Rural Health Policy - 2008 Outreach Directory

Topic Areas

Obesity

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

The network partners consist of eight members of the Pike County Consortium and four members of the Bullock County Consortium; and community supporters in both counties.

Areas Served

Rural Pike and Bullock counties.

Target Population Served

Program Director

Terry Watkins

Troy University

PO Box 928

Troy, Alabama 36081

Phone: (334) 808-2886

Fax: (334) 566-5015

Troy University

Troy, AL 36082-0001

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

Troy University has initiated a partnership of community agencies committed to the development and implementation of a comprehensive, countywide health risk prevention and outreach project. The project will focus on preventing school-age obesity and increasing physical activity using the Coordinated Approach to Child Health Model, a school-based nutrition program. Goals of the project are (1) to form a supporting network to the consortia in Alabama’s Bullock and Pike counties that reflects the growing cultural diversity; (2) to advance the scope of the existing rural health promotion program to prevent obesity in school-age children; (3) to implement a health prevention and education project in the public schools that will provide school children with the information and skills they need to avoid health-damaging behaviors and to live healthy lifestyles; and (4) to encourage parents and extended family participation in health risk prevention and education programs to dissolve barriers to healthy lifestyles.

The project will target students in grades 3 through 5 in rural Pike and Bullock counties where unmet health needs and at-risk behaviors present serious health risks and contribute to educational and social problems. The target populations will be multicultural, representing all racial, social, and economic backgrounds in the two counties. Contributing to the overall ill health of community youth is the lack of parental awareness concerning health topics and detached parental involvement in child health issues. Implementation of the project will provide students with the skills they need to make healthy choices for life and will strengthen communities by increasing collaboration among parents, teachers, and other school partners.

Access barriers include inadequate or lack of health insurance, lack of Medicaid providers, cultural and spiritual barriers, lack of education and awareness, language barriers, and difficulty getting to a health care facility due to the lack of public transportation. In the past, this project made a significant difference in the lives of youth in Pike County. By expanding this program to Bullock County, more students will be given a head start on a healthier life. Bullock County is designated as a Medically Underserved Area for dental and primary health care professionals.

Topic Areas

Heart disease, Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension, Disease management, Faith-based health advocacy

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Parish Nurse Disease Management Program

Areas Served

The target population of under and uninsured residents of Talladega County, Alabama with chronic diseases of Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes and/or Hypertension.

Target Population Served

The goal of this project is to increase the quality and years of life for individuals with chronic diseases of CHF, COPD, Diabetes and/or Hypertension.

Project Summary

The goal of this project is to increase the quality and years of life for individuals of the target population of under and uninsured residents of Talladega County, Alabama with chronic diseases of Congestive

Program Director

Margaret Morton, Ed.S., Executive Director

Sylacauga Alliance for Family Enhancement, Inc.

P.O. Box 1122

Sylacauga, Alabama 35150

Phone: (256) 245-4343

Fax: (256) 245-3675

E-mail: mortonm@safesylacaupa.com

Sylacauga Alliance for Family Enhancement, Inc.

Sylacauga, AL 35150

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes and/or Hypertension. The vehicle by which is through a community partnership using a computer-assisted Parish Nurse Disease Management Program (PNDMP). This PNDMP provides a community based holistic approach and extends the impact of the Parish Nurses with the use of Family Health Advocates (FHAs) using laptop computers to access the management information system. The use of FHAs will expand an existing innovative community disease management program of parish nursing by enabling more clients to be enrolled for a longer period of time. Utilization of a management information system (MIS) by the community consortium providers, a parish nurse and the family health advocates will allow for efficient and effective exchange of information and standardization of data collection in a community setting. Indicators of success of this project will be a 94 percent increase in enrollment, achievement of one or more of individual health goals, an improvement in quality of life as indicated by results of a SF36 survey, a 30 percent increase in pharmaceutical support (or $250,000), a 50 percent increase in the number of social and health services provided to the target population and a 30 percent increase in the utilization of the community health network MIS. This project builds on existing research on the relationship between spirituality and health, the effectiveness of lay community health workers, and enabling technology. The further development and expansion of a PNDMP in addition to meeting real needs in this rural community provide a replicable model for use in other rural communities.

Topic Areas

Health care

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 124,122.00

· Year 2 - 123,292.00

· Year 3 - 100,000.00

Partners to the Project

Rural Assistance Program for Churches and Schools (RAPCS).

Areas Served

Green, Sumter, and Marengo Counties. These counties are rural, medically underserved, and have a large African American population.

Target Population Served

The target population includes school students, churchgoers, senior citizens, parents, and the working poor. The project consortium includes local hospitals, health centers, school systems, churches, and community-based organizations.

Project Summary

Program Director

Marcia Antoinette Lankster, R.N., B.S.N.

Tombigbee Healthcare Authority

Bryan W. Whitfield Memorial Hospital

105 Highway 80 East

Demopolis, AL 36732

Phone: (334) 287-2579

Fax: (334) 287-2594

Tombigbee Healthcare Authority

Demopolis, AL 36732

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

The Rural Assistance Program for Churches and Schools (RAPCS) will provide access to health care for disadvantaged populations in Green, Sumter, and Marengo Counties. These counties are ranked among the poorest in the State and the Nation. They are rural, medically underserved, and have a large African American population. The prevalence rates of numerous chronic health disorders are higher in this area than other comparable areas in Alabama, which overall has higher rates than other States. In addition to higher rates of chronic disease, the area suffers from inaccessibility to health care due to the unavailability of public transportation. There also are major behavioral and social problems, such as teen pregnancy, low birth weight, high tobacco use, and alcohol and drug abuse problems. According to the most recent census data, the average median household income is 36 percent of the State average. These persons also are the ones without health insurance coverage. Those who are covered have government-provided insurance such as Medicare and Medicaid. Census data also show that individuals in the targeted counties have a high school graduation average of 67 percent—below the State average. Low education and employment perpetuate the economic problems and often result in poor health practices and local of knowledge about accessing and using health care resources. These factors and others provide insurmountable barriers to health care in this region of Alabama.

The purpose of this project is two-fold: 1) To improve access to health care by establishing outreach health care sites throughout the counties in schools and churches where people are isolated and lack direct access to health care, and 2) To implement a health education campaign that would increase public awareness of health care resources and services in the community. These goals will be achieved by providing nursing services in local schools and churches; making primary health care services available in schools and churches; and increasing access to preventive health education programs. The target population includes school students, churchgoers, senior citizens, parents, and the working poor. The project consortium includes local hospitals, health centers, school systems, churches, and community-based organizations.

Topic Areas

Mental Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 139,785.00

· Year 2 - 124,971.00

· Year 3 - 99,993.00

Partners to the Project

This project is a joint effort of a consortium with 3 member agencies, Coosa County Public Schools, Cheaha Mental Health, and the Alabama Parent Education Center. These partners are completing work on an Integrating Mental Health in Public Schools planning grant from the U.S. Department of Education. The planning grant provided the consortia with the opportunity to meet frequently with each other and other key stakeholders to identify mental health needs in our community. Our community has been designated as a medically underserved community because of the limited mental health services available.

Areas Served

The entire community of Coosa County has been a part of the development of this project. When we began to identify the limited mental health services in our community as a problem

Program Director

Lucy Browning

Coosa Board of Education

P.O. Box 37

Rockford, AL

Phone: (256) 377-2385

Fax: (256) 377-2385

E-mail: lbrowning@coosaschools.k12.al.us

Coosa County Board of Education

Rockford, AL 35136-0373

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

(301) 594-4438

kmartinsen@hrsa.gov

community as a problem, we formed the Coosa County Partnership for Youth.

Target Population Served

Coosa County is a small, rural, isolated county in central Alabama. According to the U.S. Census, the population is 11,500 in a county that covers 652 square miles. The population density is 19 people per square mile and approximately 9 housing units per square mile. Our county has approximately 4,682 households, 30% of which have children under the age of 18 in the home.

Project Summary

The Coosa County Partnership for Youth is an exciting opportunity for our community. We are committed to improving the lives of youth by examining and improving the systems and processes for accessing mental health services in Coosa County. Funding from this application will allow us to work collaboratively to identify strategies for getting kids to more effective, evidence-based treatment as we build a system that eliminates the barriers to learning that all youth face. We will maximize that opportunity by working to inform the entire community about mental health issues, the importance of early identification, and how to access services. Coosa County will become a pioneer in Alabama for effective and collaborative strategies to improve the link between families, schools and mental health services.

Topic Areas

Elderly, Telehealth

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Community Health Aide/Practitioners

Areas Served

Alaska

Target Population Served

To meet the healthcare needs of elders so they can remain in their communities and stay connected to their homes and families for as long as possible.

Project Summary

The service area of this proposed project is the 34 rural communities within the Bristol Bay Area Health Corporation (BBAHC) medical care system in Alaska. Some 8,072 people live in the area, of whom 6,865 are all or part Native. The target population is the 555 persons over the age of 62 that reside in the region. The most significant

Program Director

Rose Heyano

President/Chief Executive Officer

Bristol Bay Area Health Corporation

P.O. Box 130

Dillingham, AK 99576

Phone: (907) 842-5201

Fax: (907) 842-9409

E-mail: rheyano@bbahc.org

Bristol Bay Area Health Corporation

Dillingham, AK 99576

ORHP Contact:

Sherilyn Pruitt

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-0819

spruitt@hrsa.gov

barriers to care for the elderly are language and travel to advanced medical care. Some 62 percent of elders in the service area speak a language other than English. Of those, 9 percent do not speak English at all, and 19 percent do not speak English well. There are no connecting roads or bridges between any of the villages either intraregional or to the hospital in Dillingham.

Community Health Aide/Practitioners (CHAP) provide medical services in most of the village clinics, with a few of the subregional clinics staffed with mid-level practitioners that also travel to the smaller villages and provide itinerant care. Telehealth is used increasingly to provide quality health care without the need for the patient to travel. Dillingham has the most accessible hospital; however there is no geriatric specialist available. More advanced care must be sought in Anchorage or beyond. Many elders have to move out of their villages and region as their medical needs increase because of a lack of healthcare services, distance, and travel expenses. This means that an elder is removed from his or her culture, way of life, and family, causing a great deal of stress for both the elder and family members. In the Yup’ik Eskimo and Aleut cultures, the wisdom, knowledge, and life experiences of the elderly are appreciated and acknowledged by the younger generation.

The overall goal of this proposed project is to meet the healthcare needs of elders so they can remain in their communities and stay connected to their homes and families for as long as possible. There are five program goals: 1) To increase access to specialized medical care for persons over the age of 62; 2) To increase patient translation and advocacy services for persons over the age of 62; 3) To increase provider staff knowledge of geriatrics; 4) To increase public awareness and knowledge of geriatric issues; and 5) Increase Medicare enrollment in the target population. Strategies to meet these goals include contracting with an itinerant physician specializing in gerontology or internal medicine; referring elders for assessments and treatment; providing transportation for elders to the specialty clinic; and using telehealth capabilities to provide services to elders in the remote villages; hiring two FTE Patient Advocate/Translators to assist elders in accessing care; providing staff with in-service training and community education regarding geriatric issues; and providing education to identified patients regarding the benefits of applying for Medicare coverage.

The realization of these goals will greatly enhance and improve all aspects of health care for the elderly, which will allow them to remain in their villages and to continue benefiting the entire community. Another benefit of accomplishing these goals is that medical providers, elders, and community members in general will have an increased awareness and knowledge of elder health care issues. Medical staff will be able to provide higher quality health care services with an increased understanding of geriatric assessment and treatment. It is anticipated that this project will be self-sustaining at the end of the 3-year project period.

Topic Areas

Colorectal cancer

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Kenaitze Indian Tribe (KIT), the Ninilchik Traditional Council, and the Alaska Native Tribal Health Consortium (ANTHC).

Areas Served

Rural Alaska communities of Kenai, Soldotna, Nikiski, Kasilof, Sterling, Cooper Landing, Hope, Ninilchik, Anchor Point, and Homer.

Target Population Served

Program Director

Diana Turner

Executive Director

Kenaitze Indian Tribe

P.O. Box 988

Kenai, AK 99611

Phone: (907) 283-3633

E-mail: dturner@kenaitze.org

Kenaitze Indian Tribe

Kenai, AK 99611

ORHP Contact:

Sheila Warren

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0246

swarren@hrsa.gov

Project Summary

This project will form a Colorectal Cancer Screening Consortium through the Kenaitze Indian Tribe (KIT), the Ninilchik Traditional Council, and the Alaska Native Tribal Health Consortium (ANTHC). Cancer has been identified as the leading cause of death among Alaska Natives, with colorectal cancer as the second leading cause of cancer mortality. For the 5-year period from 1996-2000, Alaska Natives were more than twice as likely to be diagnosed with colorectal cancer as U.S. Whites. A high proportion of Alaska Native colorectal cancers are diagnosed beyond the local stage, suggesting the need for improved screening.

The consortium will serve more than 1,200 Native Alaskan/Native American adults aged 50 to 80 years residing in the rural Alaska communities of Kenai, Soldotna, Nikiski, Kasilof, Sterling, Cooper Landing, Hope, Ninilchik, Anchor Point, and Homer. Lack of flexible sigmoidoscopy services in our tribal health clinics and distance from colorectal screening services in Anchorage are significant barriers to access. Within 3 years, the consortium will increase the percentage of Native Alaskan/Native American adults over age 50 living in the central and southern Kenai peninsula who complete screening for colorectal cancer from the current rate of under 4 percent to a target rate of 50 percent. This goal will be accomplished by developing a flexible sigmoidoscopy clinic at KIT health clinic; sending one advanced nurse practitioner and one registered nurse to ANTHC for approved training in flexible sigmoidoscopy procedures; and conducting weekly flexible sigmoidoscopy clinics to over 500 patients in the next 3 years, with additional colonoscopy referrals to Alaska Native Medical Center.

The consortium will monitor project progress, identify and problem-solve barriers, develop local capacity, and seek ways to expand outreach, networking, and public education. ANTHC will provide intensive training in flexible sigmoidoscopy procedures, as well as onsite follow-up and technical assistance with both Tribes. The two Tribes will set up a referral mechanism, as well as patient pre-screening and flow charts to be placed in patient medical records so that individual patient progress and follow-up can be tracked by medical care providers in each clinic. KIT also will add the Colorectal Cancer package to its RPMS tracking system. Both Tribes will provide patient education and preparation, reminder calls prior to procedures, and assistance with transportation through the low-cost area transit system or mileage reimbursements. Each Tribe will implement public education and outreach.

The project will coordinate its efforts with our local health and social service provider network, the Kenai Health Services Opportunities Collaborative, State Office of Rural Health, State Colorectal Cancer Task Force, and Alaska Tribal/rural providers.

Topic Areas

Hospice/Medicare

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Eastern Aleutian Tribes, Providence Hospice, Aleutian Pribilof Islands Association, and Alaska Native Tribal Health Consortium this demonstration will allow Eastern Aleutian Tribes (EAT) to expand access to hospice services for rural Alaskan residents by using its mid-level practitioners and health aides to provide in-home hospice services.

Areas Served

Both tribal and non-tribal members, who reside within the Eastern Aleutian Tribes and Aleutian Pribilof Islands Association service area.

Target Population Served

According to the Alaska Native Epidemiology Center, malignant neoplasms accounted for 50% of the total Alaska Native death count in the Aleutians East Borough between 1998 and 2002. (Alaska Native Epidemiology Center, Regional Health Profile for Eastern Aleutian

Program Director

Liam Chris Devlin

3380 C Street, Suite 100

Anchorage, AK

Phone: (907) 564-2501

Fax: (907) 277-1446

E-mail: chrisd@eatribes.net

Rural Alaska Hospice Outreach Project

Anchorage, AK 99503-3440

ORHP Contact:

Jacob Long Rueda III, Ph.D., M.P.H., MED

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0649

jrueda@hrsa.gov

Tribes for Eastern Aleutian Tribes, April 2006). There were a total of 1,120 reported cancers in Alaska Natives in the Anchorage Service Unit. The top five cancers among Alaska Natives were (highest to lowest) lung, colon/rectum, prostate, orallpharynx, and stomach. Cancer incidence rates are greater for Alaska Natives in the Anchorage Service Unit then for the United States white population. (Alaska Native Epidemiology Center, Regional Health Profile for Eastern Aleutian Tribes, April 2006).

Project Summary

The proposed Rural Alaska Hospice Outreach (RAHO) project is designed to test whether hospice services provided by a rural demonstration hospice program to Medicare beneficiaries in rural Alaska who lack an appropriate caregiver and who reside in rural areas of Alaska would result in wider access to hospice services, benefits to the rural community, and a sustainable pattern of care.

Medicare Hospice care is an entitled benefit covered under the Medicare Hospital Insurance program and is available to all beneficiaries enrolled in Medicare Part A. However, rural Alaskans are being denied access to hospice care because CMS Conditions of Participation (COP) require specifically defined services that are not possible in very rural, isolated areas of the United States -like bush Alaska. Tribal and non-tribal healthcare organizations in Alaska must collaborate to work with current COP’s or change paradigms such that hospice services are: 1) facilitated or enhanced through the collaboration of tribal and non-tribal entities and, 2) authorized to be provided beyond the current service area definition that is classically defined by close geographic locality to the providers of care.

Topic Areas

Substance abuse prevention/treatment

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,996.00

· Year 2 - 125,000.00

· Year 3 - 99,996.00

Partners to the Project

Areas Served

Navajo Nation and is part of Navajo County in northeastern Arizona.

Target Population Served

1) To increase access and participation of youth in substance abuse prevention education by using community-based education programs that encompass the Dine traditional philosophy; and 2) To increase access and participation of youth and their families in culturally appropriate substance abuse intervention and treatment programs. The population to be served will be children and youth (age 4-18) and their families who reside in the Hardrock community.

Program Director

Germaine Simonson

Hardrock Council on Substance Abuse, Inc.

P.O. Box 26

Kykotsmovi Village, AZ 86039

Phone: (928) 725-3800

Fax: (928) 725-3731

E-mail: gsimonson@hotmail.com

Hardrock Council on Substance Abuse, Inc.

Kykotsmovi Village, AZ 86039

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The Hardrock Youth Wellness and Prevention Program is a collaborative effort of the Hardrock Council on Substance Abuse, Inc. (a local non-proft corporation), the Hardrock Chapter House (a local governmental subdivision on the Navajo Nation), and the University of Arizona Mel and Enid Zuckerman Arizona College of Public Health’s Project EXPORT. The purpose of the collaboration is to strengthen their collective efforts in building a strong infrastructure for substance abuse prevention, intervention and treatment at the community level.

The Hardrock community lies in the heart of the 27,000 square mile boundary of the Navajo Nation and is part of Navajo County in northeastern Arizona. Health disparities are critical health issues for this isolated rural community, especially because of its unique history. It is one of 11 Navajo communities that experienced Federal relocation, land loss and livestock reduction as a result of the 1974 Navajo-Hopi Land Settlement Act. Access to health care is a major problem for the Hardrock community as the distance to hospitals and clinics is over 60 miles away and the community has severely limited and/or nonexistent medical and behavioral health service providers.

The impact and extent of substance abuse has been well documented in the past decade including 19 deaths in the community in 1995. In a recent community-based survey in 2004, 84 percent of respondents reported some association with someone, including themselves, who is abusing alcohol or some other substance. More than two-thirds of respondents knew of someone that was killed due to alcohol or substance abuse since 1995.

The Hardrock Youth and Wellness Program has two main goals: 1) To increase access and participation of youth in substance abuse prevention education by using community-based education programs that encompass the Dine traditional philosophy; and 2) To increase access and participation of youth and their families in culturally appropriate substance abuse intervention and treatment programs. The population to be served will be children and youth (age 4-18) and their families who reside in the Hardrock community. The program will provide direct educational interventions through a 6-week summer program and an additional 2-week long program during winter and spring school breaks. It will also provide intensive outreach, monitoring, and follow up to youth and their families linking them with existing community-based intervention and treatment services.

Topic Areas

Oral Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Rural school districts (Elfrida, Double Adobe, Ash Creek, Cochise, McNeal and Pearce) and a federally qualified community health center (Chiricahua Community Health Centers)

Areas Served

Sulphur Springs Valley of southeastern Cochise County

Target Population Served

Children in the remote and sparsely populated Sulphur Springs Valley of southeastern Cochise County.

Project Summary

The Sulphur Springs Valley Health Care Consortium is a group of rural school districts (Elfrida, Double Adobe, Ash Creek, Cochise, McNeal and Pearce) and a federally qualified community health center (Chiricahua Community Health Centers) dedicated to providing primary dental and medical care to the students and their families. The

Program Director

Jennifer “Ginger” Ryan

Chiricahua Community Health Centers, Inc.

10566 Highway 191

P.O. Box 263

Elfrida, AZ

Phone: (520) 642-2222

Fax: (520) 642-3591

E-mail: gryan@cchci.org

Chiricahua Community Health Centers

Elfrida, AZ 85610

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

plan is to dace CCHCI’s Mobile Dental Unit at each school to provide full dental treatment plans for eligible students. The initial screenings (including x-rays and an examination by a Dentist) and services of the Dental Hygienist will be done without charge. In addition, a board certified pediatrician will perform medical assessments on the children, focusing on respiratory issues, two times per month.

The program is in response to requests from community groups for dental and medical services for children in the remote and sparsely populated Sulphur Springs Valley of southeastern Cochise County. CCHCI, whose headquarters are in Elfrida, acquired a state-of-the-art mobile dental facility in July of 2006 with funds from a grant from the Office of Oral Health, Arizona Department of Health Services. The unit is equipped to provide both dental and medical services.

The plan is for the unit to travel to one school at a time. A Dentist will examine the children and provide a treatment plan. Once the necessary restorative work has been completed, sealants and varnishes will be provided to prevent tooth decay. The program includes education on good oral hygiene for both the students and their families. A pediatrician will provide medical assessment focusing on asthma screening and other respiratory related issues. Once all of the eligible children in a school have been seen, the unit will move to the next school. During the summer months, the unit is scheduled to provide services in remote, underserved areas.

Topic Areas

Chronic illness, Diabetes

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 162,765.00

· Year 2 - 167,648.00

· Year 3 - 172,677.00

Partners to the Project

The consortium for the Chronic Care Education Outreach Program consists of White River Rural Health Center, Inc., the lead applicant; Woodruff County Nursing Home; Des Arc Nursing and Rehabilitation Center; Baptist Health; and Arkansas Department of Health Diabetes Control Center.

Areas Served

Woodruff and Prairie counties in the Arkansas Delta region.

Target Population Served

Expand an existing chronic illness self-management education program to focus on the elderly

Program Director

Steven F. Collier

White River Rural Health Center, Inc.

P.O. Box 497

Augusta, Arkansas 72006-0497

Phone: (870) 347-2534

Fax: (870) 347-2882

White River Rural Health Center, Inc.

Augusta, AR 72006-0497

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

The consortium for the Chronic Care Education Outreach Program will expand an existing chronic illness self-management education program to focus on the elderly in Woodruff and Prairie counties in the Arkansas Delta region. The program will enhance the capacity of existing community agencies to respond to the needs of the increasing population with diabetes and other chronic illnesses. Collaboration between community partners will result in organized assessments, planning, and coordination of local resource agencies to cultivate a regional comprehensive continuum of care for people with chronic diseases. The program will use self-management interventions to reduce health disparities and increase access to recommended health care services for people living with diabetes and other chronic illnesses. It also will incorporate a chronic care model used by the Bureau of Primary Health Care and will provide services at long-term care facilities to enhance access by the elderly population. All activities will be coordinated with primary care services currently provided in the area. The program will focus on increased access to prevention, early detection, and treatment of diabetes and cardiovascular diseases through the provision of a comprehensive self-management education class on these chronic illnesses.

Woodruff and Prairie counties, the target counties, have a combined population of 18,280. Seventeen percent of the population is older than 65 years. The Arkansas Department of Health reports that diabetes prevalence increases by age to an estimated 14.6 percent for those older than 65 and estimates that more than 450 residents older than 65 currently have diabetes. In addition, the rates of diabetes, cardiovascular disease, and heart disease are higher in the target counties than in other counties in the state. Residents of Woodruff and Prairie counties live below 200 percent of the Federal poverty level, and the two counties are officially designated as Health Professional Shortage Areas and Medically Underserved Areas. Barriers to access of health services include a 45-minute drive to any kind of specialty care, and much of the population remains undiagnosed for diabetes or cardiovascular disease.

Topic Areas

Chronic Disease

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 181,944.00

· Year 3 - 115,297.00

Partners to the Project

The ministerial alliance, the school districts and Ozark health Foundation.

Areas Served

Ozark Mountain Health Network (OMHN) serves the residents of

Van Buren and Searcy counties.

Target Population Served

Community health center, rural health clinics, federally qualified health center, nursing shortage area, state, and local health departments.

Project Summary

The project focuses on primary care and wellness and disease

Program Director

Darrell Moore

Ozark Health Foundation

P.O. Box 74

2500 Highway 65 South

Clinton, AR

Phone: (501) 745-7004, ext. 107

Fax: (501) 745-4203

E-mail:

darrell.moore@myozarkhealth.com

Ozark Mountain Health Network

Clinton, AR 72031

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eileen.holloran@hrsa.hhs.gov

prevention strategies. OMHN (or any of their partners or any organization in the service area) has not received a rural health network outreach mant. We have received the rural health network planning grant in 2003 and the network development grant in 2005.

The current service providers in this area include Ozark Health, Inc.; Boston Mountain Rural Health Center, Inc.; DHHS/DOH/Van Buren County local health unit; DHHS/DOW/Searcy County local health unit; Health Resources of Arkansas, Inc.; Ozark Health Foundation; Baptist Health, Inc.; and seven primary care physicians. All (there are no health care providers in the area who are not involved) of the current service providers in this two county area are involved in OMHN. These providers’ missions are consistent with the mission of OMHN, and each of the providers will be positively affected by goals and activities of the outreach program.

Topic Areas

Substance Abuse, Prevention Education

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Adolescent Drug Abuse Prevention and Treatment Project (ADAPT)

Areas Served

Mendocino County, which is designated as a Medically Underserved Population.

Target Population Served

Program goals are to reduce high-risk behavior for alcohol and other drug use among youth; to increase refusal skills and knowledge of harmful effects of substance abuse among youth; and to increase prevention knowledge and awareness among parents.

Project Summary

The Mendocino County Health Department and its partners developed the Adolescent Drug Abuse Prevention and Treatment Project (ADAPT) in response to the need for substance abuse prevention and treatment services for rural youth in northern California. ADAPT will team a substance abuse therapist ADAPT

Program Director

Patricia Guntly

Mendocino County Health Department

1120 South Dora Street

Ukiah, California 95482-6340

Phone: (707) 472-2637

Fax: (707) 472-2658

Email: guntlyp@co.mendocino.ca.us

Mendocino County Health Department

Ukiah, CA 95482-6340

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

will team a substance abuse therapist with an intervention specialist to increase youth resiliency—while reducing the incidence and harmful effects of substance abuse—through prevention, intervention, and treatment. The three primary components of the program are substance abuse treatment; prevention education and opportunities for personal growth and development through service learning, project-based modules, and outdoor adventure; and family strengthening services. Program goals are to reduce high-risk behavior for alcohol and other drug use among youth; to increase refusal skills and knowledge of harmful effects of substance abuse among youth; and to increase prevention knowledge and awareness among parents. Services will be provided at schools, community-based organizations, and county Alcohol and Other Drug Programs (AODP) offices.

Widespread production, use, and abuse of alcohol and other drugs as well as economic impoverishment exist in Mendocino County, which is designated as a Medically Underserved Population. Summary results for the California Healthy Kids Survey show a high level of youth experimentation and involvement with alcohol and other drugs. However, substance abuse treatment services for youth are extremely limited throughout the county, especially in the targeted communities of Willits (population 13,500) and Potter Valley (population 1,900). In Potter Valley, substance abuse treatment is not available in any form; the AODP office in Willits offers limited treatment to youth in alternative school or criminal justice settings, but no treatment to youth in mainstream settings. In addition, residents in both Potter Valley and Willits must travel 25 miles to Ukiah for specialized services, and transportation is very limited. ADAPT will provide services to youth age 13 through 18.

In addition to the lead applicant, the Mendocino County Health Department’s Division of Alcohol and Other Drug Programs, ADAPT consortium partners include Howard Memorial Hospital, Nuestra Alianza, Potter Valley Community Center, Potter Valley Community Health Center, Potter Valley Community Unified School District, Sherwood Valley Rancheria, Willits Action Group, and Willits Unified School District.

Topic Areas

Mobile clinic, Telehealth technology, Primary care services, Specialist consultation

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Tulare Local Healthcare District (Tulare District Hospital, TDH) is the lead agency of a consortium composed of Tulare Community Health Clinic (a Federally Qualified Health Center), public health nurses from Tulare County Office of Education’s Migrant Education Program, Tulare County Asthma Coalition, Alta Vista School District, Pixley Union School District, and Love In the Name of Christ (a 501(C)(3) non-profit community based organization).

Areas Served

Alta Vista and Pixley in Tulare County, which is located in the Central Valley of California.

Target Population Served

The purpose of the Mobile Clinic/Telehealth Outreach Project is to provide primary health care services and specialist consults, including dental services, to underserved residents in rural Tulare County

Program Director

meade hallock

Tulare Local Healthcare District

869 N. Cherry Street

Tulare, CA 93274

Phone: (559) 685-3414

Fax: (559) 685-3835

E-mail: mhallock@tdhs.org

Tulare Local Healthcare District

Tulare, CA 93274

ORHP Contact:

Sherilyn Pruitt

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-0819

spruitt@hrsa.gov

Project Summary

These partners formed this consortium to address the lack of basic healthcare available in the rural, impoverished areas of Alta Vista and Pixley in Tulare County, which is located in the Central Valley of California. The purpose of the Mobile Clinic/Telehealth Outreach Project is to provide primary health care services and specialist consults, including dental services, to underserved residents in rural Tulare County. TDH will visit each site once a week, on a set schedule, bringing health care directly to the community in a Mobile Health Clinic. Telehealth Monitors placed at each school site will provide live access to the nurse practitioner on the Mobile Clinic, Monday through Friday.

The low income population of these areas is designated a Medically Underserved Population, as well as a Medically Underserved Community. In addition, the target areas are designated as primary care Health Professional Shortage Areas. (Alta Vista is in an unincorporated region east of Porterville, MSSA 231/232.)

The focus of the Mobile Clinic/Telehealth project will be primary care, women’s health (with an emphasis on OB care), pediatrics, asthma, diabetes, and hypertension. Specialist consults and dental care will be provided at Tulare Community Health Clinic. Public health nurses from Tulare County Office of Education’s Migrant Education Program will work closely with the Mobile Health Clinic to provide these communities with access to health care.

Tulare County has the highest rate of diabetes in the State, and the second highest rate of teenage pregnancy. Central Valley has the highest rate of childhood asthma in California. The target population is Hispanic agricultural workers and their families. The Census Bureau reports that Tulare County has the fifth highest percentage of poverty and the third-highest percentage of people with less than a high school diploma in the nation. Statewide, census statistics reveal that Tulare County has the highest percentage of poverty, unemployment, and lack of education in California. Nearly two-thirds of the population under age 18 in Tulare County live below 200 percent of poverty—the highest rate in the State. Tulare County is the leading agricultural producer in the Nation, yet the Hispanic agricultural workers who harvest these crops live in extreme poverty and suffer from poor housing conditions, malnutrition, and lack of medical care. School officials in the areas targeted by this grant confirm that over 80 percent of students are Hispanic, and 93-100 percent of students at each school qualify for the Federal Free or Reduced Lunch Program.

The Mobile Clinic/Telehealth project will provide primary and preventative medical care for these impoverished communities by taking services directly to the community. By placing permanent telehealth monitors at each site, individuals without transportation can walk to the school sites and receive medical treatment and consultation Monday through Friday. Tulare Community Health Clinic will provide specialist consultations and dental care by referral. Love INC is already well established in all targeted areas, delivering food and basic necessities to the communities through a network of local churches.

Topic Areas

Health insurance enrollment, Primary care, Dental care, Case management

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Lindsay and Woodlake school district Healthy Start and Family Resource Centers and the Children’s Health Initiative coalition through First 5 Tulare County are partnering with the Children’s Hospital Los Angeles’ e-Dental Health.

Areas Served

Lindsay and Woodlake within the central California county of Tulare.

Target Population Served

To provide a comprehensive continuum of health care service for uninsured children.

Project Summary

The Rural Health Services Outreach Grant for Tulare County’s Children’s Health County’s Children’s Health Initiative specifically

Program Director

Janie Elson

Lindsay Unified School District

475 E. Honolulu

Lindsay, CA 93247

Phone: (559) 562-5974

E-mail: jcelson@lindsay.kl2.ca.us

Lindsay Unified School District

Lindsay, CA 93247

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

focuses on increasing medical and dental access in two, majority-Latino, low-income, rural farm communities of Lindsay and Woodlake within the central California county of Tulare. Lindsay and Woodlake school district Healthy Start and Family Resource Centers and the Children’s Health Initiative coalition through First 5 Tulare County are partnering with the Children’s Hospital Los Angeles’ e-Dental Health program to provide a comprehensive continuum of health care service for uninsured children.

The Tulare County Children’s Health Initiative (CHI) is focused on increasing dental and medical health access for children ages 0-18 through outreach and enrollment into publicly funded programs and by offering a new gap insurance product, Healthy Kids, for children ineligible for state Medicaid (known as Medi-Cal) or the State Children’s Health Insurance Program (S-CHIP, known as Healthy Families in California). Healthy Kids is a new, local public/private partnership program with comprehensive medical, dental, and mental health benefits mirroring the state Healthy Families program. It is scheduled to launch in January 2006. Healthy Kids will be for children in families with incomes up to 300 percent of the Federal Poverty Level, regardless of immigration status, and is modeled afer similar successful programs in other California counties.

The project begins with health insurance enrollment at local sites for children in Lindsay and Woodlake into current public programs Medi-Cal and Healthy Families, if eligible, or Healthy Kids—all in one application and one appointment for all children. An e-Dental Health network at school sites that connects the rural communities of Woodlake and Lindsay with a newly created e-Health Center at Children’s Hospital Los Angeles will utilize telecommunications technology to provide dental consultation and treatment or treatment referral. Participation in the e-Dental program requires some sort of insurance coverage. It is estimated that 30 percent of the two towns’ children are ineligible for public programs. These children will qualify for the new Healthy Kids program. Referral appointments from the school e-Dental site to local dentists will be tracked by local case managers, along with quarterly follow-up with families of children enrolled into Healthy Kids in order to provide health care utilization assistance.

Project funds will provide a.5 FTE Certified Application Assistor/case manager each in Woodlake and Lindsay and Healthy Kids insurance premium costs for 55 children ages 6-18, which will allow services identified by the e-Dental and other health providers to be accessed. First 5 Tulare County will subsidize Healthy Kids premium costs for children ages 0-5.

Topic Areas

Satellite clinic, Bilingual specialty services, Telemedicine technology, Substance abuse treatment

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,120.00

· Year 2 - 124,238.00

· Year 3 - 94,942.00

Partners to the Project

Areas Served

City of Avalon

Target Population Served

Services will especially benefit the medically fragile and low-income island residents.

Project Summary

Located on Santa Catalina Island, 26 miles off the coast of Long Beach, California, Catalina Island Medical Center (CIMC) provides 24-hour emergency room services, acute care, skilled nursing care, rehabilitation services, and primary care services to residents and visitors of Santa Catalina Island. There are 3,127 year-round

Program Director

Dawn Sampson

Avalon Medical Development Corporation

Catalina Island Medical Center

100 Falls Canyon Road

P.O. Box 1563

Avalon, CA 90704

Phone: (310) 510-0520

Fax: (310) 510-2381

Avalon Medical Development Corporation

Avalon, CA 90704

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

residents of the City of Avalon, the island’s only incorporated city. Forty six percent of the island population is Hispanic. Its physical beauty and rustic charm make Catalina an attractive tourist destination, drawing 1,000,000 annual visitors to the island.

While the picturesque Avalon may appear to be an idyllic small town, the City struggles with many of the same problems as much larger cities, and has added barriers to accessing services due to the island’s physical isolation from the mainland. Catalina Island is designated a Health Professional Shortage Area. Like most rural facilities, CIMC requires local financial support to keep the doors open. The current needs to be addressed with this project are as follows:

· The rugged West End of Catalina Island has never had local primary medical care services available to its 493 year-round residents, 1,648 summer residents, and hundreds of boaters and divers. To reach CIMC, located in the main city of Avalon for primary care, residents of the West End must travel the 23 mile, 1.25-hour trip over mountainous terrain and partially paved roads. To reach a mainland facility they must travel at least 1 hour by boat, then find ground transportation. The only transportation service between the West End and Avalon costs $46 per round trip, and only one trip per day is available. Ownership of private vehicles is limited by high barge costs to the island, high cost of required liability insurance, and high gasoline costs (currently $4.71 per gallon).

· There is a lack of specialty services on all parts of the island. In the main city of Avalon, CIMC ’s medical providers refer patients in need of specialty care to the mainland, but compliance with these referrals is poor due to financial, logistic, and frequently language barriers, particularly for the low-income population. Especially needy are those patients who require psychiatric services and diabetic patients requiring ophthalmology services.

