obese, 46.7% have hypertension, and our rate of preventable heart disease deaths is over twice the national rate (131.7 per 100K vs. 59.7 per 100K). Primary Focus Area: Obesity; Secondary Focus Area: Cardiovascular disease Network Partnerships: 6 members: 1 public rural nonprofit as lead applicant (Delta Health Alliance [DHA]) & 5 clinics for services (Leland Medical Clinic, MississippiCare of Oxford, Delta Regional Health Clinic, Clarksdale Regional Health Clinic, Arcola Health Clinic); as well as 4 fitness centers, 1 social service collaborative and 1 economic group for programmatic support (non-MOU partners) Capacity to Serve Rural Underserved Populations: DHA has successfully developed, implemented and evaluated community-based research initiatives for underserved rural populations since 2001 in partnership with communities, agencies and institutions. We marshal cross-sector partners to improve health service delivery, including the development of a regional electronic health record system, a FQHC look-alike clinic, 3 Promise Neighborhoods, 9 Head Start/Early Head Start centers, and over 20 other p
rograms addressing care coordination, wellness education, workforce development, maternal and infant health, and other community-based services. DHA currently oversees externally funded research initiatives in 29 counties of Mississippi with an operating budget of over $40 million. We have the capacity and experience necessary to design and implement a community-based research initiative, observe its impacts, make mid-course corrections, evaluate outcomes, disseminate findings, then assist with replication to similar rural communities that could benefit from such programs. Evidence-Based Model: American Medical Group Association’s Obesity Care Model Collaborative (OCMC), a population health-based model incorporating interventions across four domains – Community, Healthcare Organization, Care Team, and Patient/Family – in a holistic, patient-centered approach to obesity care and management, with special modules for patients with a secondary diagnosis of cardiovascular disease. Project Activities: Deploy Community Health Workers (CHWs) to work with rural clinics to improve care coordination by linking primary care settings and real-world community resources. CHWs will assist in the development of personalized wellness plans with customized goals and actionable items; provide health education; provide assistance enrolling in social services including transportation and child care; incorporate physical fitness and nutrition supports to reach health goals; and to foster community involvement. Expected Outcomes: Reduction of rates of obesity & hypertension as measured by clinical tests; increase in # of adults following fitness/nutrition plans; increase in # of adults in control of high blood pressure; adherence to treatment plans; improvement in health education (individual and community). Funding Preference: DHA is requesting based on Qualification 1: Health Professional Shortage Area as in official HPSA counties and Qualification 2: we are located in a Medically Un
derserved Community.