Applicant Organizational Information Virginia Commonwealth University School of Nursing 1100 East Leigh Street, Richmond, VA, 23298-5070 Facility Type: Public/State Controlled Institution of Higher Education Website: https://nursing.vcu.edu Designated Project Director Information Lana Sargent, Interim Associate Dean Office of Practice and Community Engagement, Associate Professor. 804-828-3410. lsargent@vcu.edu Network Planning Project Mobile Connections for Care Transitions: A Model for Rural Health and Wellness Legislative Aims Aim #2: Expand access to, coordinate, and improve the quality of basic health care services Aim #3: Strengthen the rural healthcare system Focus Area VCU School of Nursing’s MHWP focus area is Care Coordination. Proposed Service Region Middle Peninsula (Essex, Middlesex, King William, King & Queen, Matthews), and Northern Neck (Lancaster, Richmond, King George, Northumberland, Westmoreland) Counties, Virginia Population to be Served Our network will serve individuals undergoing medical transitions of care associated with prisoner reentry into the proposed service region. Network Members -Bay Rivers Telehealth Alliance (BRTA; non-profit) -Bay Aging Housing and Transportation (BAHT; non-profit) -Peer Recovery Services of the Middle Peninsula and Northern Neck Community Service Board (PRS, non-profit) -VCU Tappahannock Hospital (VCUTH, Hospital) -Ledwith-Lewis Free Clinic (LLFC, non-profit) -Northern Neck Regional Jail (NNRJ, correctional facility) All our proposed network members are in HRSA-designated rural counties in Virginia: BRTA, LLFC, and VCUTH are in Essex County; BAHT and PRS are in Middlesex County; and NNRJ is in Richmond County. Network members are fully supported in joining the network. Experience in Serving Rural Underserved Populations MHWP is a nurse-led care coordination and wellness program operated by the VCU School of Nursing in the HRSA-designated rural Essex County, Virginia. Our prop
osed network members also all operate in overlapping counties of rural Eastern Virginia, including the Middle Peninsula and Northern Neck Regions, and provide services to address the needs of medically underserved areas. Our MHWP team has over 12 years of experience providing wellness and care coordination services for underserved communities. BRTA is a non-profit telehealth network established in 2012 that develops and provides telehealth projects to improve health and access to health care. BRTA was named a Rural Health Community Champion by HRSA in 2018. BAHT is a non-profit organization established in 1978 that provides public transportation services to help individuals access health care. PRS is part of a statewide network of community service boards established in 1974 and provides peer support and recovery and wellness programs for individuals with substance use disorders. VCUTH is a major hospital serving rural Eastern Virginia, located in Essex County. LLFC was established in 2005 to provide access to healthcare for underserved communities in the Tappahannock area, Essex County. The goal of our proposal is to formally connect our network members with the Northern Neck Regional Jail and other correctional facilities in the Northern Neck and Middle Peninsula regions to create a streamlined referral process for individuals undergoing reentry from incarceration to access the services provided by our network members. The network will be designed to help individuals overcome the unique challenges of accessing care transitioning from incarceration to a rural, medically underserved region. We will emphasize a focus on navigating the transition of care for substance use disorders (SUDs) due to the higher prevalence of SUDs in the population our network aims to serve. Funding Opportunity Notification VCU MHWP learned of this funding opportunity through an HRSA news/email release. Funding Preference Our network qualifies under funding preference, Medically Underse
rved Community/Population