· Drug and alcohol dependencies are a large problem in our community, but there are no local chemical-dependency treatment programs.

A consortium consisting of Catalina Island Medical Center, Loma Linda University Medical Center, and the USC Catalina Island Hyperbaric Chamber, with the help of the Santa Catalina Island Company and Two Harbors Enterprises, will utilize creative outreach models to bring primary care services through a satellite clinic to the remote island community of Two Harbors. The consortium will also bring bilingual specialty services to the island city of Avalon using telemedicine technology. Services will especially benefit the medically fragile and low-income island residents. In addition, a program feasibility study on development of a chemical dependency treatment program will help the island’s sole community health care provider/Critical Access Hospital to tailor strategic program planning to the unique needs of the island population while striving to develop a positive operating margin to guarantee continuing operations.

Topic Areas

Oral Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The program was initiated by a group of community organizations including Day Kimball Hospital, the Northeast District Department of Health, GFHC, the local council of governments, the transit district, and a local pediatric dentist.

Areas Served

Rural Windham.

Target Population Served

Preschool/school-aged children and young pregnant women.

Project Summary

The Save Smiles Oral Health Project reduces oral health disparities for low-income preschool and school-aged children and young pregnant women in rural Windham, which is located in the poorest

Program Director

Dr. Margaret Ann Smith, DMD

Generations Familv Health Center. Inc.

1315 Main Street - Suite 2

Willimantic, CT 06226-1953

Phone: (860) 450-7456, ext. 132

Fax: (860) 450-7475

E-mail: margaret.ann.smith@penemco.com

Generations Familv Health Center. Inc.

Willimantic, CT 06226-1953

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

county in Connecticut. Windham’s population is 55% Hispanic; 45% of the Hispanic population is uninsured. Thirty-one percent of Windham children live in poverty; 50% are on Medicaid, and 31% speak a language other than English at home. Windham has the highest rate of homelessness in Connecticut and a population that includes many recent immigrants, who are migrant workers. High rates of drug use and teen pregnancy compound the problems of endemic poverty in Windham.

Children and low-income young pregnant women have high rates of gross dental decay and few options for oral health care. Apart from GFHC’s dental clinic, which has a long waiting list, there is only one dentist in Windham who accepts Medicaid reimbursement. There are no pediatric or dental specialists in the area who accept Medicaid. Since 1994, Windham has been a designated dental shortage area.

The project’s goals are based on a comprehensive community planning process and needs assessment that began in early 2006. Participants in the planning process represented the majority of our target population. Project goals focus on providing access to oral health services in community settings, providing preventive services, including age-appropriate oral health instruction, and implementing a community education and advocacy campaign to increase the community’s dental IQ and lessen oral health disparities locally and statewide. Save Smiles’ goals are designed to:

· increase awareness about and access to oral health care for the target

· population;

· provide preventive services that will lessen the target population’s need for

· emergency and restorative oral health services;

· create a replicable, cost-effective project;

· build Windham’s cultural competence;

· increase community and legislative support for oral health care for all; and

· increase the oral health status of the community.

Topic Areas

Prenatal Services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

LRHC will collaborate with two private obstetricians, two hospitals, and other state and community agencies and programs to build a countywide network.

Areas Served

Sussex County, Delaware

Target Population Served

The target population includes underserved and vulnerable pregnant women.

Project Summary

La Red Health Center (LRHC) will expand an existing program to offer prenatal and labor/delivery services to underserved and vulnerable pregnant women in Sussex County, Delaware. LRHC will develop a formal promotoras program, utilizing an indigenous case

Program Director

Brian Olson

La Red Health Center

505-A West Market Street

Georgetown, Delaware 19947-2321

Phone: (302) 855-1233

Fax: (302) 855-1020

La Red Health Center

Georgetown, Delaware 19947-2321

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

management model developed to facilitate access to medical care in underserved communities. The goals of this project are (1) to improve perinatal health outcomes and reduce disparities as a result of expanded access to care and education for low-income, at-risk women and (2) to develop a comprehensive countywide promotoras program to provide outreach, community health education, case management, and other services to encourage early entry to prenatal care, concordance with medical advice, and subsequent medical care for infants and children.

The program will serve rural Sussex County, which is the largest county in Delaware in terms of land mass and has a population of 156,638. The entire county is federally designated as a Medically Underserved Area, a low-income Health Professional Shortage Area (HPSA), and a dental HPSA. The lack of access to prenatal care for both uninsured and Medicaid-enrolled women has created a crisis in the county. No private obstetricians in western Sussex County accept patients with Medicaid into their practice, other obstetricians in the county limit the number of patients with Medicaid they will treat, and uninsured patients cannot pay the required fees for prenatal care. Most uninsured women served by an existing LRHC program did not seek early prenatal care. This trend, combined with limited provider availability, compounds the problem of early access to care. Thus, there is a tremendous need for LRHC’s prenatal services.

To address the demand for prenatal services, LRHC will partner with two private obstetricians, two hospitals, and other state and community agencies and programs to build a countywide network. Existing capacity for the prenatal program will be doubled and complemented by an aggressive campaign of community education urging early entry to care.

Topic Areas

Primary care, Mental health services, Substance abuse treatment, Dental care

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Guidance Clinic of the Middle Keys has collaborated with Rural Health Network of Monroe County, FL, Inc., in the limited provision of its services to the homeless.

Areas Served

Provided mental health and substance abuse services for the people of Monroe County.

Target Population Served

Comprehensive health care program targeted to the uninsured and homeless.

Program Director

Dan Smith

Rural Health Network of Monroe Co., FL, Inc.

P.O. Box 4966

Key West, FL 33041

E-mail: dsmith@rhnmc.org

Rural Health Network of Monroe Co., FL, Inc.

Key West, FL 33041

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

The Rural Health Network of Monroe County, FL, Inc. (RHNMC) was created in 1993 in response to the enactment of Florida Statute 381.0406. This Act mandates the formation of health networks throughout the State in certified rural areas for the purpose of providing “... a continuum of quality health care services for rural residents through (local) cooperative efforts...”. In May 2000, through support received from a HRSA Office of Rural Health Policy Outreach grant, RHNMC secured funding to initiate a primary care program, through the use of a single medical mobile van. Since that time, this organization has expanded its services to include yet another mobile medical van, two “fixed site clinics, and a dental clinic, thereby extending services in the Florida Keys over a 120-mile linear island chain.

This project is designed to build upon previous accomplishments established by this network organization through its local partners, and through funding granted by HRSA to create a meaningful, sustainable and lasting provision of comprehensive primary care. In responding to the Florida Statute-mandate to ensure a continuum of care, RHNMC has entered into local communities with an intent of not duplicating services, creating service access where those service may be lacking, and more importantly, to work within and without a network framework to improve health care services where possible. RHNMC seeks to partner with a local for-profit hospital network member and with the largest substance abuse and mental health facility in this county to offer outpatient primary care, outpatient mental health and substance abuse services, and access to dental care for uninsured residents of the Lower Florida Keys—10 hours a day, 7 days a week.

For almost 30 years, the Guidance Clinic of the Middle Keys (GC 1K) has provided mental health and substance abuse services for the people of Monroe County. As a recent (ORHP) outreach grantee (May 2003 - April 2006), GCMK has partnered with RHNMC in the limited provision of its services to the homeless. The Lower FL Keys Health (Hospital) Center (LFKHC; a founding RHNMC member) has voiced its desire to merge the resources of RHNMC, GCMK, and itself to create a seamless and comprehensive health care program targeted to the uninsured and homeless. This project is the first merger of its kind in county history, bringing together a for-profit hospital/primary care service, not-for-profit mental health and substance abuse care and not-for-profit primary and dental care.

Topic Areas

Oral health care

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include Floyd County Health Department, Coosa Valley Technical College, Floyd College Health Sciences Division, Floyd Medical Center, Northwest Health District, and Rome/Floyd County Commission on Children and Youth.

Areas Served

The five counties are located in the foothills of the Appalachian Mountains.

Target Population Served

The regional dental clinic will offer a full range of pediatric and adult dental services, including outpatient dental care for young children with serious dental needs. The need for dental services among low-income families in the target area is tremendous.

Program Director

Patricia Townley

Floyd County Board of Health

315 West 10th Street

Rome, Georgia 30165-2638

Phone: (706) 802-5444

Fax: (706) 802-5445

Floyd County Board of Health

Rome, GA 30165-2638

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The new Floyd County Dental Clinic will operate as a regional clinic, serving residents of a five-county area in rural northwest Georgia. The goal of the clinic is to increase access to oral health care for residents in the region. The regional dental clinic will offer a full range of pediatric and adult dental services, including outpatient dental care for young children with serious dental needs. The clinic will accept adult and pediatric emergencies and will have an oral surgery program as well. Opening the clinic will provide many residents in the region access to high-quality dental services that are currently unavailable to them. The need for dental services among low-income families in the target area is tremendous. Only four dentists accept Medicaid, and acceptance is sporadic. Low-income families with dental insurance cannot find a provider who will take them as patients. A mobile dental clinic provides limited services to only a fraction of the residents in need of dental care, and clients in need of follow-up care have no local options.

The five counties are located in the foothills of the Appalachian Mountains. The total population of the five-county area is 260,591. According to 2000 Census data, 88 percent of the population is white, 8 percent is African American, and 4 percent is Hispanic. The Hispanic population in the area has grown significantly in the past 10 years, because of employment opportunities. However, their jobs are often minimum wage with no health insurance benefits.

Access to oral health care is problematic for many residents in the target area, especially for those with low income or who lack insurance. The five county health departments have no public health dental facilities and only one mobile dental van. Four counties in the target area are designated as Medically Underserved Areas or Medically Underserved Populations. One of the counties is designated as a Dental Health Professional Shortage Area.

Topic Areas

Health Education

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 198,810.00

· Year 2 - 198,092.00

· Year 3 - 198,896.00

Partners to the Project

The East Central Georgia Regional Teen Wellness Coalition comprises eight county community collaboratives—Glascock Action Partners, Jenkins County Family Enrichment Commission, Lincoln County Family Connection, McDuffie County Partners for Success, Screven County Community Collaborative, Taliaferro County Family Connection, Warren County Family Connection, and Wilkes County Community Partnership (all of which have included and supported school health programs in their strategic plans—as well as Medical College of Georgia, University of Georgia (College of Family and Consumer Science), and the East Central Public Health District.

Areas Served

The rural underserved service area includes eight counties: Glascock, Jenkins, Lincoln, McDuffie, Screven, Taliaferro, Warren, and Wilkes.

Target Population Served

The proposed East Central Georgia Regional Teen Wellness Initiative will increase awareness and access to health promotion services by providing ongoing leadership training regarding healthy lifestyles for local youth; encouraging these youth to take a leadership role in planning, implementing, and monitoring local health promotion/education projects; and supporting these you as they plan and coordinate an ongoing local health lifestyles education outreach campaign for youth in the proposed service area.

Program Director

Mary Ann Kotras

East Central Georgia Regional Teen Wellness Coalition

Lincoln County Commission

P.O. Box 68

Lincolnton, Georgia 30824-0068

Phone: (706) 595-3112

Fax: (706) 595-3113

East Central Georgia Regional Teen Wellness Coalition

Lincolnton, GA 30824-0068

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

Experts agree that decisions youth make regarding lifestyle and personal behavior in adolescence have tremendous future consequences. These consequences include, but are not limited to, lifelong substance abuse (e.g., tobacco, alcohol, other drugs); teen parenthood and subsequent low educational attainment and low socioeconomic status; and/or eventual chronic disease (e.g., cardiovascular disease, stroke, diabetes, cancer). The proposed East Central Georgia Regional Teen Wellness Initiative will increase awareness and access to health promotion services by providing ongoing leadership training regarding healthy lifestyles for local youth; encouraging these youth to take a leadership role in planning, implementing, and monitoring local health promotion/education projects; and supporting these you as

they plan and coordinate an ongoing local health lifestyles education outreach campaign for youth in the proposed service area.

The rural underserved service area includes eight counties: Glascock, Jenkins, Lincoln, McDuffie, Screven, Taliaferro, Warren, and Wilkes. The proposed population is 7,452 youth (age 10 to 18). The region displays demographic characteristics similar to many poor rural areas, including high percentage of minority residents, isolation, poverty, negative health indicators, lack of educational attainment, and a struggling rural economy. According to the 2000 census, the region is home to 75,184 individuals: 59 percent white, 40 percent African American, and 1 percent other. More than one out of every four children (age 0 to 17 years) in the region is currently living below the poverty level. Much of this poverty is a result of adolescent childbearing. Nearly one-fifth (18.4 percent) of the total births to region residents were to unwed teen females, and more than one out of every two (56.0 percent were to unwed mothers (regardless of age). More than one out of every three female-headed households with children under age 18 in the region are currently living below the poverty level.

An estimated 6,920 county residents are in need of alcohol treatment services, and 2,977 are in need of drug treatment. State mental health officials estimate that only 20 percent of those who need treatment services will actually demand or want the assistance. Many of these adults are raising young children and making their children victims of the downward negative spiral of intergenerational addiction and its consequences.

In 2002, 60 percent of all deaths in the region were due to heart disease, stroke, diabetes, and cancer. Death and disability from these diseases are related to a number of modifiable risk factors, including high blood pressure, high blood cholesterol, diabetes, having a sedentary lifestyle, being overweight, and smoking.

Topic Areas

Dental clinic services, preventative dental care

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 169,004.00

· Year 2 - 160,198.00

· Year 3 - 161,620.00

Partners to the Project

The South Georgia Regional Dental Outreach Initiative comprises the Turner County Board of Education, the lead applicant; Public Health District 8-1; area volunteer dentists; and five community collaboratives—Fitzgerald-Ben Hill Policy Council for Children and Families, Irwin County Family Connection, Turner County Connection, Wilcox County Family Connection, and Worth County Family Connection.

Areas Served

The service area is a five-county underserved area in rural southern Georgia with a population of 67,463 individuals.

Target Population Served

The initiative will provide (1) dental services for at least 1,500 individuals; (2) dental health preventive education for more than 15,000 individuals annually though onsite services provided in school systems, pre-kindergarten programs, Head Start, daycare centers, nursing homes, health department clinics, employee screenings at local businesses, and community health fairs and other community sites; and (3) an area dental services referral network for individuals with no other dental care options.

Program Director

Brenda Lee

Turner County Board of Education

213 North Cleveland Street

Ashburn, GA 31714-0609

Phone: (229) 567-9066

Fax: (229) 567-2877

Turner County Board of Education

Ashburn, GA 31714-0609

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The goals of the South Georgia Regional Dental Outreach Initiative are to increase the number of individuals who receive preventive dental screening, the number of individuals who have access to dental clinic services, and residents’ awareness of the importance of dental hygiene and preventive dental care. To accomplish these goals, the initiative will provide (1) dental services for at least 1,500 individuals; (2) dental health preventive education for more than 15,000 individuals annually though onsite services provided in school systems, pre-kindergarten programs, Head Start, daycare centers, nursing homes, health department clinics, employee screenings at local businesses, and community health fairs and other community sites; and (3) an area dental services referral network for individuals with no other dental care options.

The service area is a five-county underserved area in rural southern Georgia with a population of 67,463 individuals. Demographic characteristics of the region include a high percentage of minority residents, isolation, poverty, negative health indicators, lack of educational attainment, and a struggling rural economy. The racial/ethnic composition is 67 percent white, 32 percent African American, and 1 percent other. Employment prospects for local residents are limited due to lack of funding. Attempts at supporting health and dental health promotion have been inadequate. There is a shortage of dentists in the area, and at-risk residents without private dental insurance must go without preventive dental care and have to ignore dental problems because of inadequate financial resources. All five counties in the region are Medically Underserved Areas, and three are designated as Dental Health Professional Shortage Areas.

Topic Areas

Perinatal health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 148,994.00

· Year 2 - 124,908.00

· Year 3 - 100,000.00

Partners to the Project

Wayne Memorial Hospital, Evans Memorial Hospital, Candler County Health Department, Tattnall County Health Department and Wayne County Health Department.

Areas Served

Two of the counties, Candler and Tattnall, do not have birthing hospitals, and women must travel long distances to hospitals in Wayne and Evans counties for delivery. All four targeted counties are Federally designated Medically Underserved Areas.

Target Population Served

Perinatal health program to improve health outcomes for women, infants and children.

Program Director

Janice Massey

Evans County Health Department
P.O. Box 366

4 North Newton Street
Claxton, GA 30417
Phone: (912) 739-2088

E-mail: jamassey@gdph.state.ga.us

Evans County Health Department

Claxton, GA 30417

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

Evans County Health Department, along with its network partners, seeks to implement Best Babies, a perinatal health program to improve health outcomes for women, infants and children in Candler, Evans, Tattnall, and Wayne Counties in southeast Georgia. Best Babies will offer a comprehensive, integrated approach to perinatal care for women in these counties who are at high risk for adverse birth outcomes including maternal or infant mortality, low birth weight, very low birth weight, or other medical or developmental problems. The coordinated system of care will include identification of women who are at high-risk for poor birth outcomes, intensive case management, and home visits by registered nurses.

Network partners include the lead agency, Wayne Memorial Hospital, Evans Memorial Hospital, Candler County Health Department, Tattnall County Health Department and Wayne County Health Department. Two nurses will be hired to provide services to program participants under the direction of a project director.

The four targeted counties have high rates of poverty, ranging from 27 percent of the population of Evans County to 16.7 percent in Wayne County . The statewide rate of Georgians living in poverty is 12.3 percent. The population of the target area is 66 percent Caucasian, 28 percent Black, and 6 percent Hispanic. Evans, Candler, and Tattnall counties have seen tremendous growth in their Hispanic populations over the past 10 years.

Infant mortality rates (IMR) and neonatal mortality rates (NMR) are higher than those for Georgia and substantially higher than Healthy People 2010 objectives. IMR and NMR rates for Blacks are significantly higher than for Caucasians or Hispanics. Two of the counties, Candler and Tattnall, do not have birthing hospitals, and women must travel long distances to hospitals in Wayne and Evans counties for delivery. All four targeted counties are Federally designated Medically Underserved Areas. Best Babies is modeled after the highly successful Perinatal Health Partners Program, which provides perinatal services to residents of 10 counties in southeast Georgia.

Topic Areas

Physical activity/fitness, Obesity/overweight

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,969.00

· Year 2 - 124,342.00

· Year 3 - 99,968.00

Partners to the Project

Areas Served

Washington County, like many rural areas, has a significant number of overweight and obese children and youth who generally do not seek medical services to address the causes, resultant medical problems, or possible remedies.

Target Population Served

With increased numbers of chronic illnesses, health crises, and general poor health, the implications of this large number of overweight and obese children (and adults) impact all health care systems.

Project Summary

From 1991 to 1998, Georgia reported the greatest rate of increase in

Program Director

Susan Francis

Hospital Authority of Washington County, Inc.

Washington County Regional Medical Center

610 Sparta Road

P.O. Box 636

Sandersville, GA 31082

Phone: (478) 552-3024

Fax: (478) 240-2390

E-mail:

sfrancis@wcrmc.com

Hospital Authority of Washington County, Inc.

Sandersville, GA 31082

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

prevalence of adult obesity (101.8 percent) in the United States. A recent study by the University of Georgia and the Georgia Prevention Institute at the Medical College of Georgia found that Georgia children are more likely to be overweight than previously thought, with approximately 37 percent considered too heavy. With increased numbers of chronic illnesses, health crises, and general poor health, the implications of this large number of overweight and obese children (and adults) impact all health care systems. Washington County, like many rural areas, has a significant number of overweight and obese children and youth who generally do not seek medical services to address the causes, resultant medical problems, or possible remedies. Most commonly, they are uninsured, poor, poorly educated, often isolated, and lack family support in addressing overweight/obesity.

Children are usually at the mercy of parents/caregivers in the matter of food selection, purchase, and preparation. Poor nutrition is compounded by lack of access to a comprehensive fitness program or facility because of limited or non-existent transportation. Rural children are particularly at risk as a result of multiple barriers, many of which are remediable.

The Washington County Community Wellness Consortium, a collaborative of agencies and health providers, has developed a small, multidisciplinary weight loss and fitness model program, the cornerstone of which is martial art taekwondo. This model program began July 18, 2005, with a small grant from Georgia Southern University’s Intellectual Capital Partnership Program (ICAPP). This program is already showing positive results in participants. Approximately 50 percent of the children are obese or overweight. Parents and children are enrolled. For the proposed project, additional children will be recruited from schools, health providers, the recreation department, and churches for an after-school and summer program. Transportation, not currently provided, will be provided for students.

Use of a martial arts program is a comprehensive approach to exercise and yields a wide array of benefits, such as increased self-esteem, a positive body image, goal setting, and reduced aggression. Children who participate in this proposed project will be assessed using several standard instruments. A physical exam by a pediatrician will be required. Individual fitness/wellness plans will be developed. Parents/primary caregivers and other adults will be recruited and encouraged to participate as well. The program will include 75 obese/overweight children, 25 parents/primary caregivers, and 50 non-overweight peers and/or adults. To avoid stereotyping obese children, enrollment will be open. All program participants will receive regular nutrition education and food preparation demonstrations provided by the Washington County Extension Service. Children will be required to attend 21 classes in an 8-week cycle (or three classes per week), leading to earning a series of belts. At specific intervals, children’s physical and psychosocial progress will be assessed. Interval successes and instructor feedback will motivate children and families to continue their individual plans.

Topic Areas

Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

The goals of the project will be to reduce the number of hospitalizations resulting from diabetes or diabetic complications in Irwin and Ben Hill counties by 10 percent, to increase healthy lifestyle behaviors among middle school children, and to reduce the incidence of type 2 diabetes in these two counties through awareness of prevention strategies.

Target Population Served

The target population will include individuals who have been diagnosed with type 2 diabetes, with an emphasis on those who do not have insurance and/or who live in poverty; middle school children who need to develop healthy lifestyle behaviors that will lower their risk of becoming diabetic; and the general public.

Program Director

Bridget Walters

Irwin County Board of Health

Georgia Department of Human Resources

407 W. Fourth Street

Ocilla, GA 31774

Phone: (229) 468-5003

E-mail: bmwalters@gdph.state.ga.us

Irwin County Board of Health

Ocilla, GA 31774

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

Project Summary

Diabetes is one of the nation’s most common chronic diseases and was the eighth leading cause of death in Georgia in 2001. Unfortunately, the 2000-2001 prevalence of diabetes in two rural southern Georgia counties—Ben Hill (13.2 percent) and Irwin (14.7 percent)—is more than twice that of Georgia (6.9 percent) and the United States (6.2 percent). According to a 2002 publication by the Georgia Hospital Association Research and Education Foundation, Ben Hill and Irwin Counties fall in the top 50 percent of counties in Georgia with the highest hospital admissions for uncontrolled diabetes. Considering this prevalence data, related health indicators—such as high rates of obesity and little physical activity, high poverty levels, and the racial makeup of the populations—it is clear that diabetes is a serious health issue for Ben Hill and Irwin Counties. Since these counties are medically underserved areas additional resources are critical to combat this chronic illness.

The Irwin County Board of Health, as the lead partner, proposes to work with the Ben Hill County Board of Health, Dorminy Medical Center, the Ben Hill County School System, Irwin County Hospital, the Irwin County School System, the South Central Primary Care Center, Irwin County Family Practice Associates (Dr. Howard McMahan), and the South Health District to address diabetes in these two counties. The target population will include individuals who have been diagnosed with type 2 diabetes, with an emphasis on those who do not have insurance and/or who live in poverty; middle school children who need to develop healthy lifestyle behaviors that will lower their risk of becoming diabetic; and the general public. Given the poor health status of many people in these counties, it will be important to provide education and prevention messages to the public at large in order to reduce the incidence of diabetes.

Grant funds will be used to hire a Nurse with a background in diabetes education as the Project Coordinator and a Secretary. The project also will contract with Dorminy Medical Center for 50 percent of a Registered Dietician. Services will include expanded educational classes for diabetics, including individual and group nutritional counseling, and community education programs for the public that will be offered to churches, senior citizen centers, the tech school, and others. The middle school component will focus on decreasing obesity, increasing physical activity, educating the students/parents about healthy lifestyles, and evaluating the school-based nutrition programs. During the first year, staff will be oriented, educational classes planned, local physicians educated about the project, community education approaches planned, and contact initiated with key school personnel. Program implementation will begin the last quarter of the first year. In the second year, a joint community health fair focused on chronic disease/diabetes will be held for the general public and a 10K Steps-A-Day program initiated in both communities.

Topic Areas

Diabetes

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 138,947.00

· Year 2 - 124,999.00

· Year 3 - 100,000.00

Partners to the Project

Southeast Georgia Communities Project, East Georgia Healthcare Center, Inc., and Meadows Wellness Center

Areas Served

Appling, Candler, Emanuel, Evans, Long, Tattnall and Toombs counties in rural Southeast Georgia.

Target Population Served

The target population includes Latino families with one or more members diagnosed with diabetes.

Project Summary

The goal of Latinos Reduciendo el Diabetes (LaRED) is to reduce morbidity and mortality related to diabetes among Latinos by providing culturally and linguistically appropriate non-medical case management, individualized health education, and access to clinical

Program Director

Andrea Hinojosa

Southeast Georgia Communities Project

300 S. State

St. Lyons, GA 30436

Phone: (912) 526-5451

Fax: (912) 526-0089

E-mail: ahinojosa38@aol.com

Southeast Georgia Communities Project

St. Lyons, GA 30436

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

services for diabetic program participants.

The mission of Southeast Georgia Communities Project is to promote all aspects of human dignity though self-empowerment of farmworkers and other low-income residents to become partners and contributors in problem-solving and decision-making in the communities in which they live and work. During 2005, over 2,000 clients received one or more of our services.

The target population includes Latino families with one or more members diagnosed with diabetes. Census 2000 reports significant expansion of the Latino population in southeast Georgia. Toombs COU& residents are now 8.9% Latino and candler County’s percentage of Latino residents is approaching 10%. During peak harvesting months, the number of Latinos in the region increases as migratory workers and their families arrive to pick the area’s crops, including Vidalia Onions and tobacco. The average income of farmworkers in $8,000 per year, placing them well below poverty and among the lowest paid workers in the nation. Latinos in southeast Georgia are predominantly Mexican and Mexican American from Mexico, Texas and Florida. However, the population is far from homogenous with immigrants from Guatemala, Honduras, Puerto Rico and Cuba.

LaRED will have two components. The first component targets Latino diabetics with non-medical case management and individualized education, using a home visiting model. The educational curricula and materials will be adapted from Diabetes Today, National Institutes of Health and the Cooperative Extension service. The second component will educate 335 adults and youth each year on diabetes risk factors and prevention strategies, including healthy diet and lifestyle.

Topic Areas

Pediatric Obesity

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 198,795.00

· Year 2 - 178,071.09

· Year 3 - 181,591.09

Partners to the Project

Healthy Families Active Youth partners include Terry Reilly Health Services as the lead agency, Southwest District Health Department, Treasure Valley Family YMCA, Homedale School District, and Caldwell School District. All partners have participated in a broad-based community coalition of more than 15 organizations that began in October 2003 to address childhood overweight.

Areas Served

Rural Canyon and Owyhee counties.

Target Population Served

The target population is low-income elementary school children and their families in two towns in rural Canyon and Owyhee counties.

Project Summary

Healthy Families Active Youth is a health promotion and fitness project that will target elementary school children and their parents in two towns in rural southwest Idaho to prevent and treat pediatric

Program Director

Ann M. Sandven

Terry Reilly Health Services

211 16th Avenue, North

P.O. Box 9

Nampa, Idaho 83653-0009

Phone: (208) 467-4431

Fax: (208) 467-7684

Terry Reilly Health Services

Nampa, ID 83653-0009

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

obesity. The goal of the project is to promote healthy weight and activity levels in rural children. Objectives include increasing the knowledge of healthy foods, increasing servings of fruit and vegetables, increasing the percentage of children who get at least 30 minutes of physical activity 5 days a week, stabilizing or decreasing the weight of overweight children participating in a weight management program, and promoting appropriate identification and treatment of childhood overweight by health care professionals.

The target population is low-income elementary school children and their families in two towns in rural Canyon and Owyhee counties. Nearly one in five residents in Canyon County is Hispanic, compared to one in four Owyhee County residents. Poverty rates for most of the target area are higher than state averages. The project will serve 1,400 children, at least 100 parents, and 25 health care professionals. Approximately 52 percent of participants will be Hispanics, 46 percent non-Hispanic whites, and 2 percent other ethnicities. The two counties are home to an estimated 25,319 migrant and seasonal farmworkers. An estimated 50 percent or more of migrant workers lack health insurance, compared to an estimated 18 percent of all persons in Idaho. Barriers to access of health services include poverty and lack of insurance. Language, cultural, and education barriers exacerbate health problems for which Hispanics, who make up the majority of migrant and seasonal farmworkers in the state, are at added risk. An estimated 28,000 people in the two counties lack insurance, with many more struggling with inadequate coverage. Both counties are designated as Health Professional Shortage Areas, and Owyhee County and the southern part of Canyon County are also designated as Medically Underserved Areas.

Topic Areas

Primary care, Social services, Elderly, Health promotion/disease prevention (general)

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The consortium for this project includes Gritman Medical Center/Adult Day Health, Pullman Regional Hospital, Whitman Hospital and Medical Center, the Council on Aging & Human Services/COAST Transportation, and Region II Area Agency on Aging.

Areas Served

In the rural areas of Eastern Washington in Whitman County and North Central Idaho in Latah County .

Target Population Served

To increase access to medical care and social services for seniors.

Project Summary

Program Director

Barbara Mohoney

Gritman Medical Center/Adult Day Health Program

700 S. Main

Moscow, ID 83843

Phone: (208) 883-6483

Fax: (208) 883-6489

E-mail: barbara.mahoney@gritman.org

Gritman Medical Center/Adult Day Health Program

Moscow, ID 83843

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

The primary goal of Project ACCESS (Accommodation, Collaboration for Community Education about Services for Seniors) is to increase access to medical care and social services for seniors in the rural areas of Eastern Washington in Whitman County and North Central Idaho in Latah County. The strategies proposed to increase access will enable seniors to live independently and increase the capacity of these rural communities to sustain conditions necessary for early intervention if a senior becomes at risk for problems that may impede her or his ability to living a physically and emotionally healthy life.

First, ACCESS will define and expand the senior community health services network in the rural areas. We will initiate the nationally recognized Gatekeeper program, which is a proactive network of community members trained to identify changes in behavior, routines, and other early warning signs that a senior may be at risk for a health/mental health related crisis. Given the independent nature of rural elders in Whitman and Latah Counties, at-risk seniors would remain invisible to service delivery systems without such a community-based program. Gatekeepers are trained to recognize changes and to contact a local agency on aging to engage the appropriate service delivery system. Grant funds will also initiate

care giver support groups in rural communities so that those who care for rural seniors have local access to support, respite care, information, and referrals.

Second, the grant will increase access to primary health care and related social services through an expanded volunteer corps of drivers from rural communities. Volunteer drivers will be recruited and trained by a transportation volunteer coordinator housed at the Council on Aging & Human Services/COAST in Whitman County. In addition, COAST Transportation will also work collaboratively with Latah County to identify and train volunteer drivers to respond to requests in Latah County.

Third, ACCESS will increase access to wellness and disease prevention information and referrals by developing and purchasing materials accessible to all community members and health and human service providers through medical offices, libraries, hospitals, and agencies on aging. Community education programs will also be presented, duplicated, and made available through similar venues. Local information and referrals will also be made accessible through the Washington and Idaho 2-1-1 telephone systems.

Topic Areas

Perinatal depression

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Coles County Mental Heath Center, the Human Resources’ Center of Edgar and Clark Counties, and Sarah Bush Lincoln Health Center, which comprise the organizations of RBHN, are joining forces with local health departments in Clark, Coles, and Edgar Counties to address the need for screening, assessment, and referral of women with symptoms of perinatal depression.

Target Population Served

Program Director

Linda Weiss

Executive Director

Coles County Mental Health Association, Inc.

1300 Charleston Avenue

Mattoon, IL 61938

Phone: (217) 345-1500

Fax: (217) 258-6136,

E-mail: lweiss@ccmhc.org

Coles County Mental Health Association, Inc.

Mattoon, IL 61938

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The Project for Perinatal and Postpartum Depression Detection (P2D2) is a collaborative effort of the partner organizations of the Regional Behavioral Health Network (RBHN) and local health departments in a three-county region of rural east central Illinois. All three counties are designated health professional shortage areas for both primary care and mental health. Coles County Mental Heath Center, the Human Resources’ Center of Edgar and Clark Counties, and Sarah Bush Lincoln Health Center, which comprise the organizations of RBHN, are joining forces with local health departments in Clark, Coles, and Edgar Counties to address the need for screening, assessment, and referral of women with symptoms of perinatal depression.

This project will increase community awareness about perinatal depression, improve access to mental health screenings for childbearing women, and provide assessments and linkages to appropriate treatment for women with symptoms of depression. Through collaboration with the local health departments and the WIC/Family Case Management programs, RBHN will initiate an integrated screening and assessment process directed at reaching women at the greatest risk of depression. Project partners will 1) provide community education about the symptoms of postpartum depression and how women can receive help; 2) improve the efficacy of the cross-disciplinary linkages between the mental health and primary care providers serving postpartum women; and 3) increase the number of postpartum women using behavioral health services.

Screening services will reach an estimated 1,250 women (350 in Year One, 400 in Year Two, and 500 in Year Three). Education and outreach activities will reach an estimated 500 persons each year. A key objective of the project is to strengthen the cross-disciplinary linkages between mental health and primary care services. The Women’s Mental Health Program of the University of Illinois at Chicago will provide training for project personnel and workshops for primary and mental health care providers on the issues of perinatal depression and options for treatment. A consultant will facilitate a process mapping of P2D2’s screening and assessment procedures to develop a common understanding of the process and work toward developing a uniform protocol that integrates the region’s resources for primary care and behavioral health treatment options available to women with perinatal depression. Partnering organizations will jointly host a regional conference to explore and improve the delivery of these treatment options in the targeted service area.

Topic Areas

Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 124,476.00

· Year 3 - 99,783.00

Partners to the Project

The project brings together a consortium of local organizations—Gibson General Hospital, the Gibson County Health Department, the Pike County Health Department, Tulip Tree Family Health Clinic, the Gibson County Council on Aging, the North Gibson School Corporation, and Brink’s Family Practice—along with the Indiana State Department of Health Diabetes Prevention and Control Program.

Areas Served

Indiana’s Gibson and Pike Counties.

Target Population Served

The project is designed to achieve diabetes awareness and prevention for citizens in the two counties and to provide education and support on self-management for many who have already developed the condition.

Project Summary

Lifestyles Diabetes Project will provide diabetes education and

Program Director

Sharon Goodman.

Gibson General Hospital

Rural Health Care Services Outreach Grant Program Gibson General Hospital

1808 Sherman Drive

Princeton, IN 47670

Phone: (812) 385-9462

Fax (812) 385-9415

E-mail: sgoodman@gibsongeneral.com

Outreach Grant Program Gibson General Hospital

Princeton, IN 47670

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

treatment services to the citizens of Indiana’s Gibson and Pike Counties. The project is designed to achieve diabetes awareness and prevention for citizens in the two counties and to provide education and support on self-management for many who have already developed the condition. The project brings together a consortium of local organizations—Gibson General Hospital, the Gibson County Health Department, the Pike County Health Department, Tulip Tree Family Health Clinic, the Gibson County Council on Aging, the North Gibson School Corporation, and Brink’s Family Practice—along with the Indiana State Department of Health Diabetes Prevention and Control Program.

Lifestyles Diabetes Project addresses a significant health need. According to the Centers for Disease Control and Prevention and the Indiana State Department of Health, diabetes is the sixth leading cause of death in the United States, the State of Indiana, and Gibson County. In the United States, the number of adults with diagnosed diabetes has increased 61 percent since 1991 and is expected to more than double
by 2050. According to the 2003 Indiana Behavioral Risk Factor Surveillance Systems, 7.8 percent of adults age 18 and older in Indiana have been diagnosed with diabetes.

Poor lifestyle choices and lack of awareness are root causes of the increased prevalence of diabetes and its resulting complications. Much of the burden related to diabetes, once developed, can be prevented or delayed with early detection, improved delivery of care, and better education on diabetes self-management. Moreover, better than managing diabetes is preventing its onset in the first place. Convenient access to knowledge, resources, and support—in a familiar setting—makes prevention and self-care more likely. The Lifestyles Diabetes Project aims to provide the people of Gibson and Pike Counties with this access to knowledge, resources, and support.

The Lifestyles Diabetes Project has two primary goals. First, it aims to reduce long- and short-term diabetes-related complications for as many residents as possible who have already developed diabetes. To reach this goal, the project will provide diabetes self-management education following recognized national standards at the project’s clinic and at key outreach locations. Second, we aim to promote awareness and prevention of diabetes to as many citizens as possible in the two-county area. To achieve this goal, the project will conduct awareness, assessment, and education sessions at senior citizens’ centers, schools, churches, and health fairs. It also will conduct a diabetes awareness and prevention marketing campaign. Success of the project will result in healthier communities in Gibson and Pike Counties, more effective use of existing healthcare resources, and a reduction in community health care costs.

