Telehealth Network Grant Program - Background: Rural Health Medical Program, Inc. (RHMPI) serves rural and medically underserved communities across Alabama’s Black Belt, including Dallas, Perry, Wilcox, Marengo, Monroe, and Clarke counties. Many patients experience poverty, transportation barriers, provider shortages, limited specialty access, and high rates of nutrition-related chronic disease. Diabetes, hypertension, obesity, and cardiovascular disease remain major health concerns across the service area. Access to registered dietitians, medical nutrition therapy (MNT), nutrition screening, and ongoing nutrition counseling is limited in many rural communities. Project Objective: The Rural Tele-Nutrition Network for Chronic Disease Prevention and Management in Alabama’s Black Belt will expand access to integrated nutrition services through RHMPI’s telehealth network. Over the five-year project period, RHMPI will integrate registered dietitian-led MNT, nutrition screenings, individual counseling, group education, community health worker-supported follow-up, and a targeted hybrid remote patient monitoring and telehealth tracking model into primary care, care coordination, behavioral health, mobile outreach, and specialty referral workflows. The project will focus on patients with diabetes, hypertension, obesity, and cardiovascular disease. This model directly supports the NOFO’s focus on chronic disease prevention and treatment by combining tele-nutrition services with targeted RPM and telehealth-enabled tracking to monitor patient progress, strengthen care team coordination, and evaluate outcomes over time. Activities: Tele-Nutrition Service Expansion: Provide MNT, individual counseling, group education, and nutrition screenings through telehealth for patients with identified chronic disease risks. Care Team Integration: Embed nutrition referral pathways into primary care and specialty care workflows, including chronic disease follow-up, care coordination, behavioral health, women’s health, pediatrics, annual wellness visits, and mobile unit encounters. Registered Dietitian and CHW Model: Support at least 1.0 FTE registered dietitian and at least 0.5 FTE community health worker to deliver nutrition services, coordinate referrals, support engagement, and address barriers to care. Targeted Hybrid RPM and Telehealth Tracking: Use patient-owned devices when available, limited loaner blood pressure cuffs and scales for high-risk patients, clinic- and mobile-unit-based biometric monitoring, CHW check-ins, Athenahealth EHR documentation, and Azara DRVS registry reporting to track A1c, blood pressure, BMI, weight, visit completion, and patient progress. Expected Outcomes: RHMPI expects to increase access to registered dietitian-led nutrition services; increase nutrition screenings, MNT, counseling, and group education; improve integration of nutrition services into primary and specialty care; strengthen telehealth network capacity; improve patient engagement in chronic disease prevention and management; and generate data to evaluate service delivery, patient outcomes, and sustainability. Sustainability: RHMPI will sustain tele-nutrition services through third-party reimbursement when available, integration into primary care and chronic disease workflows, care coordination support, continued use of Athenahealth and Azara DRVS reporting, future grant opportunities, and partnerships with rural health, public health, and community-based organizations. This project aligns with HRSA’s goals by expanding nutrition services in rural and medically underserved communities, increasing telehealth network capacity, integrating nutrition into primary and specialty care, and generating data to evaluate program activities and outcomes.
