Wednesday, May 14, 2025
5/14/2025
Rural Northern Border Region Outreach Program - The Littleton Regional Healthcare Mobile Integrated Healthcare (LRH-MIH) program addresses the unique healthcare access challenges faced by residents of Northern New Hampshire (NH), an area characterized by vast geography, limited transportation infrastructure, and a low socioeconomic status population. The LRH-MIH program was initially launched in 2022 to offset the effects of the COVID-19 pandemic on the diabetic population. However, with the decline in COVID prevalence and the identification of a broader need for improved healthcare access for our communities, this proposal intends to expand the scope of the program. This expansion now includes high utilizers of emergency medical care and those at risk for hospital admissions/readmissions in Coös and Grafton Counties, focusing particularly on low-income individuals, those requiring additional healthcare support, and older adults. The expanded LRH-MIH program seeks to build and strengthen partnerships with local primary care offices, healthcare, and social services in the region to increase patient referrals and focus area on addressing health disparities and ensuring comprehensive care coordination for our population. The program consortium members - LRH, Lisbon-Emergency Medical Services (EMS), Linwood Ambulance, and Littleton Fire & Rescue - are located within the Northern Border Region Commission (NBRC) area, and have extensive experience providing healthcare to our rural area, playing critical roles in the program’s success. These organizations work collaboratively, leveraging their deep community ties and expertise to deliver integrated care. The program activities include developing referral processes within the applicant organization to streamline patient enrollment, evaluating and forming new partnerships with organizations in the region, and disseminating program success stories in newsletters and local media features. Further, the program activities include MIH visits that provide comprehensive patient assessments to identify social determinants of health and the development of individualized care plans to address an array of patient needs to ensure continuity and/or coordination of care. These activities aim to increase the number of patients enrolled in the LRH-MIH program and ensure they have access to primary care and preventative services while decreasing the utilization of hospital and emergency medical services (EMS) and the emergency department (ED). Within 3 years, expected outcomes include enrollment of at least 500 patients into the program, ensuring 90% have a regular source of primary care within three months of their enrollment, referring 100% of those needing additional support to appropriate services, and facilitating a 20-25% reduction in hospital admission and readmissions rates and non-emergent EMS transports and ED visits. Focusing on these goals, the program aims to improve health outcomes, reduce healthcare costs, and create a healthier, more engaged population in Northern NH. Located in the heart of the community the program aims to serve, LRH has been providing healthcare to the greater North Country community for over 100 years. LRH has a demonstrated long-standing commitment to addressing the needs of rural, underserved populations in the NBRC; evident through LRH’s history of providing quality healthcare and conducting regular Community Health Needs Assessments to address community health priorities. Further, the successful establishment and implementation of the current LRH-MIH program demonstrates LRH's capability to expand and sustain the program, ensuring it meets the evolving healthcare needs of the region. Notification of this funding opportunity came through a selectman in the town of Lisbon, NH. LRH and the targeted service area meet the following funding preferences: located within an officially designated health professional shortage area and a medically underserved community and serves medically underserved populations.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).