Topic Areas

Mental Health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,999.00

· Year 2 - 124,999.00

· Year 3 - 100,000.00

Partners to the Project

The Dunn Center, a community mental health center, is collaborating with Family Health Services, Inc. (a local community health center) and Affiliated Service Providers of Indiana, Inc., (a network of behavior health providers).

Areas Served

Rural communities of Fayette, Franklin, and Rush counties in Indiana.

Target Population Served

To improve the health and wellness of low-income and elderly.

Project Summary

The Dunn Center, a community mental health center, is collaborating with Family Health Services, Inc. (a local community health center)

Program Director

Heidi Miller

Family Health Services

509 Harcourt Way

PO Box 21

Rushville, IN 43173

Phone: (765) 932-3699

Fax: (765) 932-4164

E-mail: hmiller@fhshelps.org

Dunn Center

Richmond, IN 47375

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

And Affiliated Service Providers of Indiana, Inc., (a network of behavior health providers) to improve the health and wellness of people living in the rural communities of Fayette, Franklin, and Rush counties in Indiana, especially the low income and elderly. These goals will be accomplished by decreasing barriers to care, providing prevention and early intervention education, increasing treatment effectiveness, and expanding the program to include an eight-county region.

These proud, rural communities show the signs of suffering from the fallout of lack of jobs, lack of health insurance or having inadequate insurance, drug and alcohol addiction, and the long term ramifications of chronic illness. Fayette County is partially designated as medically underserved area. Rush County is a health professional shortage area for residents at 200 percent or below the poverty level. All of Franklin County is a health professional shortage area, a medically underserved, and a mental health shortage area.

These challengers are inter-related. The Primary Care Plus + program will be managed and governed by an Advisory Committee composed of specialists with expertise in the integration of mental health services into primary care. Dunn Center, a nonprofit mental health agency, will provide managerial and fiduciary oversight of the program. It also will oversee most aspects of the project’s mental health treatment component, including diagnostics, short-term crises management, individual counseling, group psychological education, and group counseling. Patients needing intensive treatment will be referred to the Dunn Center or another appropriate service provider, such as psychiatrists for pharmacological consultations. Dunn Center will also provide transportation and translators.

The program will be housed at Family Health Services’ two health centers that serve Fayette, Franklin, and Rush counties. Family Health Services will provide the project director, clinical office space in each county, management of integration to primary care, coordination of services, support staff, child care, and translators as needed. The program will address the racial, cultural, and socioeconomic needs of each patient individually. Affiliated Service Providers of Indiana, Inc., (ASPIN) will provide evaluation and technical assistance related to education and dissemination of outcomes. It also will oversee the replication of this model in Years 2 and 3 of the project in nearby counties.

Topic Areas

Prenatal care

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Building Healthy Families

Areas Served

Marshall County has been designated a Medically Underserved Community, and the immigrant population has been designated as a Medically Underserved Population due to language and cultural barriers in accessing health care services.

Target Population Served

The project is designed to meet the unique cultural, social, and linguistic needs of pregnant Hispanic women living in Marshall County.

Project Summary

Program Director

Jana Enfield, Project Director

Marshalltown Medical and Surgical Center

811 East Main Street

Marshalltown, IA 50158

Phone: (641) 752-1730

Email: jana@capsonline.us

Marshalltown Medical and Surgical Center

Marshalltown, IA 50158

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Marshall County, population 39,311, is located in rural Central Iowa . The county’s population has remained stable over the past 50 years; however, the demographics of the population have shifted dramatically in the past 10 years. This demographic shift has resulted in a 480 percent increase in the minority population, which includes a 1,106 percent increase in the Hispanic Community in the past 10 years.

Along with these demographic changes, local officials have witnessed an increase in the number of people living in poverty and an upsurge in the number of uninsured or under-insured residents. For economic reasons, Marshall County is designated as a Health Professional Shortage Area. Further, the county has been designated a Medically Underserved Community, and the immigrant population has been designated as a Medically Underserved Population due to language and cultural barriers in accessing health care services.

The Building Healthy Families project is a culmination of 5 years of research, data collection, review, and program planning. The project draws on the staff, expertise, and available funding of all consortium members, and develops a coordinated service delivery system that avoids duplication of effort.

The Building Healthy Families project is designed to meet the unique cultural, social, and linguistic needs of pregnant Hispanic women living in Marshall County. The project’s goal is to improve prenatal health outcomes via identification and assessment, provision of family support and health education services, and incentives to increase participation in health care and educational opportunities in the community. It will promote rural health care services by expanding our current postnatal home visitation model to include a new and enhanced prenatal service component. This project will address the severe lack of services available to our target group due to cultural and language barriers.

Topic Areas

Mental health services

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

AgriWellness, Inc., has joined the Consortium to train and serve project families through Family Support Specialists. A case manager from Rathbun will be employed to counsel and refer children in cooperation with faculty and staff, two in-kind managers, and three Specialists.

Areas Served

Wayne County

Target Population Served

Behavioral health care for children, youth, and isolated elderly members by providing outreach and education resources, and promoting greater community involvement in an integrated network of services.

Program Director

Jill Sherer

Wayne Community School District

102 N. Dekalb

Corydon, IA 50060

Phone: (641) 203-2855

Fax: (641) 872-2091

E-mail: jill.sherer@gpaea.k12.ia.us

Wayne Community School District

Corydon, IA 50060

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The proposed Wayne County Multi-Generational Behavioral Health Project will serve one of the State’s most poor, isolated, and distressed areas. This community also is home to the State’s largest number of elderly residents over the age of 85. Located in southern Iowa along the Iowa-Missouri border, Wayne County suffers troublesome economic, education, and environmental problems that have for years damaged the mental and behavioral health of its children and youth, families, schools, and communities. These four strata of life will be integrated into this project.

The Project aims to increase access to behavioral health care for children, youth, and isolated elderly members by providing outreach and education resources, and promoting greater community involvement in an integrated network of services. It represents a new transition from mental health to a broader, more pervasive behavioral health condition that has emerged as the county’s most telling unmet need. The target population consists of 1,500 Mercer County children and elderly persons.

The project has four goals.

· Goal 1 focuses on school-based identification, problem-solving, and documentation of students with behavioral health problems. It employs a Behavioral/Learning Area Support Team (BLAST) model from the Rathbun Area Mental Health Center in Centerville, Iowa and the UCLA Center for Mental Health in Schools.

· Goal 2 involves linking school-based children and their families to intensive behavioral health services; faculty and staff consultations, counseling, and referrals. AgriWellness, Inc., has joined the Consortium to train and serve project families through Family Support Specialists. A case manager from Rathbun will be employed to counsel and refer children in cooperation with faculty and staff, two in-kind managers, and three Specialists.

· Goal 3 focuses on providing behavioral health services to at-risk children and their families through community-based mentoring development together with professional training.

· Goal 4 involves Sowing the Seeds of Hope (SSoH) training for specialists and staff, and developing a new behavioral health/emergency health care outreach network for rural, isolated elderly persons.

The Consortium has developed from its roots in 1999: It includes Wayne County School District, the Seymour School District, Wayne County Public Health; Wayne County Home Care Aide Agency, Regional Department of Human Services/Wayne County; Area Education Agency 15, Rathbun Area Mental Health Center; Wayne County Hospital, and the local Extension Service. Also represented in the consortium is the Ministerial Alliance of Mercer County, the Wayne County Response under the auspices of Wayne County Hospital, and six other groups. Consortium and community support organizations assume specific, dynamic roles.

Topic Areas

Oral Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 143,085.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

There are two other consortium partners, United Community Health Center (UCHC), a federally qualified community health center, and Lakes Area Community Empowerment (Lakes CE).

Areas Served

The geographic service area is twelve counties in rural northwest Iowa: Buena Vista, Clay, Dickinson, Emmet, Hamilton, Humboldt, O’Brien, Osceola, Palo Alto, Pocahontas, Webster, and Wright.

Target Population Served

The target population is families with young children ages 0-5, residing in rural northwest Iowa.

Program Director

Veronica McFadden

Upper Des Moines Opportunity

620 Michigan, Suite 4

Storm Lake, IA 50588

Phone: (712) 213-9287

Fax: (712) 732-1471

E-mail: vmcfadden@udmo.com

Upper Des Moines Opportunity, Inc (UDMO)

Graettinger, IA 51342-0519

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The applicant and lead agency for the proposed project is Upper Des Moines Opportunity, Inc (UDMO). There are two other consortium partners, United Community Health Center (UCHC), a federally qualified community health center, and Lakes Area Community Empowerment (Lakes CE). The project title is Early Smiles. The target population is families with young children ages 0-5, residing in rural northwest Iowa. The purpose of the project is to “create an oral health care system”. The geographic service area is twelve counties in rural northwest Iowa: Buena Vista, Clay, Dickinson, Emmet, Hamilton, Humboldt, O’Brien, Osceola, Palo Alto, Pocahontas, Webster, and Wright.

After completion of a comprehensive oral health needs assessment, four needs were identified:

1. Limited leadership and capacity to effectively implement a prevention-focused early childhood oral health initiative.

2. Missed opportunities by early childhood health professionals to assess, screen, treat, and educate families of the importance of oral health care for young children.

3. Unrecognized and different attitudes, belief, and knowledge that prevent families from seeking oral health care and understanding the need for such care.

4. Lack of knowledge among the general community and policy makers of the importance for preventive oral health care for young children and the unrnet oral health needs and health disparities for families with young children.

Topic Areas

Dental

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Health Ministries Clinic, a non-profit medical clinic in Newton, Kansas (Harvey County); the Reno County Health Department in Hutchinson; and the Harvey County Health Department in Newton.

Areas Served

Harvey and Reno Counties show that access to dental care is the greatest unmet health care need in the two-county area.

Target Population Served

This project will not only address a tremendous unmet need for dental care for the low-income people in the area, but will also pilot a dental program model integrated with medical care now provided by the participating clinics.

Program Director

Sally Tesluk, Executive Director

PrairieStar Health Center

200 West 2nd Avenue

Hutchinson, KS 67501

Phone: (620) 663-8484

E-mail: tesluks@prairiestarhealth.org

PrairieStar Health Center

Hutchinson, KS 67501

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

PrairieStar Health Center, a non-profit rural health clinic located in Hutchinson, Kansas, is working with three health care organizations in Kansas’ Reno and Harvey Counties to establish the South Central Dental Project. PrairieStar’s partners for this effort are Health Ministries Clinic, a non-profit medical clinic in Newton, Kansas (Harvey County); the Reno County Health Department in Hutchinson; and the Harvey County Health Department in Newton.

The South Central Dental Project will establish a dental team that is shared by PrairieStar Health Center and Health Ministries Clinic. The cost of services will be offset by using a sliding fee schedule of discounts based upon the patient’s income. This project will especially focus efforts to increase access for pregnant women and children, since these populations are especially vulnerable. Additionally, it will be a model of care that integrates dental services with existing medical services provided by the partner organizations. This integration will include a Performance Improvement Committee that has medical representatives from both non-profit clinics as well as dental staff. This Committee will initially determine performance measures that bridge between dental and medical services, and will meet regularly to measure progress and/or need for improvement in meeting those measures. The Project’s primary goal is to provide access to dental care to at least 80 percent of all low-income children and pregnant women without private insurance that receive medical care at a partner organization facility. Currently, these individuals in the two-county area lack access to dental services. Needs assessments conducted in 2004 in both Harvey and Reno Counties show that access to dental care is the greatest unmet health care need in

the two-county area. Low-income participants in a Harvey County focus gro up indicated that this unmet need is so great that it negatively impacts their overall quality of life.

South Central Dental Project staff will include a dentist, two dental assistants, 1.8 FTE dental hygienist, a program manager, and administrative support staff. In addition, funding from the Rural Health Outreach Grant will be used to place case managers at both Health Ministries Clinic and Prairie Star Health Center to assist patients with registration, transportation, and other services that will improve their overall dental experience. The case managers will also contact patients the day before their scheduled appointment to remind them of the date and time to reduce no-show rates.

Topic Areas

Mental Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Southeast Kansas Area Agency on Aging (AAA), Montgomery County Public Health Department, Wilson County Public Health Department, The Sanctuary at Fredonia Regional Hospital (area provider of geriatric psychiatric care), Behavioral Health Unit at Coffeyville Regional Medical Center, Windsor Place Assisted Living, Gran Villa Assisted Living Neodesha Facility, Gran Villa Assisted Living Fredonia Facility, Windsor Place Assisted Living, and Four County Mental Health Center.

Areas Served

Through the Senior Outreach Services Consortium outreach and community-based services will be expanded in Montgomery County and initiated in Wilson County, Kansas.

Target Population Served

The target population is older adults, age 60 or older with unmet mental health and substance abuse treatment needs. These seniors are

Program Director

Steven Denny

Four County Mental Health Center

P.O. Box 688

3751 West Main Street

Independence, KS

Phone: (620) 331-1748

Fax: (620) 332-1940

E-mail: sdenny@fourcounty.com

Four County Mental Health Center

Independence, KS 67301

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

currently not being served by traditional methods due to financial, structural, and personal barriers including access and stigma. Program recipients will be older adults who are continuing to live in their own homes or are in assisted living facilities. The untreated mental health and substance abuse issues of these individuals put them at risk for exacerbation of physical health problems, suicide attempts, premature moves to long term care settings, and psychiatric hospitalization or residential alcohol/drug treatment.

Project Summary

The Senior Outreach Services (SOS) Consortium will provide mental health and substance abuse outreach services to elderly in the rural Southeast Kansas counties of Wilson and Montgomery.

In addition to outreach, non-traditional services that include community based case management and in-home therapy will be provided by this project. The consortium will consist of representatives from mental health and substance abuse treatment services, public health, aging services, hospitals, and assisted living facilities. The Consortium will form a focus group to address the needs of seniors.

The program will outreach to older adults, age 60 or older, with unmet mental health and substance abuse treatment needs. These seniors are currently not being served by traditional methods due to financial, structural, and personal barriers including access and stigma. Unmet mental health and substance abuse treatment needs results in premature placement in long-term facilities; inpatient hospitalizations for psychiatric and substance abuse problems; increased suicide risk; and exacerbation of medical problems.

The Senior Outreach Services Consortium will:

· Develop and maintain a Consortium of community agencies involved in elder care to address mental health and substance abuse treatment needs and related issues for older adults.

· Improve elder care by providing increased access to mental health and substance abuse treatment services.

· Improve mental health status for program recipients as evidenced by decreased symptoms of mental illness and substance abuse resulting in improved quality of life and functioning.

· Reduce stigma and increase community awareness of mental health and substance abuse issues for older adults in Montgomery and Wilson County communities through the SOS Consortium.

Topic Areas

School (nutrition)

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Marshall and Nemahan Counties

Target Population Served

The communities and individuals specifically and directly targeted in

Program Director

Philisha Stallbaumer

Health Education Action Partnership

119 N. Kansas Avenue

Frankfort, KS

Phone: (785) 292-4453

Fax: (785) 292-4455

E-mail: philisha@sbeconline.org

Health Education Action Partnership

Frankfort, KS 66427

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

the Promoting Healthy Lifestyles initiative in year one are children in pre-kindergarten through grade 12^th grade from Axtell, Blue Rapids, Frankfort, Marysville, Summerfield and Waterville, Kansas in Marshall County and Bern, Centralia, and Seneca, Kansas in Nemaha County.

Project Summary

Rural Kansas faces challenges of an increase in sedentary lifestyles, increase in overweight and obese citizens, and an increase in chronic disease. This is because of the struggle to adequately promote healthy lifestyles in their communities through nutrition and physical activities.

Geographical location makes it difficult for rural communities to have access to needed resources to help battle what could be called an obesity crisis in Kansas, with 60.6% of the adult population being overweight and obese. It is the early unhealthy habits children are learning that lead to adult obesity and chronic diseases.

Valley Heights, USD #498 has formed a partnership with the Marysville, Vermillion, Nemaha Valley, and AxtellBern school districts and Nemaha Valley Community Hospital, Community Memorial Hospital (Marysville), Community Hospital Onaga, and Nemaha and Marshall County Health Departments in an initiative called Promoting Healthy Lifestyles. These school districts and health care facilities make up a consortium called the Health Education Action Partnership (HEAP) and serve 17 small rural communities in Northeast Kansas. In these communities it is time to change the scene and begin promoting healthy habits that will reduce health risks and increase children’s chances for longer, healthier, more productive lives.

The above partners are collaboratively applying for the Rural Health Care Outreach Grant to plant seeds and implement activities to promote healthy lifestyles in both individuals and family settings. This grant application for the Promoting Healthy Lifestyles initiative outlines practical ways that these community partners can break down barriers of geographical locations and work together to provide healthy environments for kids. The focus of this initiative is to address the educational, physical fitness and nutritional needs necessary to promote healthy lifestyles in individuals beginning in early childhood and continuing through adulthood.

Goals for this initiative include:

1) To increase the awareness and promote the development of healthy eating behaviors and engagement in physical activity.

2) To improve the health and quality of life for children ages 4- 19 by increasing levels of physical activity.

3) To improve the health and quality of life for children ages 4- 19 by providing opportunities for nutritional education.

These goals will be met by implementing and utilizing the following activities and resources: promotional materials; assessment tools; fitness resources; physical activity events; and nutritional education. This grant application will allow HEAP to take the action they need to help promote healthy environments for children in these rural communities.

Topic Areas

Health promotion/disease prevention (tobacco, overweight/obesity, alcohol abuse)

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,974.00

· Year 2 - 124,987.00

· Year 3 - 99,986.00

Partners to the Project

The Kentucky Cabinet for Health and Family Services, and the Madison County Health Department.

Areas Served

Two rural counties of central Kentucky (Anderson and Madison).

Target Population Served

To provide health care and human services for low-income children, youth, and families

Program Director

Nicole Lavy.

Kentucky United Methodist Home

2050 Lexington Road

Versailles, KY 40383

Phone: (859) 873-4481

E-mail: nicole@kyumh.org

Kentucky United Methodist Home

Versailles, KY 40383

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

The Kentucky United Methodist Home and its partners—the Kentucky Cabinet for Health and Family Services, and the Madison County Health Department—joined forces to provide health care and human services for low-income children, youth, and families in two rural counties of central Kentucky (Anderson and Madison) through the Connections Rural Health Initiative.

Rural residents in Kentucky and the nation face a number of health disparities—among them, higher rates of the top three leading actual causes of death in the United States (tobacco, overweight, and alcohol)—and barriers to health care, especially access issues that make it difficult for citizens to obtain the care they need. While access/barrier issues abound, Connections is designed to address two in particular: the lack of transportation and the lack of insurance. We chose these two issues because they significantly reduce our families’ ability to access the care they need and because the Connections program design helps work around them. Project activities include the following:

· We will provide in-home case management and other services when possible, and we will help families arrange for transportation to other providers and services as necessary;

· We will make the evaluation of each family’s eligibility for third-party payment and support programs (Medicaid, KCHIP, K-TAP) a fundamental priority of our case management services, and we will help enroll individuals and families as appropriate.

· The Connections Rural Health Initiative will address identified health care needs, facilitate and encourage healthy behaviors, and help overcome barriers and disparities that interfere with families’ ability to foster their own and their children’s health.

We have identified four major goals:

· Seventy-five percent of families served will be able to access services independently upon discharge from the Connections program;

· Participation in Connections will result in a reduction in the number of smokers, and especially youth smokers, as compared to baseline measures;

· Eighty percent of the children in the families we serve will have a dental exam and will follow through with treatment in the year after Connections services are provided;

· Partnerships/collaborations begun through the Connections program will be self-sustaining; that is, they will continue beyond the grant period.

We have designed Connections to focus on areas where we believe we can have the greatest impact. By targeting low-income families, we serve those in greatest need. By targeting youth with our psycho-educational programs covering content areas we know significantly impact health (tobacco, diet/nutrition/exercise, substance abuse/mental health, and oral health/dental care), we maximize our opportunity to break the cycle of unhealthy behaviors and produce long-term results.

Within the three-year period of this grant, we believe we will improve the lives of the families served, strengthen current referral networks and partnerships, create new collaborations, and enhance the health of the rural communities we serve.

Topic Areas

Dental care, Minority health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The consortium is comprised of four health care agency partners: 1) Montgomery County Health Department, 2) Mary Chiles Hospital, 3) the Family Care Clinic (a rural health clinic), and 4) the Vollmer Dental Office. The consortium also includes two non-health care partners, Montgomery County Cooperative Extension Service and the Montgomery County Industrial Authority, which, with the four other traditional agencies, create an innovative partnership that is well-equipped to fulfill the consortium’s mission.

Areas Served

The consortium service area is a contiguous, six-county region of more than 1,400 square miles on the western edge of Appalachian Kentucky. All six of these counties are designated as medically underserved populations/medically underserved areas, and all but one are federally designated Appalachian counties. All counties are rural.

Program Director

Jan Chamness

Public Health Director

Montgomery County Kentucky Health Department

117 Civic Center

Mt. Sterling, KY 40353

Phone: (859) 498-3808

E-mail: janm.chamness@ky.gov

Montgomery County Kentucky Health Department

Mt. Sterling, KY 40353

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Target Population Served

The consortium’s mission is to improve access to primary care and dental care among low-income, uninsured, and underinsured residents, with a special emphasis on providing outreach services for the unmet needs of an expanding Latino population.

Project Summary

This project plans to establish an outreach program developed by the Western Appalachian Kentucky Health Care Access Consortium. The consortium’s mission is to improve access to primary care and dental care among low-income, uninsured, and underinsured residents, with a special emphasis on providing outreach services for the unmet needs of an expanding Latino population. Over the next 3 years, the consortium plans to provide 2,244 primary care visits and 315 dental care visits, as well as outreach, transportation, and other services.

The consortium is an expansion of the successful Montgomery County Migrant Coalition, a 25-plus member organization established in 2001 with funding from the U.S. Department of Agriculture. All consortium members are active participants. The consortium is comprised of four health care agency partners: 1) Montgomery County Health Department, 2) Mary Chiles Hospital, 3) the Family Care Clinic (a rural health clinic), and 4) the Vollmer Dental Office. The consortium also includes two non-health care partners, Montgomery County Cooperative Extension Service and the Montgomery County Industrial Authority, which, with the four other traditional agencies, create an innovative partnership that is well-equipped to fulfill the consortium’s mission.

The six goals of the consortium are to: 1) Expand the existing services of the collaborating organizations; 2) Advocate on behalf of the target population for improved access to existing health care resources; 3) Provide a link between providers and Latino patients; 4) Provide an interpretive link between existing and prospective employers and Latino workers to ensure a healthy Latino workforce; 5) Increase the community’s understanding of Latino culture; and 6) Develop a long-term sustainability plan for the consortium.

Through this project, the consortium will expand its capacity to offer primary care and dental services, and to develop an extensive outreach program. The consortium will use a promotora model of community health workers to reduce and eliminate barriers to care that Latinos often face, including the inability to communicate because of language barriers, lack of transportation, inability to navigate the local health care system, occupational barriers, and lack of cultural competency among local service providers.

We believe the creative strategies planned to enhance service delivery can be a model for other rural communities to follow, especially where Latino populations are relative new, such as Appalachia and States beyond the U.S.A-Mexico border. The University Kentucky College of Public Health will assist with process and outcome evaluations, and with the dissemination of findings.

Topic Areas

Diabetes

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 149,357.00

· Year 2 - 124,561.00

· Year 3 - 99,519.00

Partners to the Project

Powell County Health Department, the Estill County Health Department, the Powell County Cooperative Extension Service, and the Estill County Cooperative Extension Service.

Areas Served

Comprised of the rural counties of Estill and Powell.

Target Population Served

Provide medical and supportive services to low-income adults with diabetes and related conditions residing in Powell and Estill counties, Kentucky.

Program Director

April Stone

Kentucky River Foothills Development

176 12^th Street

Clay City, KY

Phone: (606) 663-9011

Fax: (606) 663-1254

E-mail: cfn1@foothillscap.org

Kentucky River Foothills Development

Clay City, KY 40912

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

Project Summary

Kentucky River Foothills Development Council, Inc. proposes a Rural Health Care Services Outreach Grant program to provide medical and supportive services to low-income adults with diabetes and related conditions residing in Powell and Estill counties, Kentucky. The Promoting Health among Diabetics (PHD) program will be offered in collaboration with four additional Consortium members: the Powell County Health Department, the Estill County Health Department, the Powell County Cooperative Extension Service, and the Estill County Cooperative Extension Service. The proposed program will provide supplemental diabetic supplies and equipment; prescription assistance services; transportation for non-local specialty care for diabetes and related conditions; and nutritional counseling including nutrition, diabetes self management and fitness education. The PHD project will serve 200 participants annually, for a total of 600 over the three-year project term.

Topic Areas

Obesity, Chronic Diseases, Health Education

Project Period

May 1, 2005 – April 30, 2007

Funding Level Expected Per Year

· Year 1 - 197,385.00

· Year 2 - 178,963.00

· Year 3 - 191,285.00

Partners to the Project

In addition to Louisiana Tech University, the lead applicant, consortium members include Lincoln General Hospital, Town of Dubach, Dubach High School, Dubach Revitalization Coalition, Dubach Restoration and Beautification Organization (DRABO), and Lincoln Council on Aging.

Areas Served

The project will serve the town of Dubach and surrounding rural communities in northern Lincoln Parish, Louisiana,

Target Population Served

The target populations are rural, low-income Caucasian and African American preteens to adults who are at risk of obesity and its complications and who have high levels of “health illiteracy.”

Program Director

Mary W. Murimi

Louisiana Tech University

P.O. Box 3168

Ruston, Louisiana 71272

Phone: (318) 257-2607

Fax: (318) 257-4014

Louisiana Tech University

Ruston, LA 71272

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

The purpose of the Dubach Health Outreach Project is to provide access to a multidisciplinary community-based intervention to combat obesity and related chronic diseases. The project will focus on primary care and prevention strategies along with wellness strategies that deal with obesity and related risk factors and diseases such as coronary heart disease. A consortium of preventive health service providers and agencies will maximize resources to increase the number of individuals and families receiving preventive care for obesity and related disorders, and foster positive behavior.

The project will target at-risk and obese preteens and teens by implementing a health education, nutrition, and physical education program in targeted schools with a focus on primary prevention and education. The project also will target adults, who will receive secondary and tertiary prevention services such as screening, testing, health education, nutritional assessment, and counseling.

The project will serve the town of Dubach and surrounding rural communities in northern Lincoln Parish, Louisiana, where more than 25 percent of the population lives in poverty. The target populations are rural, low-income Caucasian and African American preteens to adults who are at risk of obesity and its complications and who have high levels of “health illiteracy.” The leading causes of death in the targeted population are heart disease, diabetes, and stroke, all of which are aggravated by obesity.

All areas to be served are rural communities in which many residents have low access to primary care and preventive medicine. High consumption of dietary fat and calories and low frequency of exercise contribute to obesity in the target population. Cultural, educational, and socioeconomic barriers to access include lack of exercise facilities, lack of education, and a high poverty rate. All areas and people to receive services are in a Health Professional Shortage Area and are Medically Underserved Populations. Lincoln Parish is designated as a Medically Underserved Area.

Topic Areas

Obesity, Diabetes

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 195,140.00

· Year 2 - 184,890.00

· Year 3 - 184,890.00

Partners to the Project

Consortium members include the City of Grambling/Grambling Family Medical Clinic; Office of Public Health, Bienville Parish Health Department; Shreveport Black Nurses Association; Partners in Wellness Prevention Project; Bienville Parish School System–Arcadia School Complex; Bienville Health and Wellness Center; and Methodist Ministerial Alliance/St. Duty CME Church.

Areas Served

Rural Bienville and Lincoln parishes in north central Louisiana.

Target Population Served

The Obesity Project is a health education and screening project targeting obesity and related diseases such as diabetes, coronary heart disease, and stroke in at-risk African American adolescents and adults.

Program Director

Sharon Murff

City of Grambling/Grambling Family Medical Clinic

2045 Martin Luther King Jr. Avenue

P.O. Box 108

Grambling, Louisiana 71245

Phone: (318) 247-6120

Fax: (318) 247-0940

City of Grambling/Grambling Family Medical Clinic

Grambling, LA 71245

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

Healthy Communities of Louisiana—The Obesity Project is a health education and screening project targeting obesity and related diseases such as diabetes, coronary heart disease, and stroke in at-risk African American adolescents and adults. At the core of the problem is the lack of seamless coordination among key agencies providing preventive and medical services along with a high rate of health illiteracy among the target population, rural African Americans. The project will establish a network of preventive health service providers and agencies to increase the number of individuals receiving preventive care and screenings and foster positive behavior. The two-pronged intervention approach will target at-risk school-age individuals as well as at-risk adults who are obese and African American. The goal of the project is to serve the target population at risk for chronic diseases because of obesity through preventive services, aggressive health screening, and education, along with a seamless continuum of care and referral networks. One novel approach the project will use is to target families at family reunions to provide health education and interventions such as screenings.

Rural Bienville and Lincoln parishes in north central Louisiana—the target area—are home to some of the most poverty-stricken areas in the state and in the Nation. More than 20 percent of the total population in the state is below the poverty line, and more than 40 percent of the children in north central Louisiana under age 20 live in poverty. Among female-headed households with children under age 5, the poverty rate is a staggering 80 percent. In 2000, Bienville had a population of 15,563 (44 percent African American), and Lincoln Parish had a population of 42,173 (40 percent African American). Obesity-related diabetes and heart disease in African Americans are at epidemic proportions in the two parishes, and effective strategies are needed to reduce the burden of diabetes and other obesity-related diseases.

Geographically, Bienville and Lincoln parishes are relatively accessible to major highways, and access barriers to needed services are not so much physical distance but rather cultural and socioeconomic. In addition to poverty and lack of education, barriers include disparate medical care for African Americans, cultural mores that place a greater emphasis on preventive care for females than males, and the rural African American emphasis on family. Other barriers include a high consumption of dietary fat and calories, a sedentary lifestyle, and psycho-spiritual attitudes such as forgoing medical treatment in the belief that God will “fix it.”

Topic Areas

Medication assistance, Telehealth, Chronic Disease

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The State’s first vertical rural health network members include two state hospitals, two St. Mary Parish rural hospitals, one St. Mary Parish Federally Qualified Health Center, one Iberia Parish Federally Qualified Health Center, one tribal clinic, one Louisiana Regional Office of Public Health, one social service agency, and a representative of the St. Mary Chamber of Health Coalition.

Areas Served

St. Mary, Iberia, and Terrebonne Parishes in south central Louisiana along the Gulf Coast.

Target Population Served

The target population for the project is the underinsured and uninsured residents.

Program Director

Rev. Craig A. Mathews

ByNet Executive Director

Bayou Teche Community Health Network (ByNet)

P.O. Box 278

Franklin, LA 70538

Phone: (337) 828-5638, ext 104

E-mail: cmathews@bynet-la.org

Bayou Teche Community Health Network (ByNet)

Franklin, LA 70538

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

The CEI: Project Outreach will expand upon the Bayou Teche Community Health Network’s Information and Help Center, Medication Assistance Program, Telehealth Project, and Chronic Disease Management/Prevention Outreach Programs. Expected results of the project include:

· Increased enrollment in local, State and national programs (i.e., LaChip/Medicaid/Medicare Savings/Care for the Caregiver);

· Continued decrease in non-emergency ER use;

· Increase in outreach partners comprising Community Health Teams;

· Increase in number of comprehensive screenings (i.e. diabetes/blood pressure and service eligibility);

· Establishment of single points of entry for patient mapping;

· Leverage of State funds ($50,000) and Federal funds ($150,000);

· Increase in number of residents with an identified medical home;

· Increase in number of churches providing transportation to medical care;

· Consortium access to state-wide meetings and seminars through coordination of teleconferencing equipment; and

· Accumulation of additional data on the target population through Service Point customization and expansion.

ByNet’s St. Mary Parish (County) Chamber of Health Coalition, which is comprised of over 70 representatives of health care, social service, consumer, faith-based and governmental entities, identified five key areas of need to improve healthcare in St. Mary and surrounding Parishes. Focus groups and committee research led the coalition to identify education, consumer-finance, transportation, access to medication, and primary and specialty care as key barriers to health care access for residents. In addition, the Health Access Barriers in the State (HABITS) Survey was conducted for the three target counties. The University of Louisiana at Lafayette’s Health Informatics Center conducted the surveys used as baseline data for network program evaluation. Emergency room usage, lack of health insurance, transportation, and inability to afford needed medications were identified as key concerns for all three target areas. In 2001, the network’s consortium of members began to implement programs and services to address identified needs. In the aftermath of the September 2005 Hurricane Katrina devastation experienced in the southern coastal region of the United States, the previously identified needs have significantly enhanced to an insurmountable level. St. Mary, Iberia and Terrebone Parishes have now become home to thousands of survived families requiring these services.

The target population for the project is the underinsured and uninsured residents of St. Mary, Iberia, and Terrebonne Parishes in south central Louisiana along the Gulf Coast. This population has recently experienced an enormous influx due to Hurricane Katrina survivors who have migrated into local communities. Those organizations comprising the consortium are the founding members of the Bayou Teche Community Health Network (ByNet). The State’s first vertical rural health network members include two state hospitals, two St. Mary Parish rural hospitals, one St. Mary Parish Federally Qualified Health Center, one Iberia Parish Federally Qualified Health Center, one tribal clinic, one Louisiana Regional Office of Public Health, one social service agency, and a representative of the St. Mary Chamber of Health Coalition.

Topic Areas

Infrastructure development, Elderly (education), Medication assistance, Quality improvement

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Through a 2004 ORHP Network Development Planning Grant, the Louisiana Rural Health Association, the Louisiana Health Care Review, Assumption Community Hospital, and Assumption Rural Health Clinic developed a network dedicated to increasing adult immunizations and adult vaccinations. Network partners worked together to form the Planning Equals Access for Louisiana (PEAL) Initiative.

Target Population Served

Dedicated to increasing adult immunizations and adult vaccinations.

Project Summary

The rural composition of Louisiana’s delta region is a photograph of health care professional shortage areas, extremely low preventive health compliance rates, high poverty rates, vast geographic boundaries, and above-average geriatric populations.

Program Director

Stacy Fontenot

Louisiana Rural Health Association

167 Highway 402

P.O. Box 387

Napoleonville, LA 70390

Phone: (225) 268-0941

E-mail: fontenot@lrha.org

Louisiana Rural Health Association

Napoleonville, LA 70390

ORHP Contact:

Sheila Warren

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0246

swarren@hrsa.gov

With active participation in community forums by community members and natural growth, the initial four network partners expanded to include the Centers for Medicare & Medicaid Services and the Louisiana Department of Insurance Senor Health Insurance and Information Program. It was through this process that PEAL grew from an informal network to an emerging coalition. PEAL members successfully developed a strategic plan with the overarching goal of implementing the comprehensive, mobile strategic plan developed by collaborating partners and existing rural health coalitions. The end results were major quality improvements, transformational changes, and increased access to care in 30 rural Louisiana parishes.

The goals for this project are as follows: 1) To engage partners in making transformational changes that will enhance efficiency, increase access to care, improve service coordination, and improve quality of care; 2) To educate Medicare beneficiaries about their rights and benefits, increase the number of allied health care professionals providing preventive services, expanding the payer network via innovative approaches, and improve the use, distribution, and payment of prescription drugs among Louisiana’s rural elderly; and 3) To identify strategies for sustaining PEAL after ORHP funding ceases.

Topic Areas

Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,722.00

· Year 2 - 121,778.00

· Year 3 - 93,883.00

Areas Served

Rural, impoverished region of the Mississippi River Delta.

Target Population Served

These services will be provided to individuals at three rural health clinics, long-term care facilities, and home-bound patients. The target population will be primarily African American adults.

Project Summary

There is a lack of behavioral health care services in Louisiana’s Franklin and Tensas parishes, both of which are located in the rural, impoverished region of the Mississippi River Delta. There are two key services to be developed under the project—case management and psychological evaluation and treatment services. These services will be provided to individuals at three rural health clinics, long-term care facilities, and home-bound patients. The target population will be primarily African American adults.

Program Director

Timothy Booker

Chief Executive Officer

Franklin Parish Hospital Service District No. 1

2106 Loop Road

Winnsboro, LA 71295

Phone: (318) 435-9411X297

E-mail: tbooker@fmc-cares.com

Franklin Parish Hospital Service District No. 1

Winnsboro, LA 71295

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

The overarching goal of this project is to establish a primary care-based behavioral health program. The eight related goals that support this are:

· To identify and enroll individuals in the behavioral health care management program;

· To ensure individuals receive assessment and treatment services at one of three rural health clinics that are primary care sites in the two-parish service area;

· To expand the behavioral health program to include patients residing in area long-term care facilities;

· To expand the program upon implementation to include patients who are home-bound and actively enrolled as a home health patient;

· To reduce the incidence of serious mental illness, depression, schizophrenia, and generalized anxiety disorders;

· To reduce the proportion of homeless adults who have serious mental illness;

· To ensure program sustainability; and

· To conduct a program evaluation.

