John C. Fremont Healthcare District (JCFHD) 5189 Hospital Road, PO Box 216 Mariposa, CA 95338 Deborah Schott, RN (209) 966-3631 ext. 1050; fax (866) 208-5183 deborah.schott@jcf-hospital.com www.jcf-hospital.com JCFHD is requesting $100,000 to establish the Mariposa Rural Health Network to develop a Chronic Care Management (CCM) program. JCFHD’s focus area is a CCM progarm to reduce health disparities targeting patients with chronic conditions reliant on community services. This program will achieve all three Legislative Aims: 1) Achieve efficiencies, 2) Expand access to, coordinate, and improve the quality of basic health care services, and 3) Strengthen the rural health care system. This CCM primary care program will help with the care of chronic conditions by deploying preventive measures to reduce exacerbations of those conditions that increase emergency room visits, hospitalizations, and premature death. This program will collaborate across local provider and social service agencies to combine care, services, and education so that patients have better healthcare access as well as learn to better manage their illnesses. As an underserved, rural, lower-income community, Mariposa residents suffer from poorer health outcomes, health disparities, and other inequalities. The county has experienced declines in population and limited household growth over the last decade. Median household income is $52,614 (63% of the California median of $84,097) and 18.1% of residents live in poverty, compared to a statewide average of 12.3%. Social determinants for health are driven by higher than average poverty rates and low-income levels, combined with the inherent lack of care access associated with being a Health Professional Shortage Area (HPSA) and Medically Underserved Area (MUA). Other challenges that affect health care services are the amount of uninsured and underinsured individuals. Many local, small business employers do not offer health insurance
. The unemployment rate is higher than average, especially seasonally, and there is a substantial retiree community. The chronic care management needs of the community, specifically of those patients with chronic conditions reliant on community services, have been identified informally by providers and individuals across healthcare and social service agencies. The current lack of formal agency/organization coordination is inadvertently escalating healthcare costs. Network Planning is needed to develop a network with a structure across agencies to 1) achieve efficiencies by integrating healthcare and social services, 2) to expand access to and improve the quality of basic healthcare services, and 3) to strengthen the rural healthcare system. The Mariposa Rural Health Network will improve the quality of life of people who are struggling to manage their chronic conditions. The CCM program will increase care access, streamline services, and eliminate duplicate efforts to ensure patients needing care for chronic conditions do not continue to disproportionately drain limited public resources. The establishment of a network will ensure we, as a community, can meet as many healthcare needs as possible despite provider shortages, remote locations, low income, and under insurance. Funding is needed to support planning activities. The newly formed network consists of four members that provide healthcare and/or social services throughout Mariposa. These network members are “umbrella” organizations that collectively manage numerous departments, divisions, and/or agencies. The services provided by these network members constitute the bulk of care services provided in the community; and thus, these organizations collectively have responsibility for completing the Network Planning process. The grant awardee and lead network member, JCFHD, will complete facilitation and documentation as well as implement the Chronic Care Management Program.