Topic Areas

Cardiovascular disease

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 124,760.00

· Year 3 - 99,130.00

Partners to the Project

The Richland Parish Hospital-Delhi (RPH-Delhi) Community Wellness and Prevention Program

Areas Served

Richland Parish, in the northeast corner of the State, and is the main provider of health care services in the parish.

Target Population Served

Designed to provide health assessments, health promotion, and health education in settings such as the school, worksite, health care facility, and community.

Program Director

Jinger Greer

Richard Parish Hospital

407 Cincinnati Street

Delhi, LA 71232

Phone: (318) 878-6444

E-mail: delhihospital@yahoo.com

Richard Parish Hospital

Delhi, LA 71232

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

Richard Parish Hospital (RPH) is a critical access hospital with a 501(c)(3) nonprofit designation. It is located in Delhi, Louisiana, Richland Parish, in the northeast corner of the State, and is the main provider of health care services in the parish. The Richland Parish Hospital-Delhi (RPH-Delhi) Community Wellness and Prevention Program is a model program designed to provide health assessments, health promotion, and health education in settings such as the school, worksite, health care facility, and community.

Richland Parish is a designated health professional shortage area and a medically underserved population. There are significant access barriers to health care as reflected in the income and poverty demographics, health status indicators, and health disparities.

The primary needs to be addressed through this project are as follows:

· To increase the quality, availability, and effectiveness of community-based programs designed to prevent cardiovascular disease, improve health, and improve quality of life;

· To expand the availability of health education resources to underserved, vulnerable, and special-needs populations to reduce cardiovascular disease;

· To decrease the risk factors and the resulting high incidence rate of cardiovascular disease and correlating chronic diseases;

· To strengthen the health care infrastructure and service delivery systems in Richland Parish as they relate to the management and treatment of cardiovascular disease and correlating chronic diseases.

The network has developed the following goals:

· Develop a model comprehensive community cardiovascular disease program in Richland Parish that can be replicated in 10 other parishes;

· Increase community awareness of cardiovascular disease and associated risk factors, with a focus on Syndrome X, tobacco use, and personal stress management;

· Decrease the incidence of cardiovascular disease and the incident of associated risk factors through a behavioral modification focus that targets dietary habits, physical activity, tobacco use, and personal stress levels; and

· Enhance the management and treatment of cardiovascular disease and related risk factors by focusing on early detection, education, behavior modification, and pharmacotherapy.

Topic Areas

Obesity, Clinical Interventions

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include the Healthy Community Coalition, the lead applicant; HealthReach Community Health Centers; the University of Maine at Farmington; and Franklin Community Health Network.

Areas Served

The target population comprises residents of Franklin County and eight neighboring towns.

Target Population Served

The project will address the unmet needs of the entire population in the area with a focus on the lowest income residents, those at or below 250 percent of the Federal poverty level, who are most likely to need services and least likely to be able to afford access to them.

Program Director

Leah Binder

Healthy Community Coalition

20 Church Street

Wilton, Maine 04294-3803

Phone: (207) 645-3136

Fax: (207) 645-4138

Healthy Community Coalition

Wilton, ME 04294-3803

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

The Healthy Living Initiative of the Healthy Community Coalition will focus on community and primary care strategies to address obesity, a major risk factor for a number of diseases, as well as behavioral factors that contribute to the obesity epidemic. The initiative will integrate and expand clinical and community-based strategies for promoting proper nutrition and increasing physical activity to reduce the prevalence of overweight and obesity in rural Franklin County, Maine, and several neighboring towns. The initiative will expand the range of clinical interventions available locally for obese and overweight adults and adolescents and will educate health care providers in diagnosing overweight and obesity. A marketing campaign to promote physical activity and good nutrition will educate the community at large.

The target population comprises residents of Franklin County and eight neighboring towns. Greater Franklin suffers from an escalating rate of obesity and overweight among its 40,000 residents. In 2000, 60 percent of adults and 15 percent of children were clinically obese or overweight. The region is at higher risk for obesity and overweight than other areas of the state because risk factors associated with obesity, such as the lack of health insurance and lower education levels, are significantly higher in the county than the rest of Maine. The project will address the unmet needs of the entire population in the area with a focus on the lowest income residents, those at or below 250 percent of the Federal poverty level, who are most likely to need services and least likely to be able to afford access to them. The project also will focus on Franco-American residents who tend to have a lower socioeconomic status as well as poor nutrition and low physical activity.

Barriers to accessing services include the lack of fitness facilities in the area; low-income residents cannot afford the few that are available. After-school activities also are limited. Public transportation is unavailable. Rural residents are geographically far-flung, and geographic distances make travel difficult and time-consuming and require considerable time to accomplish routine tasks. The excessive dependence on vehicles leads to a sedentary lifestyle pivoting around vehicle usage. Seventeen communities in the Healthy Community Coalition service area are designated as either a community or population primary or dental care shortage area, and 18 communities are Health Professional Shortage Areas.

Consortium members include the Healthy Community Coalition, the lead applicant; HealthReach Community Health Centers; the University of Maine at Farmington; and Franklin Community Health Network.

Topic Areas

Aging/Elderly

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 75,000.00

Partners to the Project

HAN’s partners include Penobscot Valley Hospital (PVH) and Millinocket Regional Hospital (MRH), both of which are critical access hospitals; the University of New England; and the University of Maine Center on Aging.

Areas Served

Nineteen rural communities in Penobscot County.

Target Population Served

The target population for this project is the near elderly (ages 55-64) and the older population (age 65 and above). HAN targeted the elderly population for special attention in its original Section 330 New Access Point grant application submitted in December 2002.

Program Director

Dawn Cook

Chief Executive Officer

Rural Maine Healthy Aging Program

Health Access Network, Inc.

51 Main Street

Lincoln, ME 04457

Phone: (207) 794-6700

E-mail: dcook@hanfqhc.org

Health Access Network, Inc.

Lincoln, ME 04457

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

Health Access Network (HAN) is a 330-funded community health center that provides primary care services to residents of 19 rural communities in Penobscot County—one of Maine’s most remote, rural locations in the isolated northern region of the State. The target population for this project is the near elderly (ages 55-64) and the older population (age 65 and above). HAN targeted the elderly population for special attention in its original Section 330 New Access Point grant application submitted in December 2002. Since that time, HAN has worked diligently to meet the needs of its service area’s older residents, as well as the near elderly, with nearly one-third of its present patient population falling within the ages of 55-65 and older. One of HAN’s main goals is to develop a comprehensive medical and social service resource for the area’s aging population.

For this project, HAN’s partners include Penobscot Valley Hospital (PVH) and Millinocket Regional Hospital (MRH), both of which are critical access hospitals; the University of New England; and the University of Maine Center on Aging. An additional 16 local, regional, and statewide organizations and individuals support this project.

According to recent reports, Maine’s elderly population continues to increase. Maine’s population 65 and older is now at 15 percent, compared to 12 percent for the nation. Maine’s aged population ranks third in the country, trailing behind only Florida (17 percent) and West Virginia (16 percent). Its median age (40.6), which has increased by 2 years since 2000, is now the highest in the country. While Maine’s population is projected to grow only slightly—less than 9 percent by 2017—the age distribution will change dramatically. Forecasters predict that the number of children will shrink 3 percent; the working-age adult population will grow only 5 percent; and the elderly will jump 38 percent.

The State’s near-elderly and elderly population faces significant barriers in access to quality health care and support services, including lack of transportation, limited financial resources, lack of insurance coverage for many services (even for those on Medicare), and an insidious cultural bias against the elderly, promulgated by a youth-obsessed society. Additionally, as a number of needs assessments, discussions, and meetings determined, there is often a “disconnect” between providers of health care and social services, leading to acute fragmentation of care within the health care and social service system. These access issues, coupled with the fragmentation of services, result in poor health outcomes, lack of attention to preventive care, and reduced quality of life for the area’s vulnerable elderly population.

The project’s primary goals are: 1) To improve access to high quality, locally coordinated, multi-specialty and integrated health care; 2) To expand preventive services, emphasizing specific concerns for older adults, such as substance abuse, tobacco use, injury prevention, obesity, physical activity, mental health, and immunizations; and 3) To expand mental health awareness and services. Project activities include expanded case management with a geriatric focus; vigorous community outreach and education; improved preventive care and screenings; and the promotion of higher education in rural geriatrics.

Topic Areas

Service Accessibility, In-home Care, Behavioral Health

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 199,521.00

· Year 2 - 199,521.00

· Year 3 - 199,521.00

Partners to the Project

The Worcester County Health Department, consortium members include the Worcester County Department of Social Services and the Worcester County Commission on Aging.

Areas Served

Worcester County

Target Population Served

The target population—adults age 60 and older.

Program Director

Rebecca Shockley

Worcester County Health Department

P.O. Box 249

Snow Hill, Maryland 21863-0149

Phone: (410) 632-1100

Fax: (410) 632-0906

Worcester County Health Department

Snow Hill, MD 21863-0149

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Project Summary

The Worcester Adult Centralized Care, Evaluation, and Support Services (ACCESS) Collaborative will expand services that promote independent, unrestricted living for Worcester County’s aging population. Goals include the provision of leadership and direction to the Worcester ACCESS project, increased accessibility to services for older county residents, and increased utilization of available services. New and expanded services will address the need for in-home care services and accessible behavioral health services for older county residents. Worcester ACCESS will increase the accessibility of in-home personal care, chore, and home improvement services using the Asset-Based Community Development approach, which emphasizes the involvement of community assets in addressing community needs. A behavioral health team, comprising a behavioral clinical specialist and a psychiatrist, will work closely with other health care professionals to ensure that the mental health needs of older adults are met. The project will increase utilization of services and healthy behaviors in the target population through community outreach and education activities. Services will be coordinated through a single point of entry and overseen by the collaborative.

Worcester County, Maryland, is a rural, relatively poor community with complex issues affecting the health and safety of older adults. The current long-term care infrastructure cannot support the population of older residents in need of personal care assistance. The population of residents over age 65 is increasing rapidly, and chronic and disabling conditions make it difficult for older adults in the county to remain independent. The target population—adults age 60 and older—comprises 26 percent of the total county population of 46,543 in 2000. Between 1990 and 2000, the number of adults age 65 and older increased 55.8 percent. The influx of retired persons into the county, Maryland’s only Atlantic seacoast county, has created an additional challenge for service providers. Future growth in the aging population is expected to continue as a result of the retiring population coming into the county as well as the aging of the baby boomer population already living in the county. Access barriers include inadequate long-term care services and the lack of personal care providers, resulting in only 50 percent of total needed care being met. Worcester County is designated as a Health Professional Shortage Area for primary care, dentists, and mental health.

In addition to the Worcester County Health Department, consortium members include the Worcester County Department of Social Services and the Worcester County Commission on Aging.

Topic Areas

Dental

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Children’s Regional Oral Health Consortium (CROC) include the Eastern Shore Area Health Education Center (AHEC); the University of Maryland Dental School; two federally qualified community health centers, Choptank Community Health System, Inc. and Three Lower Counties, Inc.; and a local hospital, Shore Health System, Inc. Funds.

Areas Served

Six counties on the mid and lower Eastern Shore.

Target Population Served

To address disparities in access to, and use of, oral health care services for children and low-income families.

Program Director

Jacob F. Frego

Executive Director

Eastern Shore Area Health Education Center

814 Chesapeake Drive

P.O. Box 795

Cambridge, MD 21613

Phone: (410) 221-2600

Fax: (410) 221-2605

E-mail: jfrego@esahec.org

Website: www.esahec.org

Eastern Shore Area Health Education Center

Cambridge, MD 21613

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

In 2005, the Eastern Shore Oral Health Action Network (ESOHAN) was developed as a result of an Office of Rural Health Policy Network Development Planning Grant. The primary goal of the ESOHAN is to address disparities in access to, and use of, oral health care services for children and low-income families. Through this network planning process, a service delivery consortium was created to address oral health access issues, particularly in Dorchester County, Maryland. The members of the Eastern Shore Children’s Regional Oral Health Consortium (CROC) include the Eastern Shore Area Health Education Center (AHEC); the University of Maryland Dental School; two federally qualified community health centers, Choptank Community Health System, Inc. and Three Lower Counties, Inc.; and a local hospital, Shore Health System, Inc. Funds from the outreach grant will be used to improve the availability of and access to preventive, restorative, and rehabilitative oral health care for low-income children on the Eastern Shore.

On the Eastern Shore, dental disease and lack of access to dental care is one of the most pressing health care issues. Considerable oral health disparities remain in this area, especially among the low-income and pediatric populations. Children living on the Eastern Shore exhibit more dental disease than any other area of the State. All six counties in the CROC service area have been designated Dental Health Professional Shortage Areas. Historically, local dentists have not participated in the Medicaid program because of the low reimbursement rates and the complexity of processing claims, creating additional access barriers to dental care for low-income patients. There are no dentists in Dorchester County that accept medical assistance. Children with special health care needs and those with extensive dental disease requiring sedation have to travel at least 75 miles to Baltimore to access dental care.

CROC’s work plan focuses on low-income children who are uninsured or enrolled in medical assistance. The target population for Cambridge Dental Center includes the 3,900 children residing in Dorchester County who are eligible for medical assistance. The target population for the hospital-based pediatric dental program includes low-income children in the six counties on the mid and lower Eastern Shore. There are approximately 26,800 children in who are eligible for medical assistance MA in these six counties.

There are three components to the CROC Program: 1) the development of a comprehensive dental center in Dorchester County; 2) the development of a regional hospital-based pediatric dental program for the six mid and lower Shore counties; and 3) the development of community-based clinical and educational training opportunities for dental hygiene students on the Eastern Shore.

Topic Areas

Behavioral Health, Psychiatric Services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 196,543.00

· Year 2 - 183,124.00

· Year 3 - 190,139.00

Partners to the Project

The primary members of the consortium include Alcona Health Centers, Thunder Bay Community Health Services, Alpena General Hospital, and Northern Collaborative Care.

Areas Served

Iosco, Alcona, Montmorency, and Presque Isle—in the lower peninsula of Michigan.

Target Population Served

The target population is the more than 12,000 rural adults and children in the area estimated to be in need of mental health services, including psychiatric, counseling, and referral services. These individuals face multiple obstacles to services, including low income, lack of education, cultural barriers, rural isolation, stigma, lack of facilities and resources, funding disparities, and age discrimination.

Program Director

Nancy Spencer

Alcona Citizens for Health, Inc.

Alcona Health Centers

177 North Barlow Road

Lincoln, Michigan 48742

Phone: (989) 356-0673X3916

Fax: (989) 736-8380

Email: nspencer@ncc-mi.net

Alcona Health Centers

Lincoln, MI 48742

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

Integrated Behavioral Health Care of Northeast Michigan is an expansion and enhancement project that will build on an existing clinic-based behavioral health service program. Currently, the Alcona Health Centers and Thunder Bay Community Health Services have implemented the Strosahl integrated behavioral health model at six clinics in five northeast, lower peninsula Michigan counties with two behavioral health consultants and one clinical psychologist covering all six clinics, and there is a need for more behavioral health consultants. The project will provide new psychiatric services at four clinics and will add two new behavioral health consultants and neurological health services to address the needs of the substantial elderly population. In the integrated behavioral health care model, psychologists, psychiatrists, and behavioral health consultants will be integrated members of the primary care system at Alcona Health Centers and Thunder Bay Community Health Services. The expansion of services is holistic, cost-efficient, and very much needed. Eventually, telepsychiatry will be added to improve access to care.

The target area served by the consortium comprises four counties—Iosco, Alcona, Montmorency, and Presque Isle—in the lower peninsula of Michigan. The general population in the service area is 63,000, and the target population is the more than 12,000 rural adults and children in the area estimated to be in need of mental health services, including psychiatric, counseling, and referral services. These individuals face multiple obstacles to services, including low income, lack of education, cultural barriers, rural isolation, stigma, lack of facilities and resources, funding disparities, and age discrimination. The target population is very rural and has less access to adequate health care due to income, education, and transportation issues. There are 0.25 psychiatrists as well as one psychologist and two behavioral health consultants in the four-county service area. The main providers of behavioral health are primary care physicians. The primary reason patients are generally unable to access behavioral health services is the lack of qualified behavioral health specialists in primary health care settings. The target area is designated as a Health Professional Shortage Area and a Medically Underserved Area.

The primary members of the consortium include Alcona Health Centers, Thunder Bay Community Health Services, Alpena General Hospital, and Northern Collaborative Care.

Topic Areas

EMS Providers, Capacity Building

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

In addition to Sanilac Medical Services, Inc., the lead applicant, consortium members include the Huron County Medical Control Authority, Sanilac Intermediate School District, and Huron Intermediate School District.

Areas Served

The primary target audience is residents living in Huron and Sanilac counties located in the “Thumb” of the mitten-shaped state of Michigan.

Target Population Served

The primary target audience is residents living in Huron and Sanilac counties located in the “Thumb” of the mitten-shaped state of Michigan.

Program Director

Kathy E. Balcer

Sanilac Medical Services, Inc.

119 East Sanilac Road, Suite 1

Sandusky, Michigan 48471-1184

Phone: (810) 648-3092

Fax: (810) 648-2513

Sanilac Medical Services, Inc.

Sandusky, MI 48471-1184

ORHP Contact:

Jacob Rueda

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0835

jrueda@hrsa.gov

Project Summary

The Huron-Sanilac Emergency Medical Services (EMS) Volunteer Recruitment and Retention Project will aggressively seek to reverse the declining number of active EMS providers in this rural area of Minnesota. The project goal is to increase EMS volunteers for Huron and Sanilac counties from 246 to 300 licensed volunteers, with an increase in advanced certifications of 5 percent. This will enable Huron and Sanilac counties to replace outgoing EMS volunteers and build their volunteer rosters. A two-pronged approach includes capacity building and outreach. Project strategies include increasing access to EMS training, reducing barriers to EMS training and service, increasing awareness of the value and importance of EMS, and increasing incentives for EMS volunteers.

The primary target audience is residents living in Huron and Sanilac counties located in the “Thumb” of the mitten-shaped state of Michigan. The Thumb is a sparsely populated area with a disproportionately high number of residents age 65 and older. Health care providers are challenged with meeting the needs of large populations of senior citizens and low-income residents. Both counties are low-income Health Professional Shortage Areas. Because of the overwhelming need for EMS in rural areas, all residents in Huron and Sanilac counties are beneficiaries of the program. In Huron County , 14.6 percent (5,135) of residents live in townships that are designated as Medically Underserved Communities. In Sanilac County, 44.6 percent (19,865) residents live in such designated areas. Four of the six local hospitals are Critical Access Hospitals, and 10 EMS services meet guidelines for a Critical Access Ambulance Model.

Topic Areas

Obesity/overweight

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Huron and Sanilac Counties

Target Population Served

The Task Force has emphasized the need to address childhood obesity and reach youth who have a greater propensity for change than adults.

Project Summary

The Thumb Area Nutrition and Physical Activity Campaign is a result of a community health assessment conducted by the Thumb Rural Health Network. Results indicated that the overarching issue related

Program Director

Ann Hepfer

Tuscola County Health Department

1309 Cleaver Road, Suite B

Caro, MI 48723

Phone: (989) 673-8114, ext. 115

Fax: (989) 673-6191

E-mail: ahepfer@tchd.us

Tuscola County Health Department

Caro, MI 48723

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

to death rates from heart disease, diabetes, and other chronic disease is obesity. Despite numerous health education programs that address nutrition and physical activity, 66.5 percent of adult residents and 40 percent of youth are overweight or obese. The proposed project is the result of 15 months of research and planning by the task force.

The Tuscola County Health Department will provide project management and partner with three Michigan State University Extension Services, health departments in Huron and Sanilac Counties, and rural hospitals to implement the project. The Task Force has four long term goals: 1) To increase the proportion of adults who are at a healthy body mass index (BMI) from 33.8 percent to 38.8 percent by 2015; 2) To reduce the proportion of adults who are obese from 28.8 percent to 26.8 percent by 2015; 3) To reduce the proportion of children and adolescents that are overweight or obese from 40 percent to 30 percent by 2015; and 4) To increase the proportion of children and adolescents ages 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.

The Thumb Steps Up Task Force has developed a community-wide campaign that goes beyond health education. The campaign is based on State models and Centers for Disease Control and Prevention-recommended programs. Interventions include community outreach and health promotion. Project activities include a social marketing campaign; community presentations; community activity programs; promoting local and State recognition programs for “Promoting Activity Communities” and “Healthy Eating”; and providing technical assistance to grocers, restaurants, human service providers, governmental bodies, schools, and worksites. The Task Force has emphasized the need to address childhood obesity and reach youth who have a greater propensity for change than adults. Research shows that, to impact youth, the adults and environment that they live in must also be changed. Therefore, children, their families, and the communities where they live will be the priority population targeted for interventions. Major outcomes include:

· Outcomes 1 & 2: 60 percent of focus group participants will indicate social marketing messages are credible and have the ability to influence behavior.

· Outcome 3: 90 percent of food outlets/suppliers that participate in an assessment increase their score.

· Outcome 4: Pre- and Post-Health Risk Appraisal Reports indicated a significant improvement in health indicators related to obesity.

· Outcome 5: Nine communities will receive awards from the Michigan Promoting Active Communities Program by 2009.

· Outcome 6: Nine schools complete assessments and have a Health Improvement Plan.

· Outcome 7: The percentage of youth exhibiting healthy eating behaviors will increase significantly.

· Outcome 8: The percentage of youth exhibiting physical activity behaviors will increase significantly.

Topic Areas

Obesity/overweight

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,988.00

· Year 2 - 124,999.00

· Year 3 - 100,000.00

Partners to the Project

The consortium partners are Mackinac Straits Hospital , a critical access hospital, and Marquette General Health System, a 364-bed regional referral center.

Areas Served

The project targets families in three counties in Michigan’s Upper Peninsula—Luce Mackinac, and Marquette.

Target Population Served

These youth are likely to become overweight adults with all the serious health conditions, psychological issues, and health care costs that arise with excess weight and energy imbalance.

Program Director

Laura Frisch, F.N.P.

Helen Newberry Joy Hospital

502 W. Harrie Street

Newberry, MI 49868-1209

Phone: (906) 477-6066

E-mail: frischla@portup.com

Helen Newberry Joy Hospital

Newberry, MI 49868-1209

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The problem is clear: Michigan has the third highest obesity rank in the United States, with 62 percent of adults being overweight or obese. Our children are following in our footsteps. Eleven percent are considered overweight, and 13 percent are at risk for overweight. These youth are likely to become overweight adults with all the serious health conditions, psychological issues, and health care costs that arise with excess weight and energy imbalance.

Two critical access hospitals have joined with their regional referral center to reduce the proportion of children and adolescents who are overweight or obese. The project targets families in three counties in Michigan’s Upper Peninsula—Luce Mackinac, and Marquette. These counties are home to 83,601 people. State statistics suggest there are 5,598 youth ages 5-19 in the service area who are overweight or obese.

This project takes a practical, scientific approach to what is often an emotional issue. We recognize three specific needs:

· Families lack knowledge and basic skills for translating scientific information on nutrition and exercise into everyday practice, which results in less than optimal growth and development for youth.

· Youth who have a high potential for developing metabolic syndrome often experience delayed entry into appropriate services.

· Rural communities lack the critical mass and specialty expertise to provide evidence-based programming for youth weight loss.

Local autonomy will be combined with cooperative regional efforts and evidence-based models for prevention, early identification and treatment. Site coordinators will be placed in each community to implement project activities and coordinate with local stakeholders. Consortium partners will cooperate to develop and deliver coordinated awareness and education curricula, to offer local screenings for metabolic syndrome, and to deliver a video-conferenced treatment program that will demonstrate a reduction in body mass index and improved lab values related to chronic diseases. Local staff will provide patient follow-up and communication streams among health care providers. An evaluation team, headed by a nationally recognized researcher at Northern Michigan University will conduct evaluation for process and outcome measures.

The applicant is Helen Newberry Joy Hospital and Healthcare Center, a critical access hospital with an attached long-term care facility, a rural health clinic, and three outreach health clinics. The consortium partners are Mackinac Straits Hospital, a critical access hospital, and Marquette General Health System, a 364-bed regional referral center. Staff will be dedicated to this project within each partner organization, strengthening each partner’s role while cooperating on all activities. An advisory group of project staff, community stakeholders, and representatives from the target group will oversee this project.

Topic Areas

School-based

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Collaborative efforts among six consortium members: Eastern Upper Peninsula Intermediate School District, Brimley Area Schools, Rudyard Area Schools, Engadine Consolidated Schools, War Memorial Hospital, and Mackinac Straits Hospital.

Areas Served

Eastern Upper Peninsula Intermediate School District.

Target Population Served

The consortium will target the 4 - 18 age population, with approximately 40% Native American and 60% Caucasian ethnicities. The school based health clinics will result in 4,500 health service encounters during the first year for 400 children.

Program Director

Mary Kaye Ruegg

Eastern Upper Peninsula Intermediate School District

P.O. Box 883

315 Armory Place

Sault Ste Marie, MI 49783

Phone: (906) 632-3373, ext. 143

Fax: (906) 632-1125

E-mail: mruegg@eup.kl2.mi.us

Eastern Upper Peninsula Intermediate School District

Sault Ste Marie, MI 49783

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Project Summary

The Road to Good Health project begins with a unique approach to providing health care to extremely rural communities by developing a consortium of schools and health care providers to establish school based health clinics at three school sites. Collaborative efforts among six consortium members: Eastern Upper Peninsula Intermediate School District, Brimley Area Schools, Rudyard Area Schools, Engadine Consolidated Schools, War Memorial Hospital, and Mackinac Straits Hospital. The consortium will target their efforts to the areas with the “worst of the worst” health care access according to the U.S. Department of Health and Human Services Health Resources and Services Administration designations: Trout Lake, Dafter, Chippewa, Superior, Garfield, and Bay Mills Townships. Goals of the Road to Good Health are: 1) To work together to strengthen the collaborative relationships within the consortium and expand to include additional health care providers and, 2) To capitalize on existing building and transportation infrastructure to overcome geography and inclement weather (typical barriers to access to health care in northern climates) to provide high quality health care at early stages of life for rural residents with limited health access.

Children in these townships face every possible barrier to receiving high quality health care. In addition to being federally-designated Medically Underserved Populations, the following barriers exist: elevated rates of chronic illness, unemployment rates that exceed the state average, excessive rates of single-parent families, extreme poverty, heightened rates of abuse and neglect, high rates of working parents in minimum wage jobs, extremely rural location, few health care providers, high uninsured rates, extreme weather conditions, treacherous roads, isolation, and few recreational or cultural draws for new medical providers. These are the needs we will address through school based health clinics.

A community needs assessment shows that the biggest barriers to health care access in the region are transportation, lack of insurance (1 0% -1 3% of our children are uninsured, compared to 8% uninsured in the State of Michigan), and schedule conflicts for working parents. The school based health clinics will address these barriers by bringing the services to the children, along with an aggressive insurance outreach component. A nurse practitioner and social worker/therapist will provide 70 hours/week of prevention and education activities, as well as primary care and mental health services for the designated school districts. The consortium will target the 4 - 18 age population, with approximately 40% Native American and 60% Caucasian ethnicities. The school based health clinics will result in 4,500 health service encounters during the first year for 400 children.

Topic Areas

Medical, dental, vision and mental health services

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Dental Clinics North, The Traverse Bay Area Intermediate School District, Community Health Clinic, Inc., and The Grand Traverse Regional Health Care Coalition.

Areas Served

Northwest Michigan

Target Population Served

The target population is 62,250 people from 5 years old to seniors all of whom are low-income or highly vulnerable to oral disease.

Project Summary

The Grand Traverse Regional Health Care Coalition (GTRHCC) is a community-based network with a mission to improve access to

Program Director

Arlene Brennan

The Grand Traverse Regional Health Care Coalition

3155 Logan Valley Road

Traverse City MI 49686

Phone: (231) 935-0799

Fax: (231) 935-0795

E-mail: brennangtrhcc@charterinternet.com

The Grand Traverse Regional Health Care Coalition

Traverse City MI 49686

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

medical, dental, vision, and mental health for those underserved citizens in our area in Northwest Michigan.

Summary of the Need—The target population is 62,250 people horn 5 years old to seniors all of whom are low income or highly vulnerable to oral disease. This represents 37% of the total population in the 5 county area. The evidence is clear, from our interviews and focus group of members of the target group, that they have no access to dental care. This group does not visit the dentist, 27% has active decay, and 18% look forward to having no natural teeth by age 65. The incidence of sealant protection and fluoride protection is 18%. Even with Medicaid for children only 25% of all children are receiving preventive care. This is a dental profession underserved area.

Our Partners—Our partner organization, Community Health Clinic, Inc has been in existence for 28 years and has been providing some dental care to low income patients they serve. The Clinic has formed successfully a small volunteer dentist program to provide emergency procedures. Last year, the Clinic provided approximately $62,000 of free dental care. Another partner is Dental Clinics North who provides dental services. Traverse Bay Intermediate School District is working with us to launch the school based programming.

Our Goals—Our clients indicate that they need access to dental care and a “Dental Home”. These goals are important for Health People 2010. This Collaborative will attack dental access by integrating existing resources of our community as well as adding resources to meet the needs. To really make a difference one dental record will be used in all Coalition service areas as our partner, Dental Clinics North will allow us to use its innovative Health Information Technology (paperless dental record).

Our program is multi-fold:

· School Age Programs

Ø Give Kids a Smile: oral health education, nutrition, cleaning, fluoride treatment, application of sealants, oral exams, and referral to local dentists for treatment to every student in all schools in the 5 county area (approximately 28,800 students)

Ø School Referrals - in cooperation with the health department and TBAISD, provide exams and preventive treatments at its Career Technology campus for students from 10 - 19 and refer them for appropriate treatment

· Expand the existing volunteer Dentist program to encourage all dentists and hygienists to contribute 4% of annual revenue, so as spread the treatment load over all dental professionals.

· Establish a Mobile Dental Clinic which will become the “Dental Home” for these patients with staffing drawn from an organized Volunteer Dental Program to include preventive and treatment by volunteer hygienists, assistants, and dentists

· Enhance the existing Northern Dental Plan (which provides reduced fee dental service) to allow payroll deductions of the patient pay amount.

Benefits—The 3 year outreach grant funding will allow the Collaborative to improve the oral health in this community by providing access to those who are most vulnerable: those with low income and children. This effort is sustainable because of the broad collaborative of support and by the program design. The difficult part is getting the processes in place. The Coalition will supplement HRSA grant funds with the help of our community-based collaborative.

Topic Areas

School (nutrition)

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 149,918.00

· Year 2 - 124,998.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Baraga, Houghton and Keweenaw counties in Michigan’s Upper Peninsula are rural, rugged and remote.

Target Population Served

The project will serve 400 preschool aged children and 400 parents per year. Families to be served will typically be considered at risk for several reasons: including low family income, single-parent household, history of substance abuse and other factors identified through the state of Michigan’s risk factor index.

Program Director

Teresa Frankovich, M.D., M.P.H., FAAP

BHK Child Development Board

700 Park Avenue

I-Ioughton, MI 49931

Phone: (906) 482-3663

Fax: (906) 482-7329

E-mail: tlfranko@bhkfirst.org, bhk@,bhkfirst.org

Baraga-Houghton-Keeweenaw

I-Ioughton, MI 49931

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Project Summary

Baraga, Houghton and Keweenaw counties in Michigan’s Upper Peninsula are rural, rugged and remote. The region, known as the Copper Country for its copper-mining past, is home to approximately 1,500 children aged 3 to 5. The area has higher overweight/obesity rates, poverty rates, and alcohol and tobacco use rates than the state of Michigan. This in turn raises the community’s risk for chronic illnesses such as cardiovascular disease, diabetes and cancer. Long, snowy winters and extreme travel distances (residents live in towns, townships and rural locations spread across a 2,504-square-mile area with a population density of 19 people per square mile) contribute to isolation and sedentary lifestyles. Health services beyond basic medical care are mostly non-existent.

The Healthy Families Project is a collaboration between BHK Child Development Board, an $8-million non-profit agency that operates Head Start programs; Portage Health, the community’s leading healthcare provider; and the Western U.P. District Health Dept., the region’s state-funded public health and education organization. The project seeks to improve the health and wellness of rural families with young children. The project has three cornerstone goals, each of which has specific, measurable objectives. The goals, which align with Healthy People 2010 goals, are to: 1) To improve the health and wellness of 400 preschool children; 2) To increase the health and wellness of 400 families with preschoolers; 3) To further expand collaboration between agencies/institutions promoting wellness and disease prevention and to increase utilization of their services by community members. Key activities include inclusion of research-based and validity tested physical activity and nutrition curricula in preschool classrooms; parent-involvement activities including out-of-classroom and out-of-home wellness educational classes and sessions, use of three regional Family Wellness Centers with adult and child exercise areas, educational information and health homework and special events such as sledding trips; and development of a communitywide Healthy Families Advisory Group to expand collaboration among service providers and increase service utilization rates. BHK Health Director and pediatrician Teresa Frankovich, M.D., M.P.H., will serve as project director. Erin Carter, M.S. (exercise physiology) will serve as Project Coordinator. Contractual staff will include dieticians, health educators and experienced fitness staff. An independent Ph.D.-level evaluator will conduct an independent evaluation. The project requests funding preference for these two reasons: 1) HPSA; 2) Project Focus-Wellness and Disease Prevention.

Topic Areas

Mental Health Services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 180,835.00

· Year 2 - 185,993.00

· Year 3 - 191,300.00

Partners to the Project

Consortium members include Northwestern Mental Health Center, the lead applicant; Mahnomen County Human Services; Mahnomen Health Center; Independent School District No. 432; and White Earth Reservation Health Services.

Areas Served

Mahnomen County is designated as a primary medical care Health Professional Shortage Area and a Medically Underserved Area.

Target Population Served

Program Director

Brenda Anderson

Northwestern Mental Health Center

603 Bruce Street

Crookston, Minnesota 56716

Phone: (218) 281-3940

Fax: (218) 281-6261

Northwestern Mental Health Center

Crookston, MN 56716

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The Mahnomen County Mental Health Consortium will focus on at-risk children and adolescents and their families, while expanding access of the general population to short-term outpatient services to ensure earlier intervention for individuals and families. The consortium will provide professional home-based mental health therapy services to children and adolescents and their families, with special emphasis on children and adolescents involved in the criminal justice system. It also will provide school-based mental health services to improve both social and academic performance, reduce school dropouts, and decrease out-of-home placements. Functional family therapy and family group decision-making will be adapted to address the special cultural needs of Native American children and families. Outpatient services will be initiated to ensure access to all populations to improved crisis management and to better integrate mental health with primary health services, particularly relevant to the Native American population. The project will establish an interagency process for coordinating early identification, screening, assessment, and intervention. Goals of the project are (1) to develop an interagency network of health, mental health, and human service agencies to implement early identification, screening, referral, and intervention to address the needs of at-risk families, children, and adults in need of mental health care; and (2) to improve access to mental health resources for county residents.

The target population is at-risk children and adolescents and their families in need of multiple services in Mahnomen County, a small rural county in northwestern Minnesota located entirely within the boundaries of the White Earth Indian reservation. The county has a diverse population of 5,215 people, including a significant number of Native Americans (28.6 percent of the population). With 30.9 percent of the population living in poverty, the area is among the poorest in the state and has the lowest per capita income in Minnesota. Unemployment is 8.1 percent. If estimates of the unemployed were expanded to include unemployed people who are no longer actively seeking work, the percentage of unemployed people in the county would approach 50 percent.

County residents experience mental health problems that are among the most serious of any county in the state. The challenges of poverty, cultural diversity, a failing rural economy, and natural disasters—all barriers to accessing services—also contribute to the need for mental health services. Mahnomen County is designated as a primary medical care Health Professional Shortage Area and a Medically Underserved Area.

Topic Areas

Women’s Health

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 180,019.00

· Year 2 - 194,670.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include Cass County Health, Human, and Veterans Services; Todd County Public Health; Wadena County Public Health; CentraCare Clinic; Dakota Clinic–Walker; Dakota Clinic–Menahga; Pine River Family Clinic; Wadena Medical Center; and Ottertail Wadena Community Action Council.

Areas Served

Cass, Todd, and Wadena counties, the low-income, primarily rural area the project will serve.

Target Population Served

The target population is women of reproductive age, with an emphasis on low-income or uninsured/underinsured women.

Program Director

Ane C. Rodgers

Cass County Health, Human and Veterans Services

400 Michigan Avenue, West

P.O. Box 40

Walker, Minnesota 56484-0040

Phone: (218) 547-1340, ext. 210

Fax: (218) 547-7232

Cass County Health, Human and Veterans Services

Walker, Minnesota 56484-0040

ORHP Contact:

Julie Bryan

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4223

jbryan@hrsa.gov

Project Summary

The overall goal of the program is to foster increased capacity and resources to assure rural health delivery of quality programming for women’s health, including family planning and risk reduction services in three counties in north central Minnesota. The four program goals include improving access to family services, reducing unintended pregnancy, improving the quality of women’s health care services, and improving communication between providers through consortium involvement and improved technology capabilities.

A primary point of access for women during reproductive age is for contraceptive care, and the project seeks to improve acceptance of and access to this service and to make this service more comprehensive for all women. Women will receive contraceptive care and assessment/referral for issues relating to their health. The project will use a community clinic model of service delivery and will work with family planning and general practitioners to build capacity to serve women in a holistic manner.

Unintended pregnancy is a high-priority public health problem in Cass, Todd, and Wadena counties, the low-income, primarily rural area the project will serve. The target population is women of reproductive age, with an emphasis on low-income or uninsured/underinsured women. The majority of the population in all three counties is white. The American Indian population (10.8 percent in Cass County, 0.5 percent in Todd County, and 0.6 percent in Wadena County) receives most services from the Indian Health Service, but the project will serve part of that population in outlying clinics. Todd County has a growing Hispanic community (8 percent), which the project will include as part of the target population.

Many residents in all three counties live in isolation, miles away from medical services, and must travel 75 to 80 miles to receive subsidized family planning services. Many of the most at-risk women have unreliable transportation, making access to care difficult. Other barriers to access include cost and the lack of insurance. A large percentage of the population is uninsured. Thirty percent of the population delay or fail to seek medical care because of cost or lack of insurance. All three counties are designated Health Professional Shortage Areas for primary care and Medically Underserved Areas. The project population is a Medically Underserved Population.

Topic Areas

Dental

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The project consortium also includes the University of Minnesota School of Dentistry, which will help staff the Dental Clinic with dental students; Southern Minnesota Area Health Education Center, which will support the dental students and provide links to K-12 and community resources; and Kandiyohi County Public Health and Countryside Public Health, two public health agencies currently serving the target population in the 12-county service area, who will provide the critical link to the target population.

Areas Served

The goal of the Rice Regional Dental Clinic is to increase access to dental care for uninsured and underserved residents in the 12-county service area of west central and southwest Minnesota.

Program Director

Lawrence Massa

Chief Executive Officer

Rice Memorial Hospital

301 Becker Avenue SW

Willmar, MN 56201

Phone: (320) 231-4227

E-mail: lorry@rice.willmar.mn.us

Rice Memorial Hospital

Willmar, MN 56201

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Target Population Served

The dental clinic’s target population is underserved residents in the 12-county service area, including public program patients and others who lack dental insurance or the means to access care.

Project Summary

The Surgeon General’s 2002 Report on Oral Health recognizes oral health as a significant health care concern that especially burdens the poor, children, minorities, and the elderly. Minnesota is facing major problems in dental care delivery stemming from current dental workforce shortages and rising health care costs—challenges that are exacerbated in rural communities.

The goal of the Rice Regional Dental Clinic is to increase access to dental care for uninsured and underserved residents in the 12-county service area of west central and southwest Minnesota. Strategies to support this goal include: 1) providing dental care for uninsured and underserved residents in the service area; 2) promoting careers in dentistry among people living in the area through education and public service; 3) engaging area dentists and dental hygienists in public service; 4) increasing the number of dentists and dental hygienists choosing to practice in the service area; 5) providing opportunities for inter-professional education; and 6) strengthening the dental clinic infrastructure.

The dental clinic’s target population is underserved residents in the 12-county service area, including public program patients and others who lack dental insurance or the means to access care. Eight of the twelve counties are federally designated Dental Health Professional Shortage Areas. In addition to being home to a large number of American Indians, the 12-county service area includes a significant number of ethnic minorities, including Somali, Latino, and Sudanese populations.

The Rice Regional Dental Clinic will be constructed on the campus of Rice Memorial Hospital in Willmar, Minnesota. The clinic will feature a unique dental education model. Once it is fully operational, an estimated six dental and dental hygiene students will rotate through the clinic and provide patient care on a year-round basis, supervised by the clinic’s staff, which includes a full-time University of Minnesota School of Dentistry faculty member, two dental assistants, and a dental hygienist. An estimated 8,100 patient visits will be conducted annually once the dental clinic is fully operational.

Rice Memorial Hospital is the largest city-owned hospital in Minnesota and has a history of commitment to outreach. The project consortium also includes the University of Minnesota School of Dentistry, which will help staff the Dental Clinic with dental students; Southern Minnesota Area Health Education Center, which will support the dental students and provide links to K-12 and community resources; and Kandiyohi County Public Health and Countryside Public Health, two public health agencies currently serving the target population in the 12-county service area, who will provide the critical link to the target population.

Topic Areas

Maternal/Child Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Partnership with Red Lake Children and Family Services, the Cass Lake Family Center, and Community Resource Connections, Inc.

Areas Served

Medically underserved populations in Northern Minnesota.

Target Population Served

To initiate a collaboration to provide the only early crisis intervention family support services available to American Indian youth and families within a 2-county area in rural, northern Minnesota.

Project Summary

Evergreen House requests a federal Rural Health Outreach Grant from HRSA in the amount of $375,000 over three years (May 2007

Program Director

Gary Russell

Evergreen House, Inc.

622 Mississippi Avenue

P.O. Box 662

Bemidji, MN

Phone: (218) 751-4332

Fax: (218) 751-8070

E-mail: gary@evergreenhouse.org

Evergreen House, Inc.

Bemidji, MN 56619

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

through April 2010) to initiate a collaboration to provide the only early crisis intervention family support services available to American Indian youth and families within a 2-county area in rural, northern Minnesota. Both counties are eligible rural counties and are Medically Underserved Areas (MUAs) as well as Health Professional Shortage Areas (HPSAs). This represents a needed expansion of early intervention child and family mental health services in rural, northern Minnesota, which is home to the three largest American Indian tribes in Minnesota.

The Evergreen Shelter currently provides early intervention family support services in Bemidji, Minn. A HRSA grant would enable the Shelter to hire a second family counselor whose time would be designated for providing services at the Red Lake Tribe’s Children and Family Services Department for 2 days each week, the Cass Lake Family Center (serving the Leech Lake Tribe) for two days each week, and allow one day per week in Bemidji at the Evergreen Shelter for service coordination, team meetings, and supervision. Early Intervention Family Support Services would provide approximately 60 families annually with counseling services to: encourage early identification and assessment of mental health issues for youth and/or parents, promote dental health care and annual physicals for youth referred for a residential stay at the Evergreen Shelter.

The project will serve a poverty-level and low-income Native American population – both adolescents and their families - who have behavioral and mental health issues that affect their health and safety. The majority of clients have no outside health insurance and rely primarily upon Indian Health Service hospitals and clinics. Native youth and families served will be those living on the Leech Lake and Red Lake Reservations in northern Minnesota (both are federally-recognized tribes) as well as Native Americans living in Bemidji. Both reservations are designated Medically Underserved Areas and their populations are designated Medically Underserved Populations. The two reservations are also designated Health Professional Shortage Areas.

The program’s objectives are: 1) to stabilize crisis situations for youth and families served; 2) to improve access to formal mental health treatment services and diagnostic assessments; 3) to improve access to chemical health assessments that can result in treatment services; 4) to improve family relationships and family communication for youth and families receiving counseling; and 5) to increase youth and family use of other health care services and community resources.

Topic Areas

Primary Health Care, Prevention Services, Health Education

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 196,236.00

· Year 2 - 185,750.00

· Year 3 - 178,123.00

Partners to the Project

Consortium members include the Claiborne County Public School District, Claiborne County Hospital, and West Central Public Health District 5 of the Mississippi State Department of Health.

Areas Served

Claiborne County is a designated Health Professional Shortage Area as well as a Medically Underserved Area/Medically Underserved Population.

Target Population Served

The target population is students in the Claiborne County Public School District.

Program Director

Coney L. Johnson

Claiborne County Family Health Center

P.O. Box 741

Port Gibson, Mississippi 39150-0741

Phone: (601) 437-3052

Fax: (601) 437-3051

Claiborne County Family Health Center

Port Gibson, MS 39150-0741

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Project Summary

The Claiborne County Rural Health Care Services Outreach project, established by the Claiborne County Family Health Center (CCFHC) and consortium partners, will operate three school-based health clinics to provide primary health care, prevention services, and health education on topics such as diet, nutrition, exercise, high-risk behavior prevention, and tobacco use prevention to students in grades K–12 students in the Claiborne County Public School District. The project also will provide immunization tracking as well as reproductive, dental, and mental health services. Age-specific programs will educate students on becoming responsible for their own health and practicing preventive health. Programs will include personal hygiene, health as part of one’s lifestyle, obesity/weight management classes, reproductive health/abstinence education, building positive self-esteem, and assessment for at-risk behavior or at-risk psychosocial environment factors. The school program will operate on a year-round basis approximately 40 hours a week. CCFHC and the county hospital will offer backup services when the school clinics are closed or when additional health care services are needed.

The service area, Claiborne County, is located in the mid-Mississippi Delta region—the poorest region of the United States. The target population is students in the Claiborne County Public School District. Currently, there is limited access to health care in the schools. The majority (approximately 99.8 percent) of the students in the Claiborne County School District are African American, 72 percent of whom are estimated to be at or below the 200‑percent Federal poverty level. Of the state’s 82 counties, Claiborne ranks 26th in the percentage of births to teens; almost 21 percent of all the babies born in the county are born to teenagers. Barriers to health care in the county mirror the socioeconomic and health care problems of the Delta region, ranging from lack of indoor toilets to illiteracy. The Delta region has one of the highest illiteracy rates in the Nation, with only 54 percent of the adult population completing high school. In addition to depressed economic conditions and low educational attainment, other barriers include the absence of public transportation and lack of other transportation and phone service.

Claiborne County is a designated Health Professional Shortage Area as well as a Medically Underserved Area/Medically Underserved Population. The county has only three physicians with a physician-to-patient ratio of 1:4,469.

In addition to CCFHC, the lead applicant, consortium members include the Claiborne County Public School District, Claiborne County Hospital, and West Central Public Health District 5 of the Mississippi State Department of Health.

Topic Areas

Behavioral Health Care

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 192,941.00

· Year 2 - 192,292.00

· Year 3 - 199,910.00

Partners to the Project

In addition to Princeton R-V School District, the lead applicant, consortium members include Cainsville R-I School District; Newtown-Harris R-III School District; North Mercer R-III School District; Spickard R-II School District; North Central Missouri Mental Health Center; Harrison County Community Hospital; Mercer County Health Department; Northeast Family Health Clinic; Mercer County Office, Missouri Department of Social Services; and National Alliance of the Mentally Ill of Missouri.

Areas Served

Mercer County is a designated Health Professional Shortage Area as well as a Medically Underserved Community and Medically Underserved Population.

Target Population Served

Seeks to increase access of children and isolated rural farm families to behavioral health care by providing outreach and education resources and promoting greater community involvement in an integrated network of services.

Program Director

Cheryl Snapp

Princeton R-V School District

1008 East Coleman Street

Princeton, Missouri 64673-1210

Phone: (660) 748-3211

Fax: (660) 748-3212

Princeton R-V School District

Princeton, MO 64673-1210

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The Mercer County Behavioral Health Outreach Project seeks to increase access of children and isolated rural farm families to behavioral health care by providing outreach and education resources and promoting greater community involvement in an integrated network of services. The four goals are as follows: Goal 1 focuses on school-based identification, problem-solving, and documentation of students with behavioral health problems. Goal 2 involves linkages of school-based children and their families to intensive behavioral health services, faculty and staff consultation, counseling, and referrals. Goal 3 focuses on services to behavioral at-risk children and their families through countywide asset-building activities. Goal 4 involves the training of specialists and staff and development of a new rural behavioral health/emergency disaster health care outreach network of project partners.

The service area is rural Mercer County, which is a farming area located in north central Missouri along the Iowa-Missouri border. It is one of the state’s most poor, isolated, and distressed areas. The target population is 921 Mercer County students and 124 farm families in the context of family, school, and community. The county is 98.7 percent Caucasian. In 2002, there were 3,669 residents with a median age of 42.4. Depression is a major health issue, and the county has the state’s highest suicide rate. The county does not have a mental health facility, and behavioral health problems afflict both school-age children and adults, especially those living in isolated farm families or alone.

Access barriers include rural isolation, unstable family environments, poverty, and lack of transportation. Mercer County is a designated Health Professional Shortage Area as well as a Medically Underserved Community and Medically Underserved Population.

Topic Areas

Primary Health Care, Health Education, Social Support Services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include the District III Area Agency on Aging, Lafayette County Health Department, Lafayette Regional Health Center, and Rodgers-Lafayette Health Center.

Areas Served

The target population is medically underserved and uninsured residents of Lafayette County, Missouri.

Target Population Served

Rural health education and outreach project, is to improve access to primary care health and social support services in the county through an integrated network of local providers.

Project Summary

The goal of the Lafayette County 4 Health Project, a rural health

Program Director

Kathleen Anne Howard

District III Area Agency on Aging

106 West Young Street

Warrensburg, Missouri 64093-1124

Phone: (660) 747-3107

District III Area Agency on Aging

Warrensburg, Missouri 64093-1124

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

education and outreach project, is to improve access to primary care health and social support services in the county through an integrated network of local providers. The project will incorporate community education and outreach approaches to connect vulnerable, low-income populations to an integrated network of local health and social support services. In the first year, the project will use community education and health promotion activities to address disease prevention issues and mental health topics with a special emphasis on domestic violence and child abuse. The project, which includes outreach to the seasonal migrant community, will strengthen and expand a referral process among local providers by developing a technology-aided management information system to expedite patient scheduling, intake, and follow-up.

The target population is medically underserved and uninsured residents of Lafayette County, Missouri. There is little ethnic diversity in the population, which is 96.6 white, 2.6 percent African American, 1.2 percent Latino, 0.5 percent Asian/Pacific Islander, and 0.9 Native American. The target population includes nearly 500 seasonal migrant workers and their families. Of the county population of 32,960, 25.5 percent of the residents have incomes at or below 200 percent of the Federal poverty level. In addition to poverty, barriers to accessing services include distance, transportation difficulties, lack of insurance, and lack of providers. There are 19,466 uninsured individuals in the county, and the entire population is classified as underserved because of the dearth of medical providers. The physician-to-population ratio is 3,619:1. Lafayette County is a designated Health Professional Shortage Area.

Consortium members include the District III Area Agency on Aging, Lafayette County Health Department, Lafayette Regional Health Center, and Rodgers-Lafayette Health Center.

Topic Areas

Mobile (Oral, HL)

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Southeast Missouri State University, Campbell Housing Authority, Delta Area Economic Opportunity Corporation (DAEOC), Oasis Center, and Trinity Community Church

Areas Served

The four southernmost counties located in the Missouri Bootheel, a rural, economically depressed area with critical health care needs represented by a range of health disparities.

Target Population Served

Dunklin, Mississippi, New Madrid and Pemiscot counties) have been well documented.

Project Summary

The Southeast Health On Wheels (S.H.O.W.) Mobile Project is a

Program Director

Sandy Ortiz

Southeast Missouri State University

One University Plaza, MS 1900

Cape Girardeau, MO

Phone: (573) 651-5980

Fax: (673) 651-5981

E-mail: sjortiz@semo.edu

Southeast Missouri State University

Cape Girardeau, MO 63701

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

mobile health literacy, health promotion, disease prevention, direct primary care program. The program is designed to serve the four southernmost counties located in the Missouri Bootheel, a rural, economically depressed area with critical health care needs represented by a range of health disparities. The program is administered by the College of Health and Human Services of Southeast Missouri State University. The success of this program is significantly enhanced by the active collaboration and partnership with area organizations and agencies, including a specific consortium of local grassroots organizations, faith-based groups and care providers.

The needs of the target population (Dunklin, Mississippi, New Madrid and Pemiscot counties) have been well documented. The residents of the target counties experience significantly higher rates of teen pregnancy, inadequate prenatal care, infant death rates, asthma hospitalization rates, diabetes hospitalization rates, cardiovascular disease deaths, and deaths attributed to smoking when compared to state-wide data. Additionally, residents of the target counties experience more frequent emergency room visits for chronic illness when compared to the state rates. The four target counties have also been identified as having “significantly higher” age-adjusted death rates for all causes.

Services provided by the S.H.O.W. Mobile include, but are not limited to, health literacy programs and activities (monthly national themes will be addressed as well as interventions relevant to individuals/groups as requested indicated), health promotion interventions (physical examinations and dental sealants/fluoride), disease prevention activities (vision, hearing, depression, cholesterol, blood pressure, nutrition, diabetes, and dental screenings), and the provision of primary care (diagnosis of acute episodic illness as well as diagnosis and management of chronic conditions). Telehealth services will provide residents of the target population the opportunity for sub-specialist care. The programs and services of the S.H.O.W.

Mobile will be available to all residents of the target counties, realizing that many residents are uninsured, underinsured, or face significant access to care barriers. A well documented and recurring theme identified as a barrier to care has been transportation. The mobile nature of this project serves to address this barrier.

The target population of the S.H.O.W. Mobile resides in the four southern most counties of the Missouri Bootheel: Dunklin, Mississippi, New Madrid, and Pemiscot. The residents of these counties experience higher than average poverty and unemployment rates, are geographically isolated, and have limited opportunities for educational attainment and economic stability. All of the target counties have been identified as either geographic or low income Primary Care Health Professional Shortage Areas (HPSA) as well as Medically Underserved Areas (MUA) and/or Medically Underserved Populations (MUP).

The amount of funding being requested for this project is $150,000 in Year One

($375,000 over three years).

Topic Areas

Child Sexual Abuse, Education/Prevention

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 191,318.00

· Year 2 - 165,475.00

· Year 3 - 155,267.00

Partners to the Project

Community partners in the consortium include the Butte Silver Bow Primary Health Care Clinic, Inc., the lead applicant; St. James Healthcare; Butte Silver-Bow Law Enforcement Detectives; Butte Silver-Bow County Attorneys Office; Butte Office of Department of Family Services; and Dr. Ken Graham, a private pediatrician.

Areas Served

Butte-Silver Bow County is a designated Health Professional Shortage Area (HPSA). It is a low-income HPSA and qualifies as a mental health and dental HPSA. It also is a Medically Underserved Area/Population.

Target Population Served

The target population is children at risk for sexual abuse or who have been sexually abused within Butte and the surrounding area.

Program Director

Janice Prinkki

Butte Silver Bow Primary Health Care Clinic, Inc.

(AKA Butte Community Health Center)

445 Centennial Avenue

Butte, Montana 59701-2870

Phone: (406) 496-6013

Fax: (406) 723-3059

Email: janicep@buttechc.com

Butte Silver Bow Primary Health Care Clinic, Inc.

(AKA Butte Community Health Center)

Butte, MT 59701-2870

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The Butte Consortium for Sexual Abuse Prevention was formed to address child sexual abuse in Butte and southwest Montana, where the incidence of sexual abuse is unusually high. Primary goals of the project are education/prevention, evaluation, and follow-up. The consortium will employ three strategies: (1) prevention education for preschool and young children (grades K–3) using the Talking About Touching personal safety curriculum; (2) evaluations for suspected victims of child sexual abuse at the Child Evaluation Center; and (3) professional therapeutic support services for the victims and their families as well as for children at risk for sexual abuse. Few children in Butte receive education from their families about how to stop or prevent someone from sexually abusing them, and almost no services are available to assist children or their families once sexual abuse occurs. This project seeks to remedy the lack of services and meet the ever-spiraling needs associated with child sexual abuse and its aftermath.

About 1,300 cases of child abuse or neglect are reported in the area each year. There are 220 registered sexual and violent offenders in Butte, a large number for a community of 33,000. In the past 4 years, more than 370 children were evaluated for child sexual abuse, but research suggests this number is low and represents only about one-fourth of the number of incidents that actually occurred. Butte is a very poor community, where the prevalence of alcohol and drug abuse and violence contributes to the growing problem of child sexual abuse. Ninety percent of the alleged child abuse and neglect cases in Butte involve drugs or alcohol use.

The target population is children at risk for sexual abuse or who have been sexually abused within Butte and the surrounding area. Additional unmet needs in the community—isolated geography, large numbers of low-income residents, depressed economy, and a culture of violence and addictive behaviors—all contribute to the high rate of child sexual abuse. Butte is located in Silver Bow County, a rural area located in the northern Rocky Mountains. Of its population of 33,300, 95.4 percent are Caucasian, 2.7 percent Hispanic/Latino, 2.0 percent Native American, 0.2 percent African American, and 1.1 percent other. Currently, 40 percent of Butte’s (Silver Bow County) population lives at or below 200 percent of the Federal poverty level, and 53 percent of the total public school student population qualifies for free or reduced lunches.

Barriers to services for prevention of child sexual abuse include lack of education and awareness, insufficient financial resources, addictions, and lack of therapy and support services for children and families. Butte-Silver Bow County is a designated Health Professional Shortage Area (HPSA). It is a low-income HPSA and qualifies as a mental health and dental HPSA. It also is a Medically Underserved Area/Population.

Topic Areas

Chronic disease, Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

St. Vincent Healthcare (tertiary hospital and Level II trauma center, internists, and diabetes center); Northwest Research and Education Institute (continuing medical education, community education, the Mansfield Health Education Center and Library, and Partners in Health Telemedicine Network); and the South Central Montana Community Mental Health Center (regional mental health services).

Areas Served

Wheatland Memorial Hospital serving residents of Wheatland, Golden Valley, Judith Basin and portions of Sweet Grass and Meagher Counties.

Target Population Served

All residents of the area living with chronic illnesses will be targeted for this program to reduce poor health outcomes and increase healthy years of life in which they can continue to live on their own.

Program Director

Gary Scott Mitchell.

Wheatland Memorial Hospital & Nursing Home

530 3rd Street, N.W.

Harlowton, MT 59036-0307

Phone: (406) 632-4351

E-mail: sgmitche@svh-mt.org

Wheatland Memorial Hospital & Nursing Home

Harlowton, MT 59036-0307

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

The Chronic Care Outreach Program (CCOP) was created through the collaborative efforts of Wheatland Memorial Hospital and several urban partners—St. Vincent Healthcare (tertiary hospital and Level II trauma center, internists, and diabetes center); Northwest Research and Education Institute (continuing medical education, community education, the Mansfield Health Education Center and Library, and Partners in Health Telemedicine Network); and the South Central Montana Community Mental Health Center (regional mental health services). All of the urban partners are located in Billings Montana.

The Chronic Care Outreach Program will plan self-management interventions and programs to reduce health disparities and increase access to nationally recommended health care services for residents living with diabetes and other chronic illnesses. All residents of the area living with chronic illnesses will be targeted for this program to reduce poor health outcomes and increase healthy years of life in which they can continue to live on their own. Local health care systems and community resources will be used to streamline activities to prevent duplication of services and bring additional assistance to the population of this area that are living with diabetes and other chronic illnesses.

The service area proposed includes the Wheatland Memorial Hospital (WMH) service area, the lead organization in the consortium. WMH is located in Harlowton Montana, a ranching community in central Montana with approximately 1.6 people per square mile. The population of the service area is estimated to be 4,000 people, with WMH serving residents of Wheatland, Golden Valley, Judith Basin and portions of Sweet Grass and Meagher Counties. The nearest tertiary care facility is 92 miles south of Harlowton in Billings Montana, the largest urban center in Montana. The next closest tertiary care service is located in Great Falls Montana, 130 miles north. Lewistown, Montana, is located 60 miles from Harlowton to the east, which is a secondary care facility.

Topic Areas

Mental health, Substance abuse, Telemedicine

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

the Tribal Health Department, the Tribal Family Violence Resource Center, Indian Health Service and the Department of Psychiatry, Harvard Medical School in Boston, Massachusetts.

Areas Served

Fort Peck Indian Reservation in rural northeastern Montana

Target Population Served

The Rural Access: Mental Health Care Project will increase behavioral and mental health care services to low-income American Indian children and youth living.

Program Director

Kenneth Smoker

Fort Peck Assiniboine Sioux Tribes

P.O. Box 1027

Poplar, MT 59255

Phone: (406) 768-3469

krsmoker@yahoo.com

Fort Peck Assiniboine Sioux Tribes

Poplar, MT 59255

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The Rural Access: Mental Health Care Project will increase behavioral and mental health care services to low-income American Indian children and youth living on the Fort Peck Indian Reservation in rural northeastern Montana. The Fort Peck Indian Reservation is one of the poorest areas in the United States, with a poverty index three times higher than the State of Montana. This project was developed by the superintendents of the reservation based school districts, the Tribal Health Department, the Tribal Family Violence Resource Center, Indian Health Service and the Department of Psychiatry, Harvard Medical School in Boston, Massachusetts. The schools district computer communications systems will be upgraded to the compatibility of Massachusetts General Hospital and Harvard Medical School to initiate telemedicine psychiatric counseling services with post-doctoral students at Harvard Medical School. The project also establishes a Harvard Medical School Psychiatric Internship Program that will station a post-doctoral fellow on the Fort Peck Indian Reservation for 6 months per year. The project consortium estimates that psychiatric care services will be increased by 420 new patient visits in both Year 2 and Year 3.

Topic Areas

Mental health, Substance abuse

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The CHC will collaborate with two other federally supported mental health/substance abuse service providers in the county, Center for Mental Health and Boyd Andrew Community Services.

Areas Served

Lewis & Clark Counties

Target Population Served

Low-income Lewis & Clark County residents have high rates of mental illness, yet access to affordable mental health care services is almost non-existent.

Program Director

Katherine McIvor

Executive Director

Cooperative Health Center, Inc.

1930 Ninth Avenue

Helena, MT 59601

Phone: (406) 457-8956

Fax: (406) 457-8990

E-mail: kmcivor@co.lewis-clark.mt.us

Web site: www.co.lewis-clark.mt.us/health/cooperative/index.php

Cooperative Health Center, Inc.

Helena, MT 59601

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

Low-income Lewis & Clark County residents have high rates of mental illness, yet access to affordable mental health care services is almost non-existent. A 2003 survey of 200 Cooperative Health Center (CHC) patients indicated that 23 percent had been diagnosed with depression, 35 percent had had generalized anxiety, 46 percent experienced somatic complaints, and 14 percent had been diagnosed with an alcohol or drug problem. The three-agency consortium formed for this project will provide access to mental health and substance abuse services, regardless of patients’ ability to pay.

The CHC will collaborate with two other federally supported mental health/substance abuse service providers in the county, Center for Mental Health and Boyd Andrew Community Services. Center for Mental Health will provide mental health services to CHC patients with severe mental health problems that are not within the scope of CHC’s ability to treat. Boyd Andrew, which provides chemical dependency treatment services, will provide in-service trainings for CHC care providers and hold four appointment slots per month for CHC patients seeking treatment for substance use disorders.

Mental health and substance abuse (MH/SA) services provided will include screening, assessment, diagnosis, case management, cognitive-behavioral therapy, brief problem-solving therapy, solution-focused therapy, mastery of panic and anxiety, brief alcohol intervention, and psychotherapy, when judged appropriate. MH/SA services will be delivered during patients’ primary care visits and during one-on-one visits with MH/SA providers, who will include a CHC mental,health specialist and a Center for Mental Health case manager, both working at the CHC clinic site. Primary care providers will introduce the mental health specialist to the patient in the exam room when the provider determines the patient needs mental health or substance abuse care. This approach will integrate mental health and primary care services, reducing stigma and increasing the number of patients served. All CHC patients will be screened for MH/SA issues 5 afternoons a week at the start of the project, expanding to 5 full days as the project progresses.

The CHC will assess the effectiveness of treatment for depression by using Key Depression Care Measures from the Depression Collaborative. Effectiveness of treatment for anxiety will be assessed with the appropriate sections of Prime MD, a widely used mental health diagnostic/assessment questionnaire. The CHC will track MH/SA patients with an expanded registry modeled on the Depression Collaborative registry. The case manager will use the registry to follow patients’ progress and manage their treatments, medications, and connections with necessary community services.

The CHC targets Lewis & Clark County residents living below 200 percent of poverty. Of county residents of all ages, 28.6 percent lived below 200 percent% of poverty in 2000, and 44 percent of those were uninsured. CHC will focus first on delivering MH/SA services to its current patient population, which consisted of 6,082 unduplicated patients in FY 2005. Six percent of the patient population is homeless.

Topic Areas

Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Rural medically underserved population of east central Nebraska.

Target Population Served

The specific needs of the underserved population of Hispanic individuals and families

Program Director

Rebecca Rayman

Good Neighbor Community Health Center

2282 East 32^nd Avenue

Columbus, NE 60681

Phone: (402) 563-9224X210

Fax: (402) 563-0554

Email: rrayman@ecdhd.com

Good Neighbor Community Health Center

Columbus, NE 60681

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

Significant discrepancies exist in the availability of behavioral health resources for persons living in rural areas. For example, in 1999, 87 percent of the Mental Health Professional Shortage Areas in the United States were in non-metropolitan counties (Bird, Dempsey, and Hartley, 2001). In rural Nebraska, there are federally designated Mental Health Professional Shortage Areas in 88 of Nebraska’s 93 counties. Of the State’s 146 board certified and licensed psychiatrists, 326 licensed practicing psychologists and 1,890 licensed mental health practitioners—a significantly disproportionate number (26 percent)—serve 850,000 rural residents (47 percent of the State’s population) residing over a 70,000 square mile area. Meanwhile, 74 percent of behavioral health professionals provide services to the 53 percent of the population residing in metropolitan areas. An estimated 20 percent of children and adolescents ages 9 to 17 also have identifiable mental illnesses each year (Schaffer, Fisher, Dulcan et al., 1996), with even less access to specialty services and preventive care then available for adults.

A consortium consisting of the Good Neighbor Community Health Center (GNCHC), Boys and Girls Homes of Nebraska (BGHN), the East Central District Health Department (ECDHD) –all from rural Columbus, Nebraska—and the Behavioral Health Clinics training program of the University of Nebraska Medical Center (UNMC) have joined forces to address these issues. Using an approach that integrates behavioral health into primary care practice, the consortium will add behavioral health faculty and trainees from the training program at UNMC to its existing array of services at the Good Neighbor CHC and to the diagnostic and treatment services of the Boys and Girls Homes programs. The overall goals of the project are:

· To reduce discrepancies in the availability of outpatient behavioral health care to the rural medically underserved population of east central Nebraska through the provision of expanded services and increased numbers of behavioral health providers

· To reduce the number of inappropriate out-of-home placements for children and adolescents through the provision of integrated behavioral health team evaluations for juvenile justice and child protective service agencies in East Central Nebraska; and

· To evaluate the effectiveness of an integrated behavioral health program in the primary care Good Neighbor Community Health Center and replicate the program in at least one additional site in Nebraska by the end of the 3-year grant cycle.

Funding from the project will go towards: 1) increasing current GNCHC psychiatric availability, 2) providing child-adolescent psychology service provision, and 3) recruitment, training, placement, and retention of behavioral health professionals (social workers, counselors, psychologists, psychiatric nurses, and other behavioral health professionals) in rural primary care settings. Funding will also be used to address the specific needs of the underserved population of Hispanic individuals and families through support for a Spanish-speaking interpreter and a van driver who will assist rural patients with transportation needs to get to their BH appointments.

The Behavioral Health Clinics training program at UNMC has a history of integrating behavioral health into primary care practices and has HRSA training funds (Allied Health and Graduate Psychology Education grants) that will provide further support for this rural behavioral health effort.

Topic Areas

Elder Care

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 149,976.00

· Year 2 - 242,955.00

· Year 3 - 392,931.00

Partners to the Project

Saint Francis Medical Center will partners for services with Aurora Memorial Hospital and the Aurora Senior Center in Aurora, NE, Howard County Community Hospital and the St. Paul Senior Center in St. Paul, NE, and Litzenbenberg Memorial Hospital and the Central City Senior Center in Central City, NE, and the Midland Area Agency on Aging for the May 1, 2007 - April 30, 2010 grant period.

Areas Served

Hall, Boone, Greeley, Hamilton, Howard, Merrick, Nance and Sherman counties, and approximately 553 elderly residents who reside in Buffalo, Madison, Platte, Valley and Wheeler counties.

Program Director

Marjorie Jones

Saint Francis Medical Center

2126 West Faidley Avenue

P.O. Box 9804

Grand Island, NE

Phone: (308) 398-2601

Fax: (308)-398-5823

E-mail: mjones@sfmc-gi.org

Saint Francis Medical Center

Grand Island, NE 68802

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

Target Population Served

The Central Nebraska Home Services Telecare Project proposes to serve the 15,466 elderly residents (age 65 and older) in nine counties. The Staying Well at Home Coalition works with about 750 patients a year through home healthcare services.

Project Summary

The Staying Well at Home Project, based in Grand Island, NE, includes Saint Francis Medical Center, Aurora Memorial Hospital, Litzenberg Memorial Hospital in Central City, Howard County Community Hospital in St. Paul, the Aurora Senior Center, the Central City Senior Center, the St. Paul Senior Center and the Midland Area Agency on Aging as members. The plan defines three levels of intervention to help elderly residents live independently, avoid frequent re-hospitalization and maintain a high quality of life:

1. Establish a preventative program for elderly residents at risk for chronic diseases or acute healthcare to live longer independently with a better quality of life through the on-site education and telehealth monitor stations that record vital signs, located at the Aurora, Central City and St. Paul senior centers and Wellness WorWor Su Salud in Grand Island. These stations, available for public use, will be able to transmit data to Home Care Services at Saint Francis Medical Center and provide trended data to each participant’s local doctor.

2. Provide collaborative care management through a quantitative patient assessment and a Staying Well at Home plan focused and uniform discharge plan that makes patient-specific referrals to identified community, family and medical resources). The patient assessment and pathway plan will be developed by the Staying Well at Home Coalition Task Force.

3. Develop patient participation in the management of disease through prompt feedback from the monitoring of vital signs relevant to a patient’s disease process. The project will include the placement of 28 health monitors furnished through the project and 20 provided by the Saint Francis Medical Center Foundation in the homes of patients identified with the greatest need (provided by scoring from the Staying Well at Home assessment criteria)

The project has identified these key issues: 1) frequent re-hospitalizations and physician visits can be avoided; 2) travel difficulties for aging patients who live significant distances from primary healthcare providers; 3) healthcare provider shortages that threaten the quality of patient case management; 4) chronic disease scores that are higher than the national mean for endocrine, circulatory, respiratory and musculoskeletal categories; 5) an inability of patients to fully understand instruction from physicians and a reluctance to ask questions; and 6) an expressed desire by elderly patients to live independently.

The Central Nebraska Home Services Telecare Project proposes to serve the 15,466 elderly residents (age 65 and older) in nine counties: Hall, Boone, Greeley, Hamilton, Howard, Merrick , Nance and Sherman, and approximately 553 elderly residents who reside in Buffalo, Madison, Platte, Valley and Wheeler counties. The Staying Well at Home Coalition works with about 750 patients a year through home healthcare services.

The use of telehealth monitors will allow more frail elderly residents to: 1) live at home, 2) improve self-management of their chronic conditions, 3) become more aware of changes in their health status resulting in efforts to seek treatment in a timely fashion, 4) become less reliant on emergency care that results in frequent hospitalization.

Topic Areas

Dental services

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 90,000.00

· Year 3 - 26,625.00

North Platte, Nebraska

Target Population Served

Have formed a very limited dental clinic for youth up to age 18 whose families meet the income requirements for Medicaid.

Project Summary

West Central District Health Department (WCDHD) has recognized a need for access to dental care among residents of its service area who either rely on Medicaid or who self-pay for dental care. A survey of residents in the eight counties served by WCDHD confirmed that Medicaid and self-pay residents forego dental care at much higher rates than their privately insured counterparts. Part of the reason for this is that only one dentist in North Platte accepts new Medicaid patients. For the most part,

Program Director

Shirleen Smith

West Central District Health Department

111 North Dewey

North Platte, NE 69101

Phone: (308) 696-1201

E-mail: shirleensmith@allltel.net

West Central District Health Department

North Platte, NE 69101

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Medicaid patients must travel outside the service area to get dental care. As a result, WCDHD and other organizations in North Platte have formed a very limited dental clinic for youth up to age 18 whose families meet the income requirements for Medicaid. The experience with that clinic has convinced WCDHD and its partners that a permanent clinic that serves both adults and youth is needed.

Therefore, WCDHD and its partners are establishing a permanent dental clinic in North Platte, Nebraska, to serve Medicaid recipients and low-income self-paying residents. During the first year of operation, the clinic will be open on a half-time basis and will be staffed by a halftime dentist, a full-time dental assistant who will also act as an office manager, and a half-time receptionist that will be staffed by volunteers through the Retired Senior Volunteer Program. During the first year, the clinic expects to serve 1,000 patient visits. Services during the first year will not include more elaborate restorative procedures such as dentures and bridges. During the second year, the clinic will again be open on a half-time basis, but the staff will be expanded to include a half-time dental hygienist. Dental services will also be expanded to include dentures and bridges. During the second year, the clinic expects to serve 1,800 patient visits. In the third year, the clinic will be open on a full-time basis and expects to serve 3,900 patient visits.

Quarterly evaluation meetings with consortium members and dental staff to assess financial and patient flow will be held for the duration of the grant period. WCDHD and its partners intend for the clinic to be self-sustaining by the end of the grant period.

Topic Areas

Human service training

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Great Basin College, Nevada Department of Health and Human Services, the Nevada State Office of Rural Health, Indian Health Service-Southern Band Health Center, BrightPath Adult Enrichment Center, and Partners Allied for Community Excellence (P.A.C.E. Coalition).

Areas Served

Elko, Eureka, Humboldt, Lander, and White Pine

Target Population Served

To develop and implement a Human Services program that offers a Certificate and an Associate of Applied Science degree; work with service providers to develop 20 practicum/clinical sites for hands-on student learning; and enroll at least 20 students in the Human Services Program.

Project Summary

Founded in 1967, Great Basin College (GBC) is the oldest, public community college within the Nevada System of Higher Education (NSHE). Located in the rural high desert of northeastern and central

Program Director

Dr. Michael McFarlane

Vice President for Academic Affairs

Great Basin College

1500 College Pkwy

Elko, NV 89801

Phone: (775) 753-2187

E-mail: mikem@gwmail.gbcnv.edu

Great Basin College

Elko, NV 89801

ORHP Contact:

Julie Bryan

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4223

jbryan@hrsa.gov

Nevada, GBC’s service area covers over 45,000 square miles and includes the counties of Elko, Eureka, Humboldt, Lander, and White Pine. The area has 78,000 residents and has been classified as “frontier” with an average of less than two people per square mile. Overall, GBC’s service area encompasses only 3.9 percent of the total population of Nevada.

GBC is developing and implementing a Human Services Certificate Program and a Human Services Associate of Applied Science Degree Program, that will train and educate individuals for jobs that support the delivery of a broad range of health-related services currently lacking in GBC’s expansive, rural service area. The human service profession promotes improved service delivery systems by filling positions that address the quality of direct services as well as the accessibility, accountability, and coordination among professionals and agencies of these services. Examples of service delivery settings include mental health agencies; agencies serving the elderly; family, child, and youth service agencies; correctional agencies; and agencies/programs concerned with alcoholism, drug abuse and violence.

The development of the Human Services Program will be accomplished by the project consortium members, which include: Great Basin College, Nevada Department of Health and Human Services, the Nevada State Office of Rural Health, Indian Health Service-Southern Band Health Center, BrightPath Adult Enrichment Center, and Partners Allied for Community Excellence (P.A.C.E. Coalition).

The project will seek to accomplish the following goals:

· To develop and implement a Human Services program that offers a Certificate and an Associate of Applied Science degree;

· Work with service providers to develop 20 practicum/clinical sites for hands-on student learning; and

· Enroll at least 20 students in the Human Services Program.

Topic Areas

Health care

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,994.00

· Year 2 - 149,994.00

· Year 3 - 99,998.00

Partners to the Project

Center for Cognitive Aging’s (CCA) Alzheimer Disease Diagnostic and Treatment Center (ADDTC).

Areas Served

Geographically remote areas of Nevada and other western states.

Target Population Served

This project primarily serves the elderly, 65 year of age and over, including American Indian and Hispanic populations.

Project Summary

The goal of the Rural Dementia Telemedicine Initiative (RDTI) project is to establish a long-term, sustainable method of service delivery to Alzheimer’s (dementia) patients, caregivers, and health care professionals involved in the delivery of diagnosis, disease management, and treatment in rural and underserved communities of Nevada and other western states through the Center for Cognitive Aging’s (CCA) Alzheimer Disease Diagnostic and Treatment Center (ADDTC) via telemedicine. Through the capabilities that telemedicine offers the RDTI program can bring urban medical

Program Director

Sylvia Elexpuru

Project Director

BrightPath Adult Day Services, Inc.

P.O. Box 279

Elko, Nevada 89803

Phone: (775) 778-0547

E-mail: selex@frontiernet.net

BrightPath Adult Day Services, Inc.

Elko, Nevada 89803

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

specialists face-to-face with patients in geographically remote areas of Nevada and other western states. Individuals identified by community screening sessions or through physicians’ offices will also be afforded follow-up care and ongoing medication management. In addition to medical care, the telemedicine project will be used to train health care professionals, health care providers and caregivers; and to provide a venue by which support groups can meet. The project is also aimed at reducing the economic burden associated with long-term care costs for patients, families, and employers through early identification and intervention of Alzheimer’s disease and other dementias.

Approximately 381 patients and their families will benefit by using the RDTI program over the next 3 years. This project primarily serves the elderly, 65 year of age and over, including American Indian and Hispanic populations, which are spread over 95,763 square miles in the rural and frontier areas of Nevada alone. The RDTI project, which can tap into existing telemedicine facilities and networks, substantially reduces expenses for equipment and has the potential to become a model for other rural and frontier areas of the country.

Topic Areas

Chronic Disease Management, Diabetes, Congestive Heart Failure, Telehealth

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 182,000.00

· Year 2 - 183,031.00

· Year 3 - 189,643.00

Partners to the Project

The Consortium for Chronic Disease Management includes VNA at HCS, a subsidiary of Home Healthcare, Hospice and Community Services, Inc., the lead applicant; the Cheshire Medical Center; and Dartmouth-Hitchcock Keene (a multispecialty physician practice).

Areas Served

Two towns (Acworth and Charlestown in Sullivan County) in the service area are designated as Medically Underserved Populations.

Target Population Served

Implementation of a chronic disease management program for individuals with diabetes and congestive heart failure in rural southwestern New Hampshire.

Project Summary

The focus of the Rural Outreach for Improvement of Chronic Disease Management Project is implementation of a chronic disease management program for individuals with diabetes and congestive heart failure in rural southwestern New Hampshire. Specific goals for

Program Director

Judith P. Harris

Home Healthcare, Hospice and Community Services, Inc.

312 Marlboro Street

Keene, New Hampshire 03431-4163

Phone: (603) 352-2253 or (800) 541-4145

Fax: (603) 358-3904

Home Healthcare, Hospice and Community Services, Inc.

Keene, NH 03431-4163

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

the project are significantly reduced hospitalizations, reduced emergent care, better access to care and services, and improved patient quality of life and satisfaction. Implementation of telehealth technology is an essential element in the program. A primary care physician, cardiologist, or clinic or home care nurse will identify patients at risk for heart failure or diabetes. A feature of the project is incorporation and development of clinical pathways for patients with heart failure or diabetes in relation to acceptable blood pressure, weight, and other markers, so that primary care interventions can occur in a more timely way and “crises” can be avoided. The project will implement wellness and prevention strategies by introducing patients to self-help materials and educational resources upon discharge from an acute hospitalization, clinic visit, or home health care admission.

The service area is rural and isolated with no divided highways. The general population in the area is 97.3 percent white. The chance of experiencing chronic illness increases significantly with age, and the poor and less educated have an increased likelihood of chronic illness. The target population is people older than age 65. A significant proportion of the target population also is at high risk because of poverty, isolation, mental health issues, disabilities, and transportation barriers. Residents older than age 65 represent 13.7 percent of the service area population, and the accelerating older population is a major concern with regard to increasing levels of chronic illness. Income and education levels vary widely across the area, and poverty—often accompanied by lack of education—is a pervasive barrier to accessing health for many in the region, exacerbating problems with insurance, the ability to pay for medications, and transportation. Fifty-six percent of the state’s elderly do not have prescription drug coverage. Problems related to transportation include long distances and travel times to health care resources, lack of coordinated public transportation, and long winters with heavy snow, which make travel difficult for visiting nurses and other home care providers as well as for patients. Two towns (Acworth and Charlestown in Sullivan County) in the service area are designated as Medically Underserved Populations.

Topic Areas

Chronic disease, Telehealth

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Areas Served

State of New Hampshire

Target Population Served

The target population includes three groups: 1) low-income and uninsured adults; 2) low-income, uninsured and underinsured elderly; and 3) individuals with chronic illness such as diabetes and CVD/hypertension.

Project Summary

The Caring Community Network of the Twin Rivers (CCNTR) is a recognized nonprofit organization in the State of New Hampshire formed in 1996. CCNTR has been working as a collective to create a coordinated, accessible system of care across the region. This project will enhance existing mechanisms and expand the capacity of the network to provide effective, coordinated, and accessible services throughout the region that improve health outcomes of uninsured clients with chronic illness and provide appropriate services such as emergency room care.

Program Director

Richard D. Silverberg

Health First Family Care Center

841 Central Street

Franklin, NH 03235

Phone: (603) 934-0177, ext. 107

E-mail: rsilverberg@ccntr.org

The Caring Community Network of the Twin Rivers

Franklin, NH 03235

ORHP Contact:

Elizabeth Rezai-zadeh

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-4107

erezai@hrsa.gov

Individuals in the Twin Rivers face higher rates of many health risk indicators than the rest of the state. There are disparities among chronic disease factors, and socio-economic indicators. In addition, residents face significant barriers to access service and prevention programs including: geographic or social isolation, lack of transportation, lack of awareness of services, uncertainty of how to access service, lack of insurance, not enough insurance, and fear of stigmatization or reprisal. These barriers reduce use and inhibit the continuity of care, decreasing the overall effectiveness of the service delivery system.

There are three target groups who will benefit from the activities in this proposal: (1) low-income and uninsured adults, (2) low-income, uninsured and underinsured elderly, and (3) individuals with chronic illness such as diabetes and CVD/hypertension. These populations overlap and are inter-related. The proposed project develops roles that will support several models that have been proven effective in this and other areas, will replicate those models for new populations, and will expand the reach of mechanisms that work well in other parts of the country for use here. These staff positions include:

· 175 days of contracted outreach care coordination each year will be arranged with existing network staff to work with residents that need to be connected to primary care and other supports;

· One FTE disease manager who will work with primary care providers, nutritionists, and other health care professionals to provide health education, counseling, and coordinated care planning to people living with chronic disease;

· .25 FTE project manager to integrate care coordination and disease management with the system of uncompensated care, and overall project management.

· A CCNTR staff evaluator will be contracted. A small amount of consulting time will be used to develop modifications to telehealth tools.

The proposed project will positively impact service delivery in the region. It will: (1) identify best practices in disease management, planned care visits, and coordination currently used by medical providers to implement them region-wide, (2) incorporate the use of electronic tools, developed with an outside source of revenue, to use a shared client data base for health education, coordination, referral, and chronic disease registry (3) enhance client access to the above services and to other services available in the region, and (4) increase the level of disease and care management available, resulting in improved patient health outcomes.

Topic Areas

Mental health, Telehealth

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The Northern Tele-psychiatry Initiative consortium members are Northern Human Services, the lead applicant; the New Hampshire Department of Health and Human Services, Bureau of Behavioral Health; NAMI New Hampshire, and the Behavioral Health Network.

Areas Served

Northern Grafton, Carroll, and Coos Counties. Medically underserved areas.

Target Population Served

To improve the mental health of children and teens.

Project Summary

The Northern Tele-psychiatry Initiative will provide access to child psychiatry through telemedicine in northern New Hampshire. The Northern Tele-psychiatry Initiative will improve the mental health of children and teens, reduce the number of admissions to child psychiatric in-patient units, and help prevent the inappropriate

Program Director

Michael Kasson

Northern Human Services

87 Washington Street

Con way, NH 03818

Phone: (603) 447-3347

Fax: (603) 447-8893

E-mail: mkasson@northernhs.org

Northern Human Services

Con way, NH 03818

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

prescribing of psychotropic medications by primary care practitioners to children and adolescents.

The project plans on establishing videoconferencing systems in Wolfeboro and Berlin in Year 1, increasing the number of systems to Conway and Colebrook in Year 2 and installing the final system in Littleton in Year 3. The Northern Tele-psychiatry Initiative will be examining options for changes to the New Hampshire Medicaid State plan and third party payers for telemedicine. The Northern Tele-psychiatry Initiative will also promote the use of child tele-psychiatry through education of community leaders and family members. Finally, the Northern Tele-psychiatry Initiative will evaluate the project on an ongoing basis to ensure the satisfaction of the child tele-psychiatry treatments.

The Northern Tele-psychiatry Initiative covers a medically underserved area. Currently, there are no child psychiatrists in northern New Hampshire, geographically 43 percent of the rural northernmost portion of the State. The target population, which is 98 percent Caucasian, is 24,927 children, age 0 to 17, who are residents of northern Grafton, Carroll, and Coos Counties—a region that covers 4,447 square miles. Due to the loss of traditional industries in northern New Hampshire, the primary jobs are low-paying (an average of less than $23,000) in the tourism, food service, and retail industries. Access barriers to services include long distances outside of northern New Hampshire to private child psychiatrists or child psychiatric in-patient units; year-long waits for evaluation by private child psychiatrists; lost income to caregivers resulting from the geographic isolation and the lack of local child psychiatrist.

Topic Areas

Oral Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Littleton Community House Annex, Dalton Elementary School, New Hampshire Department of Health and Human Services, Lancaster Elementary School, New Hampshire Community Technical College, National Guard Armory-Berlin, National Guard Armory-Littleton

St Ann’s Good Shepherd Perish, Lane House, Littleton Head Start Program, St. Barnabus Church, and Woodville Elementary School

Areas Served

Northern Grafton and Coos Counties in Northern New Hampshire.

Target Population Served

The North Country Health Consortium proposes to expand its public health mobile dental service, The Molar Express, to serve a target population of unserved and underserved adults residing in the service area. The Molar Express has been providing preventive, diagnostic and restorative dental care to Medicaid eligible children in Northern New Hampshire since July of 2005.

Program Director

Martha McLeod

North Country Health Consortium

646 Union Street

Littleton, NH

Phone: (603) 444-4461

Fax: (603) 444-4460

E-mail: mmcleod@nchcnh.org

North Country Health Consortium

Littleton, NH 03561

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The applicant has selected this project to address barriers to oral health care suffered by the target population living in Northern Grafton and Coos Counties in Northern New Hampshire. These barriers include a Dental Health Professional Shortage Area (DHPSA) designation for the entire service area: little or no Medicaid reimbursement for oral health services available to the age 65 and under population, a weekly wage almost 23 percent lower than the state average and access to health insurance that is 20 percent lower than the state average.

In addition, surveys conducted by area health care providers indicate that in some communities considerably less than 50 percent of the adult population received regular preventive dental care, over 50 percent indicated that they needed dental work done and that over 30 percent surveyed indicated lack of ability to pay for services precluded access to such services.

To improve the oral health status of unserved and under-served North Country adults through a collaborative program of preventive, diagnostic and restorative care for and education of the population.

· Expand capacity of the Molar Express dental clinic to provide services to the target population through recruitment and credentialing of additional paid and volunteer dentists.

· Improve oral health status and facial appearance of the target population.

· Improve oral health knowledge and behavior through a comprehensive program of education on good oral health.

· Ensure the sustainability of these oral health services by fostering collaboration to determine strategies for long-term viability of all Molar Express services.

The North Country Health consortium members will guide and steer all facets of this project with support from key staff drawn from Consortium personnel and clinical personnel working for the Molar Express.

Topic Areas

Substance Abuse, Mental Health Disorders

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include Border Area Mental Health Services, Inc., the lead applicant; Fort Bayard Medical Center–Yucca Lodge; Gila Regional Medical Center; Hidalgo Medical Services; Presbyterian Medical Center; and Ben Archer Health Center.

Areas Served

Grant, Hidalgo, Catron, and Luna counties in southwestern New Mexico.

Target Population Served

The main goals of the project are (1) to increase access to appropriate levels of care for mental health and/or substance abuse services; (2) to increase capacity to provide services to individuals with substance abuse and/or mental health disorders; and (3) to improve access to and management of psychotropic medications.

Project Summary

Program Director

Silvia Madrid

Border Area Mental Health Services, Inc.

P.O. Box 1349

Silver City, New Mexico 88062-1349

Phone: (505) 388-4497

Fax: (505) 534-1150

Border Area Mental Health Services, Inc.

Silver City, New Mexico 88062-1349

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

abuse and/or mental health disorders; and (3) to improve access to and management of psychotropic medications. Activities include developing protocols with key referral sources, developing protocols among treatment providers so that individuals can access appropriate levels of care in an efficient and smooth manner, providing technology for distance training and consultation, addressing the shortage of professionals through partnerships with universities and policy changes at the state level, and improving access to psychotropic medications through training and information using best practices. In addition, the project proposes an innovative, comprehensive approach to substance abuse outpatient treatment that incorporates gender-specific and trauma-based approaches, as well as research-based therapeutic practices and supportive services.

The service area includes Grant, Hidalgo, Catron, and Luna counties in southwestern New Mexico. A high percentage of residents in the region live in poverty, ranging from 18.7 percent in Grant County to 32.9 percent in Luna County, compared to 18.4 percent for New Mexico and 12.4 percent for the United States. The percentage of the population below two times the Federal poverty level and not on Medicaid is estimated at 27.9 percent. The project will target children, adolescents, and adults who have mental health or substance abuse disorders as well as their family members. The demographics of the mental health target population are representative of the region where the ethnic breakdown is 51 percent Hispanic/Mexican and 49 percent white. The enhanced outpatient substance abuse treatment will target three subpopulations: (1) adults involved with the court system, (2) substance-abusing adult women with children, and (3) adults with substance abuse or co-occurring disorders. In the target region, there is a severe lack of services for persons with substance abuse and/or mental health disorders. The four counties face tremendous challenges in providing behavioral health services due to barriers such as a shortage of providers and practitioners (especially those who are bilingual), weak linkages with referral sources, a lack of integrated services for co-occurring substance abuse and mental health disorders, the lack of insurance coverage for substance abuse disorders, and culture or language. The target area for the project is a designated Medically Underserved Area and a Health Professional Shortage Area for mental health professionals.

Topic Areas

Early childhood mental health services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Core members of the Northern New Mexico Rural Infant Mental Health Consortium have come together to address the need for expanded infant mental health services in Rio Arriba County. These partners include Las Cumbres Learning Services, Las Clinicas del Norte, La Clinica del Pueblo, the Rural Psychiatry Program at the University of New Mexico Health Sciences Center, and El Centro de los Niños.

Areas Served

The project will serve the residents of Rio Arriba County, a largely rural and mountainous region between Santa Fe and the Colorado state line.

Target Population Served

Provide access to mental health services for high-risk families with young children, from birth to age 5.

Program Director

Deborah Harris-Usner

Las Cumbres Learning Services, Inc.

P.O. Box 1362

Espanola, NM 87532-1362

Phone: (505) 753-4123

Fax: (505) 753-6947

Las Cumbres Learning Services, Inc.

Espanola, NM 87532-1362

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

The Northern New Mexico Rural Infant Mental Health Consortium project will provide access to mental health services for high-risk families with young children, from birth to age 5. The project will serve the residents of Rio Arriba County, a largely rural and mountainous region between Santa Fe and the Colorado state line. The project will use a three-pronged approach: (1) provide comprehensive, expanded infant mental health services at three sites; (2) provide training, consultation, and capacity-building to health care and early childhood development programs; and (3) increase access to, and utilization of, infant mental health services by developing bilingual outreach materials, home visits, and child assessments and by strengthening collaborative referral networks. The project will utilize a successful, evidence-based model that combines home-based, center-based, and community-based services in counseling, case management, parenting skill development, client advocacy, and early intervention.

The target population is families with young children in Rio Arriba County, which has high rates of poverty, lack of health insurance, alcohol and drug abuse, and other health problems. The county has an extremely high risk of and high prevalence of infant mental health problems—problems that are directly related to the area’s high rates of substance abuse, teen pregnancy, domestic violence, poverty, and child abuse and neglect. Nearly one-quarter of the county’s families live below the poverty level, and 35 to 40 percent of the county’s residents lack health insurance. Approximately 73 percent of the county’s 41,190 residents are Hispanic, and 14 percent are Native American.

Barriers to access to health services include the high rate of poverty, geographic isolation and lack of transportation, lack of health insurance, and inadequate health care resources. The county qualifies as a Medically Underserved Area and includes 13 divisions designated as Health Professional Shortage Areas.

Topic Areas

Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 – 98,702.00

Partners to the Project

Collaborative Action for Taos County Health (CATCH)

Areas Served

Taos County

Target Population Served

To deliver Prescription Assistance to a target population defied as residents of Taos County 18 years and older with a diagnosis of type 1, type 2, or gestational diabetes who are up to 185 percent of the poverty level.

Project Summary

The word Taos means ‘red willow’ in the Tewa language. Two features dominate this sparsely populated region—the high desert mesa, split in two by the 650-foot-deep chasm of the Rio Grande; and the Sangre de Cristo range, which tops out at 13,161-foot Wheeler Peak, New Mexico’s highest mountain. The County is situated where

Program Director

Kelly Shull

Program Director

Taos Health Systems

Holy Cross Hospital

P.O. Box DD

Taos, NM 87571

Phone: (505) 751-5711

E-mail:

kshull@taoshospital.org

Holy Cross Hospital

Taos, NM 87571

ORHP Contact:

Jacob Rueda

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0835

jrueda@hrsa.gov

the western flank of the Sangre de Cristo range meets the semiarid high desert of the upper Rio Grande Valley. It is comprised of several small villages scattered throughout the mountainous region, the Taos Pueblo, and the Picuris Pueblo, both inhabited for over 1,000 years. The County is spread out over 2,203.17 square miles, with a density of 13.6 persons per square mile.

In this beautiful and rugged landscape, 9.5 percent of the adult population has a diagnoses of diabetes compared to 8.9 percent statewide. Approximately 17 percent of people aged 40 and over in New Mexico have diabetes. Hispanics comprise 58 percent of the population in Taos County. One in four Hispanics are uninsured. In addition to being more prevalent, diabetes in Hispanics tends to be more severe than non-Hispanic whites. Among Hispanics, diabetes occurs at a younger age, more often requires insulin to be controlled, results in more limb amputations, contributes to eye disease, is responsible for six times higher incidence of kidney failure, and results in a death rate two to four times the rate for non-Hispanic whites.

While Native Americans comprise a smaller percent of the population (7 percent) they too are two to three times more likely to be at risk for diabetes and less likely to have private health insurance than either Whites or Hispanics. A combined 65 percent of the Taos County population (58 percent Hispanic and 7 percent Native American) is comprised of at risk populations for diabetes. In a Taos County Needs Assessment process, 144 low income County residents were interviewed in 2001 and over half the families in this interview process did without needed medical care in order to make ends meet, or gave priority to their children’s care.

This 3-year outreach proposal is focused on designing a Single Point of Entry and Lay Promotora Program to deliver Prescription Assistance to a target population defied as residents of Taos County 18 years and older with a diagnosis of type 1, type 2, or gestational diabetes who are up to 185 percent of the poverty level.

Holy Cross Hospital is a not-for-profit, 49-bed acute care hospital. Its mission is to provide preventive, curative, and supportive health care services, maintaining high quality standards and using innovative, educational, and cost effective approaches for all members of the culturally diverse Taos community and surrounding areas. Collaborative Action for Taos County Health (CATCH), a consortium, will implement a Prescription Assistance Program to assist residents in accessing no cost/low cost prescription medications. A comprehensive Single Point of Entry and a Lay Promotora Program will help to coordinate appropriate healthcare including prescription assistance, encourage self-management of diabetes through counseling and support, thereby strengthening the ability of residents to reduce the risk and/or severity of diabetes.

Topic Areas

EMS Provider Education, Older Adults, Case Management

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 190,762.00

· Year 2 - 195,520.00

· Year 3 - 199,977.00

Partners to the Project

Members of the consortium include the Livingston County Department of Health, the lead applicant, Livingston County Office for Aging, Genesee Valley Health Partnership, Department of Emergency Medicine at the University of Rochester Medical Center, and Tri-County Family Medicine.

Areas Served

Livingston County, New York is designated as a Medically Underserved Population.

Target Population Served

The target population adults age 60 and older in rural areas of Livingston County, New York.

Project Summary

In this injury and illness prevention project, the Livingston County Department of Health and its partners seek to maximize the health

Program Director

Manish Shah

Livingston County Department of Health

2 Livingston County Campus

Mount Morris, New York 14510-1122

Phone: (585) 243-7270

Fax: (585) 243-7287

Livingston County Department of Health

Mount Morris, NY 14510-1122

ORHP Contact:

Jacob Rueda

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0835

jrueda@hrsa.gov

and quality of life of rural, community-dwelling older adults and will implement a system based on emergency medical services (EMS) to screen, identify, educate, and refer rural-dwelling individuals at risk for preventable conditions. The project also will ensure patient access to long-term health care and social services using case managers and primary care physicians. Another feature of the project is the education of EMS providers regarding the appropriate care of older adults. During emergency responses, EMS personnel will screen older adults for risk of falling, medication errors, and depression; educate patients and their families during emergency responses about risks; and refer at-risk patients to a case management program. The project will expand an existing case management program to provide at-risk patients with follow-up care and will evaluate the impact of the EMS-based program by assessing critical process and outcome measures.

The target population adults age 60 and older in rural areas of Livingston County, New York. The percentage of older adults in the county is rapidly increasing, resulting in increased demands for community-based and in-home services. The county’s population is expected to grow by 4.8 percent between 2000 and 2015, but the population age 60 and older is expected to increase by 31.5 percent and the population age 85 and older by 36 percent. Older adults have a high disease burden, high risk for disability, limited financial resources, and difficulty accessing care. Patients who suffer from falls, depression, and medication errors are at risk for disability, mortality, and institutionalization. These conditions benefit from screening, but access to health care is often limited for the most vulnerable patients. There is a need to prevent diseases, injuries, and disability among older persons to maximize their quality of life and to prevent morbidity, institutionalization, and mortality. No universal access system currently exists for caregivers or recipients of services to identify and access the various services. Older adults and their caregivers typically do not know what services are available or what services they need. This project will affect all service providers and provide older adults with increased ease of access to services. The county is designated as a Medically Underserved Population.

Topic Areas

School-based services, Dental, Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Bassett Healthcare and the school districts of Delhi, Edmeston, Laurens, Morris, Sherbure-Earlville, and South Kortright.

Areas Served

Chenango, Delaware, and Otsego counties—all of which have been designated as Mental Health Professional Shortage Areas.

Target Population Served

Targeted school-age children (5-18 years of age) for services.

Project Summary

Bassett Healthcare and six school districts have formed a Consortium that seeks to expand and enhance their School-Based Health Centers (SBHC) to include dental and mental health care programs and community outreach services. Bassett Healthcare and the school districts of Delhi, Edmeston, Laurens, Morris, Sherbure-Earlville, and South Kortright are located in Chenango, Delaware, and Otsego counties—all of which have been designated as Mental Health

Program Director

Jane Hamilton, R.N.

School-Based Health Center Program Clinical Coordinator

The Mary Imogene Bassett Hospital

One Atwell Road

Cooperstown, NY 13326-1394

Phone: (607) 746-9332

E-mail: jane.hamilton@bassett.org

The Mary Imogene Bassett Hospital

Cooperstown, NY 13326-1394

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Professional Shortage Areas. Delaware County has been designated a Dental Health Professional Shortage Area.

The Consortium has specifically targeted school-age children (5-18 years of age) for services. The seven goals of the project are to: 1) increase the number of children receiving dental health care, 2) reduce the number of untreated caries in children, 3) control the number and severity of new caries developing in children, 4) reduce serious emotional disturbances (SEDs) in children and adolescents, 5) increase the number of children seen in primary care who receive mental health screening and assessments, 6) increase the number of students enrolled in Medicaid and New York State’s Child Health Plus Insurance Program, and 7) increase wellness and the access to preventive health care for students and their families without health insurance.

Input from community advisory boards and residents in the three counties determined that a number of barriers preclude the area from receiving adequate dental and mental health care for school-age children. These barriers include: lack of insurance, inability of parents to enroll in public insurance programs, limited numbers of dentists and mental health providers, limited fluoridated water, rural poverty, rugged geography and terrain, inclement weather, and lack of public transportation.

This project will use dental hygienists, a mental health social worker, community outreach staff, portable equipment for dental exams, and PDAs for data storage and case management. Staff will be hired to work in six existing School-Based Health Centers. The Consortium anticipates caring for approximately 2,800 clients.

The applicant organization for the Consortium is Bassett Healthcare, a not-for-profit rural health network of primary and specialty care providers dedicated to patient care, teaching and research. Bassett Healthcare staff will oversee grants administration (including day-to-day operations and fiscal and billing issues), and conduct the evaluation for the project. Members of the Consortium will provide office space, assist in marketing and planning, collect information, and support analysis.

Topic Areas

Diabetes, Telehealth

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,806.00

· Year 2 - 124,308.00

· Year 3 - 98,673.00

Partners to the Project

A consortium has been established between Champlain Valley Physicians Hospital Medical Center, a Regional Referral Health Care Center; Clinton County Health Department, a community health care leader; and the Joint Council of Economic Opportunity of Clinton and Franklin Counties (JCEO).

Areas Served

Clinton, Essex and Franklin Counties are medically underserved.

Target Population Served

Targeting Clinton, Essex and Franklin County residents over the age of 45 who have diabetes or are at risk for developing diabetes.

Project Summary

A consortium has been established between Champlain Valley Physicians Hospital Medical Center, a Regional Referral Health Care Center; Clinton County Health Department, a community health care

Program Director

Susannah LeVon

Assistant Director of Nutrition Services

Champlain Valley Physicians Hospital Medical Center

75 Beekman Street

Plattsburgh, NY 12901

Phone: (518) 562-7550

E-mail: slevon@cvph.org

Champlain Valley Physicians Hospital Medical Center

Plattsburgh, NY 12901

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

leader;, and the Joint Council of Economic Opportunity of Clinton and Franklin Counties (JCEO), a social service agency that conducts community outreach programs. The project is designed to finance the development, implementation, and evaluation of the North Country Diabetes Project. This endeavor has been designed based on best practice standards including the American Diabetes Association (ADA) Guidelines for quality diabetes self-management training.

The North Country Diabetes Project will target Clinton, Essex and Franklin County residents over the age of 45 who have diabetes or are at risk for developing diabetes. Innovative outreach activities will involve health professionals, as well as community workers, who provide relevant services to this population. This region is medically underserved with shortages of primary care providers. It is also socioeconomically disadvantaged. The median household income is significantly below State and national levels. Education levels are low adversely affecting health behavior and outcomes. This is reflected in the area’s level of obesity, smoking, high blood pressure, and lack of regular exercise causing significant rates of diabetes and complications from diabetes. This region reports a higher than State average of hospital admissions resulting in major health care costs and complications due to diabetes, which diminish quality of life.

Diabetes is reaching epidemic proportions in the United States. Diabetes cannot be cured. But it can be managed through life style modifications and appropriate health care. Without this intervention, patients suffer from serious complications—blindness, limb amputations, advanced renal disease and heart disease.

The North Country Diabetes Project will build ongoing community collaboration among core health care providers to increase access to diabetes care through the development of a physician referral network and establish an American Diabetes Association-recognized diabetes self management training program. The project will execute a unique community health approach including screenings, risk awareness, and education sessions, creatively using a registered dietitian at the Health Department, home health care registered nurses, JCEO case managers, and community outreach workers. JCEO volunteers will provide transportation to medical appointments for homebound seniors. Public service announcements will increase community awareness as will telehealth capability of 13 local libraries with Internet access to reliable diabetes education resources and postings for local services. Key community agencies such as the Office of Aging, The Senior Citizens’ Council, and the United Way will publicize the project’s services.

This project will reduce the impact that diabetes has on the tri-county region by increasing community awareness, improving health outcomes (i.e. decreased blood glucose levels, reduced complications and reduced hospital admissions) and increasing patient quality of life.

Topic Areas

Chronic disease, Minority health, HIV/AIDS, Mental health, Substance abuse

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The primary consortium member are the Albemarle Hospital Foundation, Inc., initially organized by Albemarle Hospital; the Albemarle Regional Health Services; Jeff Jones Consortium; Northeastern Community Development Corporation (NCDC); and the Albemarle Mental Health Center.

Areas Served

Uninsured and underserved adult populations of a six county catchment area of northeastern North Carolina: Camden, Chowan, Currituck, Gates, Pasquotank and Perquimans

Target Population Served

The service area is now seeing HIV/AIDS cases growing exponentially among African Americans and Hispanics ages 20 to 49.

Program Director

Phil Donahue

Executive Director

Albemarle Hospital Foundation, Inc.

1144 N. Road Street

Elizabeth City, North Carolina 27909

Phone: (252) 384-4072

Fax: (252) 384-4677

E-mail: pdonahue@albemarlehosp.org

Albemarle Hospital Foundation, Inc.

Elizabeth City, NC 27909

ORHP Contact:

Elizabeth Rezai-zadeh

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-4107

erezai@hrsa.gov

Project Summary

The Albemarle Hospital Foundation, Inc., and its four consortium members are focusing on providing expanded services to medically indigent, uninsured and underserved adult populations of a six county catchment area of northeastern North Carolina: Camden, Chowan, Currituck, Gates, Pasquotank and Perquimans. The project is designed to deliver inter-related healthcare activities to curb the multiple illness patterns and the high incidences of secondary conditions among the most disadvantaged by poverty, lack of education, minority status, unemployment, and uninsured or underserved.

Since the Healthy Carolinians 2002 Report, further evidence of the health trends affecting this region have been updated in the 2004 North Carolina Rural Profile by the Rural Economic Development Center and from the State’s Center for Health Statistics and the North Carolina State Office of Rural Health. They continue to show that the area is plagued with chronic cardiovascular disease, cancer, respiratory disorders, a growing problem with Type 2 diabetes and obesity. The service area is now seeing HIV/AIDS cases growing exponentially among African Americans and Hispanics ages 20 to 49.

In an effort to expand the adult services of care and support to the medically indigent, uninsured and underserved, the consortium will use grant funds to concentrate on the following activities:

· Reducing, through more cost effective means, rapidly growing infectious disease incidents by providing local access to an infectious disease physician;

· Providing more comprehensive intake coordination, psychosocial and HIV/AIDS counseling, and assist in case management of the expanding patient base;

· Improving drug access to overcome deficiencies of AIDS Drug Assistance Program;

· Overcoming cultural barriers to health care in the growing Hispanic community; and

· Becoming a rural State model for regional community health care partnerships.

By merging divergent service delivery systems and philosophies into a common vision and organization under the community care clinic model, the project hopes to expand services to the medically indigent, who traditionally experience barriers in accessing health care and may not be receiving primary care, much less care for chronic illness and/or chronic illness as a secondary condition of AIDS.

The primary consortium member are the Albemarle Hospital Foundation, Inc., initially organized by Albemarle Hospital to provide community based health care to the medically indigent; the Albemarle Regional Health Services manages the region’s core public health functions; Jeff Jones Consortium, a nonprofit organization dedicated to serving persons infected with HIV/AIDS; Northeastern Community Development Corporation (NCDC), a nonprofit organization offering a community Hispanic resource center and assistance in the areas of housing, housing counseling, small business development, child care, and skills training; and the Albemarle Mental Health Center providing a mix of outpatient mental health and substance abuse services.

Topic Areas

Safety net-Migrant

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

NC Farmworker Health Project (Satellite Outreach Clinic #1), Lee’s Chapel Advent Church (Satellite Outreach Clinic #2, Stewart’s Chapel PFWB Church (Satellite Outreach Clinic #3), and the Eastern Carolina Medical

Areas Served

Town of Clayton, Town of Smithfield - Site of Johnston Memorial Hospital and Johnston, County Health Department, and Tri-County Community Health Council - Main Site, Newton Grove

Target Population Served

Target $2,100 uninsured, migrant/seasonal farmworkers and the elderly for outreach and new access to primary medical care.

Program Director

J. Michael Baker

Tri-County Community Health Council, Inc.

3331 Easy Street

Dunn, NC

Phone: (910) 567-7004

Fax: (910) 567-5342

E-mail: ncmigrant@aol.com

Tri-County Community Health Council, Inc.

Dunn, NC 28334

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

Tri-County Community Health Council, Inc. (TCCHC) is a not-for-profit Community/Migrant Health Center funded under Sections 330(e)(g) of the Public Health Service Act. TCCHC is a corporation of five community/migrant health centers serving southeastern North Carolina. For almost 30 years, TCCHC has provided culturally competent, linguistically appropriate primary medical, dental and behavioral healthcare to vulnerable populations and the community. In response to HRSA-07-005, Tri-County Community Health Council, Inc. (TCCHC) proposes a new Rural Health Care Services Outreach Initiative targeting uninsured and underinsured migrant/seasonal farmworkers (MSFWs) and community members residing in Eastern Johnstin County.

The Johnston County Outreach Initiative (JOI), a three-year demonstration project, will provide effective linkages into comprehensive, culturally competent quality health care for those without access. The program plan identifies specific sociodemographic, economic, cultural and geographic barriers characteristic of the area and expands TCCHC’s safety net into a region without access to healthcare services. The JOI Team, consisting of a Mid-Level Provider and a Bilingual Outreach Specialist, utilizing state-of the art health records technologies, internet access and satellite clinical services, will team with TCCHC’s existing care services infrastructure to deliver healthcare to needy communities of Eastern Johnston County. JOI is strengthened by a consortium of local health and service providers by providing access to geographic and socially isolated farmworker camps and communities in Eastern Johnston County, ophthalmology, diabetic education and treatment, HIV treatment and prevention education, referrals for specialty services, including MRI, CAT and physical therapy, and hospitalization. Once fully operational in Year 2, JOI will link healthcare services (general care and specialty/chronic disease care) to 2,100 new patients of any demographic background; however, special emphasis will be placed on migrant and seasonal farmworkers, who face a myriad of health and social concerns, and uninsured/underinsured members of the community - many who have not accessed comprehensive care in years.

Topic Areas

Wellness Programs

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 199,781.00

· Year 2 - 143,399.00

· Year 3 - 122,047.00

Partners to the Project

The network partners are the Cavalier County Job Development Authority, Cavalier County Memorial Hospital, and Cavalier County Health District. Existing and supportive community (ad hoc) members are North Dakota State University Extension Service–Cavalier County Office, Cavalier County Social Services, Walhalla Economic Development, Parish Nurse-Faith Based Organization, Cavalier County Senior Meals and Services, and the City of Langdon.

Areas Served

North Dakota residents of Cavalier County, the northwest section of Pembina County, and the northern portion of Ramsey County

Target Population Served

The project will promote wellness programs to residents of every age, gender, and activity level.

Program Director

Shannon Tewksbury

Cavalier County Job Development Authority

901 3rd Street, Suite 5

Langdon, North Dakota 58249-2457

Phone: (701) 256-3475

Fax: (701) 256-3536

Email: shannon@utma.com

Cavalier County Job Development Authority

Langdon, ND 58249-2457

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

The Wellness Interventions Lasting a Lifetime (WILL) project—designed to encourage wellness and healthy lifestyles—will provide education on disease management and prevention to North Dakota residents of Cavalier County, the northwest section of Pembina County, and the northern portion of Ramsey County. The WILL project will be implemented with classes and lectures, screenings, and fitness and nutrition programs to manage chronic disease and their modifiable risk factors. The WILL Network’s goals are to implement the WILL project, to increase awareness of chronic disease conditions, to promote wellness and lifestyle change programs, to increase awareness of activity-related injury prevention and wellness programs, to increase awareness of overall occupational wellness, and to promote self-managed wellness programs. The WILL Network will deliver educational programs on a local, regional, and statewide basis through Internet technology; hold classes, lectures, general fitness and nutrition programs, and screening tests; distribute brochures; take wellness to the next level of activity in the community; and combine all community health-related resources. The project will promote wellness programs to residents of every age, gender, and activity level. Education and promotion will focus on overall wellness, and fitness and nutrition programs, with an end goal of self-managed wellness programs.

Residents of the service area are primarily Caucasians, with 0.99 percent Native Americans living in the area. In rural areas, long distance between health care facilities presents a large barrier to seeking and receiving health care. As the population continues to age, the lack of public transportation compounds this problem. In addition, the mindset and attitudes of rural residents can be a barrier to needed health care services in this area. They generally are stoic, hard-working individuals, often too proud to ask for necessary health care assistance. Depression, due to a declining farm economy, as well as aging and other stress-related issues are examples of health care needs in the service area that would benefit from the promotion of wellness education. Cavalier County is a designated Health Professional Shortage Area.

Topic Areas

Cancer

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Southwestern District Health Unit, Community Action Partnership, and St. Joseph’s Hospital and Health Center.

Areas Served

Adams, Billings, Bowman, Dunn, Golden Valley, Hettinger, Slope, and Stark counties in southwestern North Dakota . Five and a half of the counties served are designated full Health Professional Shortage Area, and six-and-a-half are Medically Underserved Areas.

Target Population Served

The target population includes four groups: 1) increase awareness of healthy lifestyles, 2) increase the availability of comprehensive screening events, 3) increase the number of cancers identified in the in situ or localized stage by 5 percent over the 1997 numbers

Program Director

Carlotta Ehlis

Southwestern District Health Unit

2869 3rd Avenue W

Dickinson, ND 58601

Phone: (701) 483-0171

E-mail: cehlis@state.nd.us

Southwestern District Health Unit

Dickinson, ND 58601

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

documented in the North Dakota Cancer Registry, 4) increase the number of participants in educational programs related to smoking, smoking cessation, and exposure to secondhand tobacco smoke in an effort to reduce the incidence of lung cancer.

Project Summary

The health care needs of the area were identified through a community health assessment initiated by the Healthy 8 Communities Network. This group is a multidisciplinary team of 55 members representing over 35 community groups from the eight southwestern counties of North Dakota. Results in 1997 and a repeated survey in 2002 indicated Areas of Opportunity for Health Action, with cancer identified as a significant health priority. The Cancer and Substance Abuse Task Force was formed in 1998 creating the Pathways to Healthy Lives program, which became a reality through funding by a Rural Health Care Services Grant from 2000-2003. The results of the 2002 assessment revealed the positive impact of the program and identified the need for program expansion to include comprehensive screenings and education for breast, prostate, lung, colorectal and skin cancer.

Pathways to Healthy Lives provides public education focusing on making healthy dietary choices, being physically active, protecting oneself from sunlight and chemical exposure, and preventing initiation or cessation of tobacco products usage. Free breast, prostate, colorectal, and skin cancer screenings to be held in local communities within the eight counties. Collaboration between community leaders, providers, clinics, hospitals, and Pathways to Healthy Lives makes it possible to offer services in local communities where people live, thus increasing accessibility and reducing the amount of distance people must travel.

The consortium for Pathways to Healthy Lives consists of members from Southwestern District Health Unit, Community Action Partnership, and St. Joseph’s Hospital and Health Center. These three agencies have partnered together since the inception of the Pathways to Healthy Lives program and to provide advisement and support.

The goals of the Pathways to Healthy Lives program are to: 1) increase awareness of healthy lifestyles, 2) increase the availability of comprehensive screening events, 3) increase the number of cancers identified in the in situ or localized stage by 5 percent over the 1997 numbers documented in the North Dakota Cancer Registry, 4) increase the number of participants in educational programs related to smoking, smoking cessation, and exposure to secondhand tobacco smoke in an effort to reduce the incidence of lung cancer.

The southwest eight counties have significant physical isolation from specialty health care providers. Harsh climatic conditions have a major impact on the ability of residents to seek medical services. Pathways to Healthy Lives serves the 38,365 residents of Adams, Billings, Bowman, Dunn, Golden Valley, Hettinger, Slope, and Stark counties in the 10,000 square mile area of southwestern North Dakota. An American Indian population resides in the northern part of Dunn County. Five and a half of the counties served are designated full Health Professional Shortage Area, and six-and-a-half are Medically Underserved Areas. In 1999, North Dakota had a per capita person income of $17,769. The national average is $21,587. Some 11.9 percent of North Dakota residents overall were below poverty level in 1999; however, 17.5 percent of Dunn, 16.9 percent of Slope, and 15.3 percent of Golden Valley county residents were below poverty levels. Also, 12.5 percent of adults in the service area lack health insurance coverage.

Topic Areas

Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Areas Served

Frontier and reservations areas of North and South Dakota.

Target Population Served

Empower non-mental health professionals, including first responders, health providers, and community members to recognize signs, make use of basic skills, and assist with accessing mental health resources.

Project Summary

The focus of the Standing Rock Reservation’s Mental Health First Aid program is to empower non-mental health professionals, including first responders, health providers, and community members to recognize signs, make use of basic skills, and assist with accessing

Program Director

Randy Bear Ribs

Standing Rock Sioux Tribe

Standing Rock Reservation

P.O. Box D

Fort Yates, North Dakota

Phone: (701) 854-7206

E-mail:

rbr_lakotawarrior@hotmail.com

Standing Rock Reservation

Fort Yates, ND

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

mental health resources in the frontier and reservations areas of North and South Dakota. As mental health resources are scarce in rural, frontier, and tribal areas, implementing a program at the grassroots level and training health professionals, paraprofessionals, and interested volunteers to better understand mental health issues and provide a supportive environment is an innovative way to address mental health problems.

Suicide in the northern plains region is at epidemic proportions requiring an immediate and innovative mental health response. Through the development of the Mental Health First Aid program, a training and curriculum will be developed consisting of a 12-hour course developed at the Centre for Mental Health Research at The Australian National University, to improve mental health knowledge, skills, and attitudes.

The Mental Health First Aid program uses five basic skill steps to address issues related to suicide: 1) Assessing the risk of suicide; 2) Listening non judgmentally; 3) Giving reassurance and information; 4) Encouraging the person to get appropriate professional help; and 5) Encouraging self-help strategies.

There are three phases to this program. First, the developmental phase includes training for trainers, adapting the Australian curriculum for use on the reservation, and piloting the training on the Standing Rock Reservation and West River Health Service area. These trainings for Standing Rock personnel will be held in the local districts and conducted by the Community Health Representatives in each district. The West River trainers will conduct the training in local communities requiring less travel by the majority of participants and trainers. In year 2, the implementation phase, the training of providers would begin emphasizing training for the medical and emergency personnel in each of the eight districts within the Standing Rock Reservation and throughout the West River Health Service area. All trainings will be conducted by the original trainers from the first year of the project. In Year 3, the expansion phase, the project will expand the previous training to include other sectors of the community such as, business, education, faith/religion, and government/public. Additionally, curricula will be developed for training new trainers and more trainers trained. Dissemination of the program into other Tribal communities would be completed during this phase.

Topic Areas

Dental, Women’s health, Prenatal care, Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Community Health Services (CHS), Mercy Hospital of Willard, and Huron County Health Department

Areas Served

Willard, Huron County, Ohio, as well as the southeast corner of Seneca County and the northeast corer of Crawford County.

Target Population Served

A consortium of three parties are working together to provide basic primary care and dental services to a target population of adults and children with incomes under 200 percent of the federal poverty level.

Program Director

Joseph Liszak

Executive Director

Community Health Services

410 Birchard Avenue

Fremont, Oh 43420

Phone: (419) 334-8943

E-mail: jliszak@fremontchs.com

Community Health Services

Fremont, Oh 43420

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

A consortium of three parties—the Community Health Services (CHS), Mercy Hospital of Willard, and Huron County Health Department—are working together to provide basic primary care and dental services to a target population of adults and children with incomes under 200 percent of the federal poverty level who live in the area of Willard, Huron County, Ohio, as well as the southeast corner of Seneca County and the northeast corer of Crawford County. This rural health outreach grant will enable community health services to expand the operation of the Willard clinic from 5 hours per week to 12 hours per week, to provide expanded prenatal services to the target population, and to provide basic dental services to adults and children.

Within the city of Willard, 16.5 percent of the population has an income less than 100 percent of the federal poverty level. This contrasts with 8.5 percent of Huron County residents and 10.6 percent of Ohio residents whose incomes are less than the poverty level. There is no safety net clinic in the area where uninsured patients may access care on a sliding fee basis other than the CHS Willard clinic, Mercy Hospital’s OB/GYN clinic, a twice monthly well-child clinic offered by the Health Department, and the Mercy emergency room. In the Willard area, there are three dentists. Only one is listed on the Huron County Department of Job and Family Services list of dentists who accept new Medicaid patients. Most people in Huron County who need dental care and lack dental insurance and the means to pay simply go without care or must drive 60 minutes to the nearest safety net, the CHS main office in Fremont, Ohio.

Community Health Services plans to close the primary care and dental service gap by expanding services from 5 hours per week at its Willard clinic to 12 hours per week, potentially open on some Saturdays, and engage in a referral arrangements with two Willard dentists who will accept uninsured patients on a modest voucher payment system. This expansion of the Willard clinic will allow the clinic to provide 1700 medical encounters per year, in contrast to the present 700 annual encounters. It will open up sufficient appointment slots to provide pap smears to 90 female adult patients as needed. The additional hours also will ensure that each of the 72 diabetics currently being treated at the clinic can be seen minimally on a quarterly basis and on a monthly basis at the point that their sugar is uncontrolled, and to aggressively treat pre-diabetes. Women in need of prenatal care will be seen at the Mercy Hospital, OB/GYN clinic. Persons in need of dental care will be referred to local dentists. These dentists will provide basic preventive and restorative services to adults and children referred to them through Mercy Hospital, who will assist with the payment of care for at least 85 children and adults each year. The Huron County Health Department will refer children to the dental services through its twice monthly well-child clinic in Willard, and will refer adults who come to its adult clinics.

Topic Areas

Overweight/obesity

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The Goal of the Twin City Hospital (TCH) Healthy Community/ Happy Children Outreach Program (HC/HCOP)

Areas Served

Village of Dennison, Tuscarawas County, and the surrounding counties of Carroll, Harrison, and Guernsey.

Target Population Served

To provide an innovative, multi-agency means to reduce the number of overweight and obese men, women, and children of all ages.

Project Summary

The Goal of the Twin City Hospital (TCH) Healthy Community/Happy Children Outreach Program (HC/HCOP) is to

Program Director

Marjorie Jentes

Chief Executive Officer

Twin City Hospital

819 N. First Street

Dennison, OH 44621

Phone: (740) 922-2800

E-mail: mjentes@twincityhospital.org

Twin City Hospital

Dennison, OH 44621

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

provide an innovative, multi-agency means to reduce the number of overweight and obese men, women, and children of all ages in the Village of Dennison, Tuscarawas County, and the surrounding counties of Carroll, Harrison, and Guernsey. The program will allow a consortium of community agencies to pool precious resources to enhance educational opportunities, outreach, facilities and services through a collaborative countywide effort. Program services will be offered to all populations regardless of their abilities to pay or ethnic backgrounds.

Twin City Hospital Healthy Community/Happy Children Outreach Program (HC/HCOP) information will be disseminated through various promotional efforts such as: mailings, speaker’s bureau activity, newspaper articles, radio public service announcements, church bulletins, grocery bag inserts, school handouts, and brochures and fliers placed in area libraries, physician’s offices, schools, and Head Start Centers. The project also plans to make information available via the Twin City Hospital’s web page at www.twincityhospital.org.

The development of the Twin City Hospital HC/HCOP will address the following health and wellness needs in the community: 1) Lack of affordable diet and exercise training; 2) Need for a central location where people can access health and wellness information that is appropriate for all age levels; 3) Need to provide treatment for obesity among all age groups; 4) Need for enhanced diabetes treatment and education; 5) Need for fitness programs for all ages; 6) Need for child care to allow busy parents the time to participate in HC/HCOP services; and 7) Need to provide local access to these services due to a lack of affordable public transportation in Tuscarawas County.

The Twin City Hospital HC/HCOP will provide the following age-appropriate services to meet the community needs listed above: 1) Provide nutrition and exercise programs for all population groups through a series of two “Fit” programs: Fit for Life for adults and Fit for Fun for children and teens; 2) Provide special health interventions for adults and children who either have diabetes or are at risk for diabetes; and 3) Provide nutrition and exercise information online on the Hospital’s website in order to improve access to health and wellness information. While the administrative function of the program will be housed at Twin City Hospital, services will be offered at various locations throughout the community in order to reach all segments of the targeted population. According to the 2000 Census, 90,914 populate Tuscarawas County.

To address transportation needs, Twin City Hospital will use school buildings in towns throughout the service area so that people can access program services without having to drive a long distance.

Topic Areas

Medication assistance

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Areas Served

Southeastern Appalachia Ohio

Target Population Served

The program will assist any resident with a prescription medication need who is not able to fill the prescription on his/her own. These individuals include uninsured, low-income/fixed income, and those residents experiencing hardships that would legitimately preclude them from fill physician-prescribed medications.

Program Director

Melinda Lutz

Zanesville-Muskingum County Health Department

205 North 7^th Street

Zanesville, OH 43701

Phone: (740) 454-9741

E-mail: mlutz@zmchd.org

Zanesville-Muskingum County Health Department

Zanesville, OH 43701

ORHP Contact:

Jacob Rueda

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0835

jrueda@hrsa.gov

Project Summary

The RxCUE program is a community-based prescription medication assistance program. This program for southeastern Appalachia Ohio involves a coalition of four core members, and six additional community agencies and stakeholders. The program will assist any resident with a prescription medication need who is not able to fill the prescription on his/her own. These individuals include uninsured, low-income/fixed income, and those residents experiencing hardships that would legitimately preclude them from fill physician-prescribed medications.

The three core consortium members are the Zanesville Muskingum County Health Department, Eastside Community Ministry, and Genesis Healthcare. Contributing members include Muskingum County Center for Seniors, Muskingum TB and Respiratory Clinic, Alfred Carr, Mental Health and Recovery Services Board, Six County, Inc., and Muskingum County Job and Family Services. These agencies and various affected individuals from the community worked for nearly 3 years to complete a needs analysis, identify target populations, develop budget start-up costs, and develop goals, objectives, and activities. RxCUE will use a three-tier system for assisting clients:

· Tier I will link individuals with free pharmaceutical-sponsored programs.

· Tier II will fill prescriptions from the State pharmacy repository. The State of Ohio passed House Bill 221 provides for the development of a State Pharmacy repository for collection and redistribution of surplus medications from individuals and agencies.

· Tier III will use the stopgap approach to filling medications through outright purchase. The purchase of medications will be done through a cooperative agreement with consortium members that use volunteer pharmacists to fill prescriptions at hospital costs. Grant money will fund the purchase of medications in this tier only. The result is an average savings of 50 percent over purchases from a private pharmacy.

This program will target approximately 1,250 unduplicated clients each year, including senior citizens, low-income individuals and families, and those with financial hardships (who do not have prescription medication insurance coverage or cannot meet deductible/co-payment requirements). Based on local statistics, the greatest needs of this target population include medication for diabetes, hypertension, pulmonary, cancer, and respiratory conditions.

Topic Areas

Alzheimer’s disease; Caregivers

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Areas Served

The target population is the service area of Northeastern Oklahoma Community Health Centers, namely Cherokee County, and its four surrounding counties

Target Population Served

Providing information and education to individuals who are caregivers to those suffering from Alzheimer’s disease.

Project Summary

In operation since April 23, 2002, Northeastern Oklahoma Community Health Centers was established in response to the

Program Director

Lori Timmons

Chief Executive Officer

Northeastern Oklahoma Community Health Centers

119 W. Main Street

Hulbert, OK 74441

Phone: (918) 772-3471

Fax: (918) 772-3102

E-Mail: lori.timmons@neochc.org

Web Site: http://neochc.org

Northeastern Oklahoma Community Health Centers Hulbert, OK 74441

ORHP Contact:

Jacob Rueda

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0835

jrueda@hrsa.gov

overwhelming need for accessible health care in rural northeastern Oklahoma. The mission of the health center is to provide high-quality preventive and primary health care to eastern Oklahoma. Since its inception, the health center has experienced rapid growth and works within a constructive, collaborative environment to expand the range of services offered. The health center operates five sites, employs eight full-time providers, and offers the full range of preventive and primary care services.

The target population of the health center is the uninsured and underinsured residents of Cherokee County, Oklahoma; however, health center patients come from across the multi-county region of northeastern Oklahoma—some driving as long as 2 hours to reach the health center. Needs to be addressed include providing information and education to individuals who are caregivers to those suffering from Alzheimer’s disease. Topics of education include available medications and treatments, legal and financial concerns, and caregivers’ high risk for stress-related illness and coping mechanisms that can be used to reduce stress-induced health risks. Services to be provided include a needs assessment, through which community-specific needs will be identified, resources available, and an action plan that will map a path toward meeting those needs. In addition, the importance of “Maintaining Your Brain” will be a focal point for education aimed at delaying the onset, and reducing the severity of, Alzheimer’s disease.

The target population is the service area of Northeastern Oklahoma Community Health Centers, namely Cherokee County, and its four surrounding counties. The goals of this project are:

· To improve the ability of area organizations to better meet the mental and physical needs of caregivers;

· To improve the ability of caregiving families to use health care and support services in their communities;

· To support the mental and physical health caregivers;

· To educate area residents about maintaining brain health and decreasing the impact of Alzheimer’s;

· To use advanced communication tools, including the Internet, to achieve goals more efficiently; and

· To develop a plan for sustainability.

Topic Areas

Cardiovascular disease, Stroke, Elderly

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,982.00

· Year 2 - 124,836.00

· Year 3 - 99,980.00

Partners to the Project

Three Rivers Community Hospital, Josephine County Public Health Department and AMR of Josephine County.

Areas Served

Josephine County, much of which is designated as a medically underserved area, is situated in the southwest corner of Oregon.

Target Population Served

This project will significantly expand and enhance treatment and prevention of cardiovascular disease and stroke; a community response to the critical needs of elderly men and women in rural Josephine County.

Project Summary

Josephine County , much of which is designated as a medically underserved area, is situated in the southwest corner of Oregon. It encompasses a geographical area spanning 1,641 square miles, and

Program Director

Sandra Olson

Director of Research & Development

Three Rivers Community Hospital

2600 Siskiyou Boulevard, Suite 100

Medford, Oregon 97504

Phone: (541) 789-5298

E-mail: solson@asante.org

Three Rivers Community Hospital

Medford, OR 97504

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

supports a population base of 77,123 persons. The over age 65 population in this area is anticipated to increase to 31 percent by 2020—about 20-30 years sooner than is projected for the nation as a whole. In Josephine County, where currently an astounding 20 percent of all residents are aged 65 or older, residents are besieged by health disparities. Of particular concern is the fact that people in Josephine County are 1.5 times more likely to die from cardiovascular disease than their cohorts throughout Oregon.

The high incidence of cardiovascular disease and stroke, coupled with the growing over age 65 population in Josephine County supports the critical need for this proposed rural outreach project entitled Heart Health: A Rural Prevention and Treatment Program. Three Rivers Community Hospital, Josephine County Public Health Department and AMR of Josephine County, in collaboration with other regional providers and consumers, have developed a rural outreach project with the following four goals: 1) To improve the capacity of Josephine County stakeholders to identify and intervene in men and women’s cardiovascular disease specific risk factors; 2) To reduce risk-adjusted rates of cardiovascular disease related morbidity and mortality by increasing the use of evidence-based practices in the prevention and treatment of Josephine County men and women; 3) To improve the capacity of Josephine County men and women at high-risk of cardiovascular disease to manage their health and receive seamless care across the continuum of heart related care; and 4) To improve the capacity for rapid transport and treatment of Josephine County ST segment elevation myocardial infarction (STEMI) patients.

These goals emerged from a community wide planning process and are responsive to the needs of this rural area to reduce risks and improve outcomes for rural elderly men and women who are at high-risk for cardiovascular disease and stroke. The strategies that will be employed and evaluated to achieve these goals include: gender sensitive education programs and materials for providers and consumers; community screenings to identify and intervene with persons at high-risk of cardiovascular disease and stroke; workflow redesign and monitoring geared to increase best practice use and improve rapid transport and treatment; and a health promotion program utilizing case management/self-management to support lifestyle change and behavior modification, resulting in reduced risks and lowered heart related morbidity and mortality rates for Josephine County men and women. This project, and its sustained operation, will significantly expand and enhance treatment and prevention of cardiovascular disease and stroke; a community response to the critical needs of elderly men and women in rural Josephine County.

Topic Areas

Substance abuse, Mental health, Migrant health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

ADAPT, Inc., Healthcare for Women, Douglas County Independent Practice Association, Douglas County Health and Social Services, and Douglas County Family Development Center.

Areas Served

Douglas County which is medically underserved.

Target Population Served

The target population includes the lack access to a continuous source of primary care.

Project Summary

Douglas County is situated in southwest Oregon. It encompasses an area that spans 5,134 square miles and supports a population base of 100,400 persons. A huge expanse of Douglas County, totaling 2,459

Program Director

John Gadrin II

ADAPT, Inc.

P.O. Box 1121

Roseburg, OR 97540

Phone: (541) 672-2691X262

drjohn@adapt-or.org

ADAPT, Inc.

Roseburg, OR 97540

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

square miles, supports a population density of fewer than seven persons per square mile, thus meeting Federal criteria for designation as a frontier area. Douglas County currently holds Federal designations as a health professional shortage area, a mental health professional shortage area, medically underserved area, and as containing a medically underserved population comprised of low-income residents and migrant and seasonal farm workers.

Douglas County’s people suffer from a number of social ills, including elevated TANF rates, elevated food stamp recipient rates, and poor high school completion rates. Documented health disparities include malignant neoplasms, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hypertension, and infant mortality. The Oregon Primary Care Association (January 2002) estimates that the county’s current safety net system of care is meeting the needs for only 6 percent of Douglas County’s low-income and medically uninsured residents. Fully 14,345 such individuals lack access to a continuous source of primary care.

Addictive disorders are evident within the population at elevated rates beginning with 12-year-old children. Studies conducted by the Center for Oregon Health Plan Policy and Research confirm that one-quarter of all Medicaid recipients are receiving prescriptions for Vicodin. While elements of addictive disorders are seen in virtually every primary care practice in Douglas County, it is the consensus of the medical community that few resources exist to help either patients or their attending primary care providers. To this end, the Rural Health Care Services Outreach project will establish a program of integrated primary and behavioral health using elements of successful, HRSA-sponsored Health Disparities Collaborative models. In specific, behavioral health nurses placed in primary care settings will provide addiction assessment, intervention, and self-care management planning for 175 patients in Year 1, and 250 patients in each Year 2 and year 3. Intended outcomes include improvements in Global Adaptive Functioning for program participants and reduction in use rates for inappropriate primary care office visits.

The project has established rigorous statistical measures, and will feature the innovative use of the PDSA model for continuing to refine the program along a continuum of quality improvement. The project is sponsored by ADAPT, Inc., Healthcare for Women, Douglas County Independent Practice Association, Douglas County Health and Social Services, and Douglas County Family Development Center.

Topic Areas

Diabetes, Overweight/Obesity, Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The Next Door, Inc. and Providence Hood River Memorial Hospital.

Areas Served

Hood River, Wasco, Klickitat, and Skamania counties.

Target Population Served

The target population includes low-income, uninsured, or underinsured residents in the rural communities of Hood River, Wasco, Klickitat, and Skamania counties, with special attention to Hispanics.

Project Summary

La Clínica del Cariño, a community and migrant health center in Hood River, Oregon—in partnership with The Next Door, Inc., a community social service agency, and Providence Hood River Memorial Hospital—is supporting a community project entitled Steps to Wellness/Pasos a Salud. This project is intended to improve the

Program Director

Margery Dogotch

La Clínica de Cariño Family Health Center

849 Pacific Avenue

Hood River, OR 97031

Phone: (541) 308-8340

Fax: (541) 386-1078

La Clínica de Cariño Family Health Center

Hood River, OR 97031

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

emotional and physical well-being of our rural community residents by providing individual and group support and education to people suffering from diabetes and/or obesity. We will particularly emphasize services for low-income and medically underserved English-speaking and Spanish-speaking residents of the rural four county target area.

Recent evidence of the reciprocal and reinforcing relationships between chronic diseases such as obesity and diabetes on depression is startling. Not only can diabetes and obesity (and their sequelae) lead to depression, but depression also can make people more likely to be obese and diabetic. Given the known stigma associated with mental health treatment, which are amplified in a rural community, approaching mental health issues from another common denominator can be an effective way to elucidate the extent of the problem and possible solutions.

Steps to Wellness/Pasos a Salud has the following four goals: 1) To address mental health issues that impact patient self-management of diabetes and/or obesity; 2) To improve patients’ ability to manage their diabetes and/or obesity; 3) To improve recognition of the importance of physical activity to the mental and physical health of people with diabetes and/or obesity; and 4) To increase community awareness of diabetes, obesity, and the concurrent emotional issues.

To accomplish these goals, a comprehensive training strategy will be implemented, using the expertise and resources of consortium members, to ensure that project staff members, including co-directors and community health promoters, are well versed in mental health, diabetes, and obesity issues. Services to the community will be provided in a four-pronged approach: 1) Education and support groups for 60 participants; 2) Lay counseling for 10 dialysis patients; 3) Case management services for 35 patients; and 4) Community outreach to 5,000 people through general outreach and 500 people in more intensive, one-on-one contact. In addition, the consortium will meet to choose and provide an intervention for obese children, the first of its kind in our community.

Steps to Wellness will target low-income, uninsured, or underinsured residents in the rural communities of Hood River, Wasco, Klickitat, and Skamania counties, with special attention to Hispanics. The project will direct program activities toward people who struggle with weight management and/or diabetes, or who have a family member with weight management issues or diabetes. The project will also identify and focus upon those, among this population, whose mental distress (depression, anxiety, or stress) is interfering with their disease self-management. Addressing both mental health and obesity/diabetes simultaneously promises to lead to more effective influence on health habits and health outcomes in our community’s vulnerable populations.

Topic Areas

Medication assistance

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Wayne Memorial Hospital, Lackawanna County, Pennsylvania , and Sullivan County, New York.

Areas Served

The consortium also represents portions of Lackawanna County, Pennsylvania, and Sullivan County, New York.

Target Population Served

The project will implement an integrated medication safety program called the IMAPS Project, or Improving Medication and Patient Safety.

Program Director

David L. Hoff

Manager of Grants and Development

Wayne Memorial Hospital Contact

601 Park Street

Honesdale, PA 18431

Phone: (570) 253-8101

E-mail: hoff@wmh.org

Wayne Memorial Hospital Contact

Honesdale, PA 18431

ORHP Contact:

Elizabeth Rezai-zadeh

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-4107

erezai@hrsa.gov

Project Summary

This project is built on the premise that a significant aspect of patient safety that can be improved is in the realm of medication, including prescription, transcription, validation, documentation, ordering, dispensing, administering, and usage of drugs and other pharmaceuticals. Wayne Memorial Hospital, a 98-bed community hospital in rural Pennsylvania, and its consortium of primary care practices throughout Wayne and Pike Counties, Pennsylvania . The consortium also represents portions of Lackawanna County, Pennsylvania , and Sullivan County, New York. The project will implement an integrated medication safety program called the IMAPS Project, or Improving Medication and Patient Safety.

Through the use of comprehensive information systems and automation the medication processes of ordering, transcribing, dispensing, and administering medication for patients served throughout the Wayne Memorial Health System and the community will be improved substantially. The project will involve sharing this vital medication information between the hospital and the physicians employed in physician practices within the community, both health system entities and private practices. The mechanism for accessing this information will be the Internet through a secured web portal. The project will include enhanced automation and information systems in the following Hospital areas: inpatient units, operating rooms, and emergency services.

The primary goal of the project is improvement in patient safety. A concurrent goal is a reduction in the need for additional services caused by medication errors and the resultant drain on both the patient’s resources and the medical resources of this medically underserved community. The objective to accomplish these goals is reduction of medication errors. Success of the project will be measured through quarterly reports identifying the number of medication errors by unit of service within the Hospital. This information will be compared to baseline (historical data) before the new system was implemented. The type of data to be collected and maintained will include: (1) the number of medications administered, both in grand totals and by department and by individual provider (nurse and/or doctor); (2) the number of medication errors and the type of errors (ordering, transcribing, dispensing, or administration errors). Specifically, the project goal will be a 50 percent reduction in medication errors over historical events.

The number of Hospital inpatients that will be affected by this project will be 4,000-4,500 per year. The number of emergency room encounters with potential for interaction with this project is 19,000-20,000 per year. The number of provider orders impacted by this system will be 435-450 per day, or 158,000 to 164,000 per year.

Topic Areas

Chronic disease, Home health services, Self-management

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,767.00

· Year 2 - 124,190.00

· Year 3 - 99,615.00

Areas Served

Oconee County, South Carolina

Target Population Served

Adults over the age of 65 years residing in Oconee County, South Carolina, have higher rates of many chronic diseases and risk behaviors than their State and national counterparts.

Project Summary

Adults over the age of 65 years residing in Oconee County, South Carolina, have higher rates of many chronic diseases and risk behaviors than their State and national counterparts. This county

Program Director

Cheryl Dye

Oconee Memorial Hospital, Inc.

298 Memorial Drive

Seneca, SC 29672

Phone: (864) 656-4442

Fax: (864) 886-9773

Email: tcheryl@clemson.edu

Oconee Memorial Hospital, Inc.

Seneca, SC 29672

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

ranks second in the State for the percentage of the population over 65 years of age at 15.6 percent. Of this population, 12.9 percent live in poverty, compared to the national average of 6.4 percent. Lack of resources makes self-management of chronic disease very challenging, often leading to the need for home health services (HHS). However, even during the episode of care offered by the two nonprofit HHS agencies in Oconee County, patients exceed the State and national average in HHS patient hospital and emergent care. After discharge from HHS, avoidable incidences of emergent and hospital care arise because of the difficulty the older adult faces in transitioning from home health services to chronic disease self-management.

In the rural, older population of Oconee County, much of this emergent and hospital care is related to congestive heart failure, diabetes, and cardiovascular disease. Frequently, such care could have been avoided if the disease had been more effectively managed through better adherence to the home health care plan and prompt recognition of “red flag” signs and symptoms. Adherence can be improved by building patients’ self-management skills and helping them navigate the complex network of health and social services. This project’s model is designed to improve chronic disease management among rural, HHS patients through trained community volunteers called “Health Coaches.” These coaches will help patients transition from home health services to self-care and family care by offering home-based education, monitoring, support, and referrals, thus reducing the risk for emergent and hospital care.

The role of the Health Coach merges community volunteer with “patient navigator” and includes: 1) Building patient chronic disease self-management skills; 2) Coordinating health care services and provider referrals; 3) Collaborating with community organizations to obtain services and make referrals; 4) Helping with medication management; 5) Arranging and reminding clients about appointment schedules and treatment regimens; 6) Making transportation arrangements for health needs; 7) Facilitating communication between client, family, caregivers, and service providers; 8) Providing and facilitating social support; 9) Implementing nutrition and physical activity educational programs; 10) Facilitating participation in immunization clinics; and 11) Facilitating enrollment in clinical trials.

The project will implement best practices such as those tested in the South Carolina Rural Geriatric Initiative Project (SC GRIP). Health Coaches will be trained using the SC GRIP curriculum for geriatric technicians and will be trained to use the State’s medical management materials, and its information and referral database. The also will be trained to implement Clemson University Extension nutrition and physical activity curricula. The project will build on these successful programs, integrate them with home health services, and organize strategies with the Chronic Care Model framework to coordinate care as the patient transitions along the continuum from acute care to self-care.

Topic Areas

Diabetes

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 149,829.00

· Year 2 - 124,989.00

· Year 3 - 99,999.00

Partners to the Project

Salkehatchie Healthy Communities Collaborative, Allendale County ALIVE, Inc., Low Country Regional Transportation Authority, Carolina Medical Associates and the Laffitte and Warren Medical Center, Allendale County Office of Aging, and Me and My Sugar Diabetes Support Group/Salk Walk.

Areas Served

Allendale County, South Carolina

Target Population Served

will improve the lives of diabetics in Allendale County, South Carolina, by providing them with the education and tools they need to take control of the disease, instead of allowing it to control their lives.

Program Director

Camille Nairn

Western Carolina Higher Education

P.O. Box 617

Allendale, SC 29810

Phone: (803) 584-3446, ext. 124

Fax: (803) 584-5038

E-mail: nairncs@gwm.sc.edu

Salkehatchie Healthy Communities Collaborative

Allendale, SC 29810

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

Project Summary

The Salkehatchie NEEDS (Nutrition, Education, and Exercise for Diabetes Stabilization) Diabetes Initiative is a Rural Outreach program that will improve the lives of diabetics in Allendale County, South Carolina, by providing them with the education and tools they need to take control of the disease, instead of allowing it to control their lives.

This outreach effort grew out of ongoing efforts of the Salkehatchie Healthy Communities Collaborative, which works with local and state healthcare providers to improve the quality of healthcare accessible to local residents. Collaborative partners focused on the need to help those non-compliant diabetics in our community understand the disease and how to control it, to reduce the negative impact on their lives and the economic burden to the community. Some of those partners came together to form the NEEDS Rural Outreach Grant Consortium.

Reports from the SC Department of Health and Environmental control indicate that in 2002, diabetes resulted in $2.3 million in hospital charges for Allendale County patients. In a county of only slightly more than 11,000 people, with the lowest per capita income and highest poverty rate in the state, any disease with that kind of impact is severe. In a county where 74% of people are overweight, about 10% have diabetes, and two local Rural Health Clinics registered 2,210 office visits in 2005 related to diabetes, the need for a diabetes education and intervention program that focuses on self-regulation of the disease was obvious to the grant Consortium.

Salkehatchie NEEDS will provide a Certified Diabetes Educator in the community, housed at the county hospital, who will oversee the NEEDS program and provide both one-on-one and group educational sessions for diabetics referred by local physicians and the ER. Through this grant, the hospital will also be able to provide a Registered Dietitian in the community for one additional day each month, during which time she will work directly with NEEDS participants to customize nutrition plans and increase their understanding of the relationship between food choices and diabetes. These educational and service components will be combined, through Salkehatchie NEEDS, with a fitness component, provided in large part by the University of South Carolina Salkehatchie and the Salkehatchie Healthy Communities Collaborative. The campus currently has the only fitness center in the county, and has agreed to open that facility to NEEDS participants. The Center’s manager will work with the CDE to tailor fitness and activity programs to individual participants’ needs and ability levels, with a focus on reducing the risk factors that often exacerbate diabetes complications, such as obesity, heart disease, and high blood pressure. Grant activities also call for the creation of a special NEEDS activity class that will allow participants referred by the CDE to do low-impact activities, such as chair aerobics, and resistance training with bands, using video guidance. Additional community partners will provide services such as inclusion of NEEDS participants in a walking program and community aerobics classes, transportation to educational and fitness activities if needed, diabetes medication and supply assistance, and access to an existing diabetes support group.

Topic Areas

Diabetes

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The network partners include a Critical Access Hospital, a for-profit hospital, two Federally Qualified Health Centers, a free clinic, a primary health care center affiliated with the USC School of Medicine, Region 3 of DHEC - the state public health agency, CareLINK - an indigent and medically underserved healthcare access program, and a private foundation.

Areas Served

Chester and Fairfield Counties

Target Population Served

Middle school students, ages 11-15, with asthma and diabetes are the primary target population for this grant.

Program Director

Beverlyann V. Austin

Fairfield Memorial Hospital

P.O. Box 620

Winnsboro, SC

Phone: (803) 712-0375

Fax: (803) 712-1683

E-mail: beverlvann.austin@fairfieldmemorial.com

Fairfield Memorial Hospital

Winnsboro, SC 29180

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

Project Summary

The Upper Midlands Rural Health Network was a 2006 recipient of a Rural Health Network Development Planning Grant and has been successful in implementing its objectives. The overarching goals of the Upper Midlands Rural Health Network are to achieve efficiencies, to coordinate and improve the quality of essential health care services, to strengthen the rural health care system as a whole and expand access. Access to health care in the two county Upper Midlands region is ranked among the lowest in the state. This Outreach Grant will seek to expand one of the objectives of the Rural Health Network Development Planning Grant that addressed planning for appropriate services for network residents including children with diabetes or at risk for developing it. The primary goals of this grant are 1) To strengthen the Network and its effectiveness in improving the system of health care in the Network region, 2) To reduce absenteeism of middle school students with the chronic conditions of asthma and diabetes, and 3) To increase community knowledge of the risk factors for diabetes and asthma and how to manage them. Middle school students, ages 11-15, with asthma and diabetes are the primary target population for this grant. Asthma/Bronchitis is the leading cause of hospitalization for children under the age of 18 in the two counties. Seventy-three children under age eighteen visited the emergency room (ER) in Chester County and 106 in Fairfield County due to asthma. Non-white children under the age of eighteen visit the ER more frequently than white children in the same age group. The secondary target population is adults who have asthma and diabetes or who are at risk of developing the diseases. Plans are to hire two school nurses to case manage children with these chronic conditions in each county school district. Also, the grant will implement an electronic school health record system to help the school nurses effectively track and manage these students.

The median household income is less than the state’s average $37,082. The percent of the African American population and the most impacted by health disparities is higher than the state’s average of 29.5%. The challenges these communities face in meeting the Healthy People 2010 goals of increasing the quality and years of healthy life and eliminating health disparities are complex and varied. Poverty, lack of education, high unemployment, unhealthy lifestyles and poor utilization of preventive health care all contribute to poor health status and strain the fragile rural health infrastructure.

The Network began the initial stage of its development in 2004 through the assistance of a minigrant from the SC Office of Rural Health in 2004. The network partners include a Critical Access Hospital, a for-profit hospital, two Federally Qualified Health Centers, a free clinic, a primary health care center affiliated with the USC School of Medicine, Region 3 of DHEC - the state public health agency, CareLINK - an indigent and medically underserved healthcare access program, and a private foundation. The SC Office of Rural Health serves in an Ex-Officio capacity and has been instrumental in providing mini-grants of approximately $65,000 since 2004 and annual technical assistance support by staff of estimated at $45,000 per year.

The leaders of the Network recognize that funding from the Rural Health Outreach Grant will ensure that the critical building blocks for an effective school nurse chronic disease case management program will be accomplished resulting in reduced absenteeism and improved academic performance of middle school students. It is hoped that this innovative program can be expanded to all grades in the years to come.

Topic Areas

Drug Prevention Services, Equine-assisted Learning

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 199,900.00

· Year 2 - 199,446.00

· Year 3 - 199,512.00

Partners to the Project

Lifeways, Inc., Walking In Grace, Native American prevention specialists, and an evaluator from Black Hills State University .

Areas Served

The target area includes the communities of Custer, Edgemont, Hill City, Hot Springs, and Oelrichs in the southern Black Hills in the southwest corner of South Dakota.

Target Population Served

The goal of the Southern Hills Leadership and Resiliency Initiative (SHLRI) is to reduce use of alcohol, tobacco, and other drugs by students in five communities.

Program Director

Sandy Arseneault

Custer School District 16-1

527 Montgomery Street

Custer, South Dakota 57730-1124

Phone: (605) 673-4540

Fax: (605) 673-4710

Email: sarseneault@csd.k12.sd.us

Custer School District 16-1

Custer, SD 57730-1124

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Project Summary

The goal of the Southern Hills Leadership and Resiliency Initiative (SHLRI) is to reduce use of alcohol, tobacco, and other drugs by students in five communities in the southern Black Hills of South Dakota. The initiative will provide alcohol, tobacco, and other drug prevention and early intervention services in grades 5 through 12 in five rural schools. There is an alarmingly high rate of alcohol, tobacco, and other drug use among the youth of in this service area, which is higher than national rates. SHLRI will use a research-based alcohol, tobacco, and other drug prevention program to address the problem through prevention and early intervention of alcohol, tobacco, and other drug addiction. The project will include a prevention curriculum for 5th through 9th grades; parent education; awareness activities for youth; early intervention programming for students in the 9th through 12th grades; incorporation of an alcohol, tobacco, and other drug prevention curriculum into health and physical education classes; and collaboration with mental health providers. Equine-assisted learning (experiential activities involving horses) will be an integral component of the early intervention program.

The target area includes the communities of Custer, Edgemont, Hill City, Hot Springs, and Oelrichs in the southern Black Hills in the southwest corner of South Dakota . South Dakota has a low rate of economic growth and a per capita income among the lowest in the United States. The closest city with 24-hour primary health and mental health services is Rapid City, which is 30 to 80 miles away. In addition, unpredictable weather from October to April and inadequate roads limit accessibility to services. Area schools have experienced continued budget cuts. South Dakota is a rural state with a rugged individualism or frontier mentality, which can be a hindrance to citizens in need of assistance. Parents and community members lack understanding of the significance of early adolescent use of alcohol, tobacco, and other drugs. Cultural barriers exist between Caucasian and Native American Lakota people residing in the area. Barriers to access include poverty, isolation, and cultural differences. The service area is designated as a Medically Underserved Area and Medically Underserved Population.

In addition to the Custer School District, members of the consortium include Lifeways, Inc., a nonprofit alcohol and drug prevention agency; Walking In Grace, a faith-based nonprofit counseling center; Native American prevention specialists; and an evaluator from Black Hills State University .

Topic Areas

Durable Medical Equipment

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 199,386.00

· Year 2 - 190,518.00

· Year 3 - 192,084.00

Partners to the Project

South Dakota CARES, the lead applicant; the South Dakota Office of Adult Services and Aging; and Northland Rehab Supply.

Areas Served

Underserved Areas. Twelve counties in South Dakota are among counties with the highest poverty rates in the United States.

Target Population Served

Helping thousands of rural South Dakotans with disabilities gain access to durable medical equipment since it began in 1999, but the need for durable medical equipment continues to be an issue.

Program Director

Ann Bush

South Dakota CARES

1351 North Harrison Avenue

Pierre, South Dakota 57501-2373

Phone: (605) 224-5879

Fax: (605) 224-1033

Email: abush@southdakotacares.org

South Dakota CARES

Pierre, SD 57501-2373

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

The Recycle for Life Program—operated by South Dakota CARES and its partners—has helped thousands of rural South Dakotans with disabilities gain access to durable medical equipment since it began in 1999, but the need for durable medical equipment continues to be an issue. Goals of the program are to strengthen 12 existing volunteer networks and create 8 new volunteer networks to aid in the solicitation, storage, transportation, refurbishing, and redistribution of previously owned equipment; to provide good-quality refurbished medical equipment to an average of 200 individuals per month by enhancing a refurbishing and redistribution system for used durable medical equipment; to educate agencies and organizations that purchase durable medical equipment for clients about medical equipment options; to sustain and expand a statewide equipment loan, donation, and refurbished equipment redistribution program; to increase a current caseload of 1,500 individuals to 2,400 individuals; and to conduct a statewide campaign for donation of durable medical equipment by individuals and agencies across the state.

Service delivery for medical equipment in South Dakota is a challenge, especially for people with disabilities in rural communities who live far from basic services. Many rural families have either inadequate or no health insurance, leaving them with limited or no access to medical equipment. For individuals with disabilities, access to costly medical equipment is difficult or impossible, and many insurers and health care providers do not cover the cost of assistive devices. More than 97 percent of South Dakota is considered frontier, rural, or reservation; 83 percent of the counties in South Dakota are federally designated Health Professional Shortage Areas, and more than 90 percent are Medically Underserved Areas. Twelve counties in South Dakota are among counties with the highest poverty rates in the United States. According to the 2000 Census, 13.6 percent of state residents have disabilities or chronic illness. In addition, 8.4 percent of South Dakotans are without access to primary care providers, 8.1 percent of the total population was uninsured in 2004, and more than 50 percent of the uninsured live below 200 percent of the federally established poverty level. South Dakota CARES has experienced an influx in the number of requests for medical equipment as state government and other agencies continue to downsize their programs.

Network partners include South Dakota CARES, the lead applicant; the South Dakota Office of Adult Services and Aging; and West Medical Supplies of Rapid City, SD and ServiceAbilities of Watertown, SD.

Topic Areas

Overweight/obesity; Diabetes

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 124,999.00

· Year 3 - 99,997.00

Partners to the Project

South Dakota Urban Indian Health, Inc., is a non-profit, Federally Qualified Health Center. Through the Keya (Lakota for Turtle) Program - Long Life for Good Health, the Keya Program

Areas Served

Pierre, Fort Pierre, and Aberdeen, South Dakota

Target Population Served

The target population is rural Lakota American Indians living off reservations to reduce overweight and obesity to prevent diabetes and to improve the health status of those with diagnosed diabetes.

Project Summary

South Dakota Urban Indian Health, Inc., is a non-profit, Federally

Program Director

Donna Keeler

Executive Director

South Dakota Urban Indian Health, Inc.

1714 Abbey Road

Pierre, SD 57501

Phone: (605) 224-8841

Fax: (605) 224-6852

E-mail: donnak@sduih.org

South Dakota Urban Indian Health, Inc.

Pierre, SD 57501

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

Qualified Health Center. Through the Keya (Lakota for Turtle) Program - Long Life for Good Health, the Keya Program Consortium seeks to reduce overweight and obesity to prevent diabetes and to improve the health status of those with diagnosed diabetes. The target population is rural Lakota American Indians living off reservations. When relocating to urban (non-reservation) areas, American Indians lose access to free health care provided by Indian Health Service and/or Tribal programs on the reservations. South Dakota Urban Indian Health has been providing health services continuously since early 1978. These clients are served at South Dakota Urban Indian Health clinics in Aberdeen and Pierre.

In addition to South Dakota Urban Indian Health, three other separately owned health care organizations have been working together for planning and implementing Keya Program activities. The other three consortium partners are non-profit health care organizations located in eastern South Dakota . They include: Avera McKennan Hospital & University Health Center, Avera St. Luke’s Health Services, and the Avera Corporate Office. Additionally, 78 rural South Dakota Urban Indian Health clients participated in a needs assessment survey to help plan for the Keya Program.

The Keya Program will expand existing diabetes prevention and education services by fostering the development of new collaborative efforts for delivery of health care among rural American Indians in residing in Pierre, Fort Pierre, and Aberdeen, South Dakota. These towns have large American Indian populations: Pierre (9 percent); Fort Pierre (5 percent); and Aberdeen (3 percent). Keya program goals to be met by April 2009 include the following:

· Rural South Dakota Urban Indian Health clients will witness a 12 percent average improvement in five targeted risk factors (glucose levels, waist circumference, blood pressure, high density lipoprotein, and triglycerides); and

· A framework for Keya Program sustainability for working with rural South Dakota Urban Indian Health clients will be developed. This will be accomplished through a variety of health promotion and education activities targeting exercise and diet, and through continued input from targeted clients.

This project aims to increase the quality and years of a healthy life and to eliminate health disparities among an estimated 873 rural South Dakota Urban Indian Health clients at risk of diabetes development or who have diagnosed diabetes. Several unmet health needs are noted: 1) Sioux American Indians are generally younger, less likely to graduate from high school, have lower incomes, and are poorer in comparison to other South Dakotans, American Indians and all persons in the United States; 2) South Dakota American Indians have the greatest infant mortality rate of any race or ethnic group in the United States; and 3) the South Dakota median age of death due to all causes is 80 years for whites, compared with 57 years for American Indians. The proposed project has planned rural health care outreach services that address social and belief differences of the target population. Linguistic barriers are not present since the target population speaks English.

Topic Areas

Child Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The interagency network is comprised of the Center for Disabilities at the Sanford School of Medicine of the University of South Dakota; Oglala Sioux Tribe Health Administration; Oglala Sioux Tribe Office of Special Education Services; Porcupine Clinic Health Board; Shannon County Public School District; and 123..Hi Baby!, Inc.

Areas Served

Pine Ridge Reservation

Target Population Served

To identify developmental concerns in children birth through five years of age.

Project Summary

The Pine Ridge Reservation: Creating an Early Health Care

Program Director

Shelly Grinde

Center for Disabilities

Sanford School of Medicine of the University of South Dakota

414 E Clark Street

Vermillion, SD

Phone: (800) 658-3080

Fax: (605) 357-1438

E-mail: shelly.grinde@usd.edu

Center for Disabilities

Sanford School of Medicine of the University of South Dakota

Vermillion, SD 57069

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

(301) 443-1902

staylor@hrsa.gov

Community project proposes to create local access to a comprehensive and culturally appropriate system of health and developmental services on the Pine Ridge Reservation in order to identify developmental concerns in children birth through five years of age and linkage to services. The lead agency for this project is the Center for Disabilities (CD), Sanford School of Medicine of The University of South Dakota. CD is part of a national network of University Centers of Excellence in Developmental Disabilities Education, Research and Service. The Pine Ridge Reservation, located in southwest South Dakota, has been designated as one of the poorest areas in the United States. Over 61% of all children are living below the national averages for poverty and the Reservation, designated as medically underserved, has a health profession shortage for dental, mental health and primary medical care. Lack of trained pediatric specialists currently requires families with young children to travel hundreds of miles to receive these services. In South Dakota, and especially on the Pine Ridge Reservation, the follow-up for most of these children is absent, inadequate or fragmented due to the following five factors that influence rural health care access: availability, accessibility, affordability, acceptability and accommodation. Early intervention services do exist through the educational system, but young children need to be diagnosed and identified as eligible before these important services can be provided.

An interagency network system was created in order to construct a comprehensive system of services for young children and their families on the Pine Ridge Reservation. Through networking and sharing of existing resources, a public awareness campaign promoting the positive benefits of developmental health and wellness for young children will be developed and implemented in all the local Reservation communities. A Reservation-wide system for developmental screening will be created and maintained with appropriate referral networks established. Pediatric specialists will be brought in on a monthly basis to work in partnership with the local health and educational services to establish a comprehensive developmental evaluation clinic where children can be thoroughly and appropriately evaluated. Linkages to early intervention and other appropriate needed services will be created as follow-up services to the clinic. Tracking and monitoring of children not eligible for services, but considered at-risk will also be created as part of this comprehensive system. The interagency network is comprised of the Center for Disabilities at the Sanford School of Medicine of the University of South Dakota; Oglala Sioux Tribe Health Administration; Oglala Sioux Tribe Office of Special Education Services; Porcupine Clinic Health Board; Shannon County Public School District; and 123..Hi Baby!, Inc. All Interagency Network members have provided a letter of commitment to work collaboratively to meet the objectives of this project.

Topic Areas

Substance abuse, Mental health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Department of Children’s Services, Ridgeview Psychiatric Hospital and Center, Inc., will partner with Methodist Medical Center, and Anderson County Health Council.

Areas Served

Anderson County, Tennessee

Target Population Served

The target population includes three groups: 1) Ensure the DEC/DEI has a stable, short-term environment (up to 6 months) that addresses the child’s physical, emotional, and

Program Director

Stacy Park

Outpatient Services Director

Ridgeview Psychiatric Hospital and Center, Inc.

240 West Tyrone Road

Oak Ridge, TN 37830

Phone: (865) 276-1219

E-mail: spark@ridgevw.com

Ridgeview Psychiatric Hospital and Center, Inc.

Oak Ridge, TN 37830

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

social well-being; 2) Ensure the parents have the skills and resources to provide positive parenting in a drug free home environment and; 3) Assess and implement a drug treatment plan for the abusing parent. The target number to serve is 72 DEC/DEI families over the 3-year grant period.

Project Summary

Each month, Anderson County, Tennessee, identifies 50 new cases of drug-endangered children (DEC) and/or drug-exposed infants (DEI). Drug-endangered children are those children whose parental drug use is endangering their lives. In Anderson County, 30 percent of the methamphetamine lab arrests include children in the home. And this explosion of methamphetamine production occurs in a community already ravaged by extremely high rates of oxycotin and other drug addiction. Drug-exposed infants are newborn babies whose mothers’ drug use during pregnancy had a harmful impact on that baby. These DEC/DEI are placed in custodial care of the natural parents, a relative, or a foster parent, dependent of the individual circumstances. The custodial parent lacks the knowledge and resources to adequately address the medical, social, emotional, and behavioral development of these at-risk children. By intervening with the family at a critical time, we intend to prevent future problems for the DEC/DEI and their family.

Our goals are to: 1) Ensure the DEC/DEI has a stable, short-term environment (up to 6 months) that addresses the child’s physical, emotional, and social well-being; 2) Ensure the parents have the skills and resources to provide positive parenting in a drug free home environment and; 3) Assess and implement a drug treatment plan for the abusing parent. The target number to serve is 72 DEC/DEI families over the 3-year grant period.

Working with our county’s Department of Children’s Services, Ridgeview Psychiatric Hospital and Center, Inc., will partner with Methodist Medical Center, our region’s primary medical health provider, and Anderson County Health Council to deliver integrated medical and mental health services to the 24 DEC/DEI and their families per year immediately upon identification. The DECSS treatment team consists of a registered nurse and a social worker who will conduct assessments and implement treatment plans through a home visitation model. The DECSS treatment intends to work with each DEC/DEI and family for approximately 6 months to stabilize each family unit and facilitate the family’s participation with a long-term provider. Our underlying strategy is to intervene when the family is most vulnerable, yet open to learning. We also aim to provide immediate support for critical concerns, and ensure the parents acquire the child advocacy skills so as to prevent future medical, social, and behavioral concerns.

The Drug Endangered Child Outreach Network, which will oversee this project, is committed to expanding the consortium to include additional community stakeholders. The DECSS is being developed as a pilot prevention project designed to address a problem that is reaching epidemic proportions in rural America.

Topic Areas

Elderly

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,981.00

· Year 2 - 122,314.00

· Year 3 - 99,111.00

Partners to the Project

Texas Independence Program (TIP) is based on nationally recognized care models, including PACE (Program of All-inclusive Care for the Elderly) and SOURCE (Service Options Using Resources in Community Environments).

Areas Served

The project service area is located between San Antonio, Houston, and Corpus Christi.

Target Population Served

TIP is designed to reduce the need for long-term institutional placement and increase options in the community for the 1,842 frail elderly and disabled residents of Texas’ Colorado, Lavaca, and Jackson Counties.

Program Director

Kathy Ball

Chief Executive Officer

Lavaca Medical Center

1400 North Texana

Hallettsville, TX 77964

Phone: (361) 645-1762

E-mail: kball@goliad.net

Lavaca Medical Center

Hallettsville, TX 77964

ORHP Contact:

Elizabeth Rezai-zadeh

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-4107

erezai@hrsa.gov

Project Summary

The Texas Independence Program (TIP) is designed to reduce the need for long-term institutional placement and increase options in the community for the 1,842 frail elderly and disabled residents of Texas’ Colorado, Lavaca, and Jackson Counties. TIP will blend primary medical care with preventive and supportive services through enhanced case management provided by project staff. Enhanced case management includes financial and programmatic integration of primary medical care with case management and home and community-based services, thereby addressing the key risk factors associated with institutionalization. TIP’s voluntary enrollees will be served by a panel of six physicians and mid-level practitioners, all of whom are members of the TIP consortium.

TIP aims to increase the cost-efficiency of Medicaid long-term care funds by using enhanced case management to eliminate fragmented service delivery, promote self-care and informal caregiver support, and reduce inappropriate emergency room use, multiple hospitalizations, and nursing home placements caused by preventable medical complications.

The project service area is located between San Antonio, Houston, and Corpus Christi, where the population density (19.5 persons per square mile) is one-quarter that of the rest of Texas and the United States (both 79.6 persons/square mile). In addition to health insurance participation rates and income and education levels significantly lower than Texas and the United States, the region exhibits an increasingly elderly population distribution. Fully 19 percent of the population is 65 years or older (Texas = 9.9 percent, United States = 12.4 percent).

TIP is governed by a 12-member board composed of community hospital leaders, registered nurses with utilization review and home health expertise, rural Health Clinic physicians and mid-levels, and elderly consumers. TIP is based on nationally recognized care models, including PACE (Program of All-inclusive Care for the Elderly) and SOURCE (Service Options Using Resources in Community Environments).

The TIP consortium has an evaluation plan with process, outcome and impact measures designed to determine the extent to which project activities result in cost efficiencies, and improved health outcomes for the elderly and disabled. The consortium will position TIP for sustainability by negotiating a home and community-based services waiver under the authority of Section 1915(c) of the Social Security Act with the state of Texas for enhanced case management, and by replicating TIP in other Texas counties.

Topic Areas

Health promotion/disease prevention (general); Chronic disease; Mental health, Substance abuse

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Sabine Valley Center, East Texas Council on Alcohol and Drug Abuse, Wiley College, and United Churches Care

Areas Served

Harrison and Marion counties.

Target Population Served

To deliver integrated primary and mental health care to isolated, chronically ill population groups. The target population for this project consists primarily of low-income adults and children with unmet health care needs, especially those with both chronic conditions (diabetes, hypertension, respiratory illnesses) and mental illness.

Program Director

Wanda Kennel

Executive Director

East Texas Border Health

401 N. Grove

Marshall, TX 75670

Phone: (903)938-1146

E-mail: wkennel@etex.net

East Texas Border Health

Marshall, TX 75670

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen@hrsa.gov

Project Summary

East Texas Border Health is a 501(c)(3) primary care clinic in rural Harrison County, Texas. For this project, East Texas Border Health has joined forces with Sabine Valley Center, East Texas Council on Alcohol and Drug Abuse, Wiley College, and United Churches Care to deliver integrated primary and mental health care to isolated, chronically ill population groups in Harrison and Marion counties. The target population for this project consists primarily of low-income adults and children with unmet health care needs, especially those with both chronic conditions (diabetes, hypertension, respiratory illnesses) and mental illness.

The goals of this project are threefold: 1) To enhance access to care for 3,000 primarily low income individuals with chronic physical and mental illness over the three year grant period; 2) To provide community-based health education designed to address the deleterious effects of chronic illness and increase capacity for self-care by 1,500 patients over 3 years; and 3) To leverage the increased access to health care and health education to improve treatment compliance and reduce related hospitalizations of participants by 30 percent in 3 years.

Harrison and Marion counties are home to 73,381 residents. The counties’ poverty level (17 percent) exceeds the national average by 36 percent. Smaller communities like Marshall and Jefferson have especially high rates, 22.8 percent and 32.9 percent, respectively. Nearly one in five residents is uninsured, and East Texas Border Health is the counties’ only provider of health care without regard to ability to pay. Harrison and Marion counties are designated as Health Professional Shortage and Medically Underserved Areas. Inadequate health care resources and persistent isolation have contributed to an overall mortality rate that surpasses Texas’; including especially high rates of death from cerebrovascular diseases, chronic lower respiratory diseases, and diseases of the heart. Additionally, over 10,000 adults and children in the counties have a serious mental illness, and isolation and resource scarcity cause many to go untreated. The resulting paranoia, confusion, and general distrust impede self-care and primary care compliance, with dangerous effect for those who also have chronic physical health conditions.

The consortium proposes to address existing health care disparities and access issues by introducing three critical resources. (1) A full time Registered Nurse (RN) will travel throughout the counties holding outreach clinics at church facilities located near highly isolated communities. These visits will be coordinated by United Churches Care. Participating churches will identify congregants and others with unmet physical or mental health care needs, assist in making appointments with prospective patients, and provide transportation if needed. East Texas Council on Alcohol and Drug Abuse will support outreach and will connect patients with substance abuse problems to available resources. East Texas Border Health will provide continuity care for patients with chronic illness. (2) The RN will complete a brief mental health assessment with each patient and will arrange for Sabine Valley Center, the state designated Mental Health and Mental Retardation Authority for Harrison and Marion counties, to care and treat eligible individuals identified as having mental health or substance abuse needs. (3) On the days that the RN is seeing patients at the church, Project OutREACH from nearby Wiley College will conduct health education classes in the waiting areas on relevant physical and mental health topics.

Topic Areas

Migrant health, Health promotion/disease prevention (general), Behavioral health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,998.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Nuevas Avenidas is a formal collaboration between Migrant Health Promotion, Community Hope Projects, AVANCE-Rio Grande Valley, and Tropical Texas Center for Mental Health and Mental Retardation Hidalgo County.

Areas Served

Hidalgo County, Texas is medically underserved.

Target Population Served

Nuevas Avenidas is designed specifically to help low-income, Spanish-speaking families improve and care for their health and take collective action to promote health in their communities

Program Director

Phillis Englebert

Migrant Health Promotion, Inc.

P.O. Box 337

Progreso, TX 78579

Phone: (956)-565-0002

E-mail: pengelbert@migranthealth.org

Migrant Health Promotion, Inc.

Progreso, TX 78579

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

The Nuevas Avenidas (New Avenues) Program will establish new routes of primary, preventative, and behavioral health care for medically underserved community members in Hidalgo County, Texas. The Nuevas Avenidas Program combines the work of Promotores and Promotoras de Salud (community health workers) with accessible primary, preventative, and behavioral health care services, case management, grassroots organizing and community coordination. The proposed program is a comprehensive, community-driven response to the health education and health service challenges of uninsured colonia families in the targeted area.

Nuevas Avenidas is designed specifically to help low-income, Spanish-speaking families improve and care for their health and take collective action to promote health in their communities. Nuevas Avenidas is a formal collaboration between Migrant Health Promotion, Community Hope Projects, AVANCE-Rio Grande Valley, and Tropical Texas Center for Mental Health and Mental Retardation Hidalgo County, located in the southern tip of Texas, is home to over 600,000 people. Some 88 percent of the population is Hispanic (Mexican and Mexican-American), and 83 percent speak a language other than English at home. About 35 percent of county residents live beneath the poverty level. Almost 1,000 unincorporated rural settlements, or colonias, exist outside of city limits. Colonias attract low-income families, about one-third of whom migrate for agricultural work in the summer months and who acquire plots of land and build incrementally. Although the unregulated nature of colonias makes data collection diffcult, colonia residents are widely believed to have low rates of insurance coverage and health care service utilization and frequently lack access to basic services such as water, electricity, and waste disposal.

The Consortium members will increase access to and use of primary, preventative and behavioral health services among underserved residents of rural colonias in southwestern Hidalgo County by sustaining a community-based health service and referral network, offering peer health education, and supporting community organizing. Migrant farmworkers trained as promotores(as) will provide individual and group health education to their peers in the colonias, and work with community members to make concrete health improvements in their communities. The entire Consortium will support the Promotores(as) and community members by offering culturally competent health services and resources; by providing case management and coordination; and by involving community members in project activities and priorities.

Over the course of the three-year program (May 1, 2006 to April 30, 2009), Nuevas Avenidas will provide primary, preventative, and behavioral health services to at least 700 low-income, uninsured individuals previously isolated from appropriate services, and will demonstrate increased knowledge of and access to health services and resources in targeted colonias. Annual, community-based assessment surveys will provide evidence of increasing knowledge of, access to and satisfaction with the health care services provided.

Topic Areas

Dental care, Diabetes, Chronic Disease, Telehealth

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 147,108.00

· Year 2 - 123,470.00

· Year 3 - 98,935.00

Partners to the Project

Areas Served

The service area is Matagorda County, Texas, and the city of Wharton in Wharton County. Both of these counties are rural and designated as medically underserved areas.

Target Population Served

To meet an identified need for health care services for poor residents of all ages. To provide health and dental services to the uninsured, low-income residents.

Program Director

Brenda Harris

Matagorda Episcopal Health Outreach Program

101 Avenue F North

Bay City, TX 77414

Phone: (979) 245-2008

E-mail: bharris@mehop.org

Matagorda Episcopal Health Outreach Program

Bay City, TX 77414

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6884

lsmetana@hrsa.gov

Project Summary

The members of the Matagorda-Wharton Health Access Consortium are the Matagorda Episcopal Health Outreach Program (MEHOP), the Stark Diabetes Center at the University of Texas Medical Branch, and Victa Edwards, D.D.S., an independent contractor who provides dental services out of MEHOP facilities. The service area is Matagorda County, Texas, and the city of Wharton in Wharton County. Both of these counties are rural and designated as medically underserved areas. The target population is approximately 12,000 low-income, uninsured residents of the service area.

The project has four goals: 1) To improve oral hygiene among low-income residents in Matagorda and Wharton Counties, and to expand a Tooth Fairy program in Wharton County; 2) To improve understanding and treatment of diabetes and other chronic conditions, and the ability of patients to self-manage care through the expansion of interactive telehealth services for consumers and their families and continuing education for providers; 3) To improve continuity of care and reduce financial barriers to care through comprehensive case management services for clients seeking medical, dental, or social services; and 4) To advance public policy regarding dental care, patient education, and case management services for low-income and uninsured rural residents in Texas by sharing outcomes of program activities with selected State and professional agencies and with health professions educators.

MEHOP is a grassroots program established to meet an identified need for health care services for poor residents of all ages. It is the only provider of health and dental services to the uninsured, low-income, heavily Hispanic (32 percent) population of the service area. The clinic’s clients have little access to secondary and tertiary medical services, and no access to dental services besides the dentist who contracts to provide care at the MEHOP site. There also is a shortage of health education programs for both patients and providers. Case management services to identify and help remove barriers to care are available on a limited basis but cannot keep up with the demand.

Grant funds will be used to like MEHOP as a practice site for dental students at a nearby junior college, bringing a currently unavailable service to the area. It also would fund an expansion of the Tooth Fairy oral health education program for kindergarten and first grade students in a local school district. Oral health education programs would be available to older students and to the community via videoconferencing technology developed as a result of MEHOP’s partnership with Stark Diabetes Center. The technology will bring diabetes self-management classes from the Stark Center to MEHOP patients and extend twice-monthly diabetes lectures to local practitioners. Access to other services for diabetic patients and other medical and dental patients with unmet needs will be enhanced by expanding case management services.

Topic Areas

Health Literacy

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 160,000.00

· Year 2 - 135,000.00

· Year 3 - 110,000.00

Partners to the Project

East Texas Medical Center, Jacksonville, Cherokee County Health Department, ACCESS, Jacksonville Independent School District, University of Texas at Tyler Nursing Program, Stephen F. Austin University School of Nursing, Trinity Counseling Associates of East Texas, Inc., and Trinity Mother Frances Health System

Areas Served

Cherokee County

Target Population Served

To provide access to healthcare resources for the uninsured, underinsured, or medically underserved citizens of Cherokee County.

Project Summary

Cherokee County, located in the piney woods of East Texas is a

Program Director

Fran Daniel

H.O.P.E., Inc.

595 Ragsdale

Jacksonville, TX

Phone: (903) 565-7781

Fax: (903) 586-2569

E-mail: frandaniel@suddenlinkmail.com

H.O.P.E., Inc.

Jacksonville, TX 75766

ORHP Contact:

Lilly Smetana

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

(301) 443-6884

lsmetana@hrsa.gov

rural county with a population of 48,464. The largest town in Cherokee County is Jacksonville, with a population of less than 14,000. Sixteen percent of the residents of Cherokee County are Hispanic and the number continues to rise. The county covers 1,052 square miles with approximately 44 persons per square mile, compared with the state of Texas, which has almost 80 people per square mile. There is no public transportation in the county or in any of the towns.

The median household income of Cherokee County is just under $30,000, compared to almost $40,000 for the state. Eighteen percent of the people in Cherokee County are living below the poverty level, compared with 16% of Texans as a whole.

There are a number of factors that contribute to the need for improved access to health care for the economically disadvantaged in Cherokee County. These include: a large percentage of the population living at or near the poverty level; a large Hispanic population with accompanying language/cultural barriers; and a large rural area with no public transportation.

As a result of the economic, geographic and language/cultural barriers, the unmet needs of our target population include access to the following: primary health care for emergency and ongoing care; health screenings to identify chronic diseases and conditions; health education programs, including disease management and monitoring; free or low cost medications; and transportation to medical appointments and to other programs that promote a healthy lifestyle.

Partners In Health for Cherokee County is designed to provide access to healthcare resources for the uninsured, underinsured, or medically underserved citizens of Cherokee County. The project’s goal is improved health of the target population through increased access to primary healthcare, participation in health education programs, and referral for eligible benefits. The project has been developed by a consortium of community organizations interested in providing better health for the underserved population of the county.

HOPE will act as a clearinghouse for the program by providing financial and health screenings and then referring those who qualify to physicians who volunteer to see the patient in their office at no cost to the patient. Hope will also refer clients to other assistance programs and will take the lead in organizing health screenings, health fairs, health education programs, and arrangements for transportation. These activities will continue in the Jacksonville area and outreach efforts will begin to serve all other areas of the county during the three years of the project.

Topic Areas

Obesity

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,717.00

· Year 2 - 124,947.00

· Year 3 - 99,959.00

Areas Served

Springfield and Windsor, Vermont

Target Population Served

The Precision Valley Physical Activity and Nutrition Consortium will increase youth (ages 10-13) and their parents and family access to physical activities and increase opportunities for healthy food choices.

Project Summary

The Precision Valley Physical Activity and Nutrition Consortium will increase youth and family access to physical activities and increase opportunities for healthy food choices in Springfield and Windsor, Vermont. This will be accomplished through an interdisciplinary consortium that has put together a services network called the “30+5” Nutrition and Physical Activity Intervention. “30+5” is short for a recommendation to children and families to get at least 30 minutes of exercise and eat 5 fruits and vegetables daily. The target

Program Director

Nancy Lanoue, MEEd

Southern Vermont Area Health Education Center

365 River Street

Springfield, VT 05156

Phone: (802) 885-2126

E-mail: nlanoue@vermontel.net

Southern Vermont Area Health Education Center

Springfield, VT 05156

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-6894

npatel@hrsa.gov

population is youth 10-13 and their parents.

The intervention combines school nursing and primary care expertise and judgment in clinical assessment with varied community resources for referral. These practitioners will have more levels of service available. The intervention will consist of a brief message and an “action pack” full of information about how, when, and where to find exercise and better nutrition opportunities including family access to low-cost fruits and vegetables, nutrition classes, and structured recreation programs. For youth, active and fun informal sports programs will be increased through volunteer leaders and scholarships for memberships and fees. A second level of intervention consists of the “30+5” clinical dietitian consultant who will counsel youth and families with an emphasis on wellness and prevention using a community outreach model. All staff of the project as well as consortium members will be working together to increase education in the middle schools and the community about the importance of physical activity and nutrition.

Both rural farm communities share a past of machine tool manufacturing which is now only a shadow of what it was a decade ago. Consequently, unemployment is the second highest in the State. The rate of poverty among single-mother families is between 60-70 percent. Median family income is $6,000-$7,000 below the state median. Surveys including the 2003 Youth Risk Behavior Survey in Vermont show that, in Springfield, 15 percent of students are at risk of overweight and 13 percent are already overweight in grades 8-12. In Windsor, 17 percent of students in grades 8-12 are at risk of being overweight, and another 17 percent are already overweight. This target group was chosen because the consortium believes that youth represent the most sustainable, long-term potential for obesity-prevention efforts.

Topic Areas

Physician Education

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 200,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

Consortium members include People Incorporated of Southwest Virginia, the lead applicant; Mt. Rogers Health District; Comprehensive Health Investment Program (CHIP) of Virginia; and two private physicians.

Areas Served

rural southwest Virginia is primarily white (more than 96 percent) from Appalachian or Melungeon heritage. The service area includes officially designated Health Professional Shortage Areas or Medically Underserved Communities or Populations. All counties to be served through the project are designated Medically Underserved Areas.

Target Population Served

The target population consists of 180 low-income families served through the agency’s CHIP and families with Medicaid-eligible children from birth to age 6.

Program Director

Robert G. Goldsmith

People Incorporated of Southwest Virginia

1173 West Main Street

Abingdon, VA 24210

Phone: (276) 623-9000

Fax: (276) 628-2931

People Incorporated of Southwest Virginia

Abingdon, VA 24210

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

People Incorporated of Southwest Virginia and its rural health outreach partners will serve low-income families in Buchanan, Dickenson, Russell, and Washington counties, located in rural southwest Virginia. Goals of the program are to improve the overall health of low-income families in the four rural counties, increase physician knowledge of community-based resources to support low-income patients’ self-efficacy, and provide community-based experience to medical residents. The project will include home visits by medical residents and human service providers, health education, early intervention for children with special needs, and use of strengths-based practices to assist families in developing self-sufficiency. The consortium also will host an information exchange forum for human service providers and physicians in the four counties. The project will link physicians, medical residents, local health districts, and human service providers.

The target population consists of 180 low-income families served through the agency’s Comprehensive Health Investment Program (CHIP) and families with Medicaid-eligible children from birth to age 6. The population in rural southwest Virginia is primarily white (more than 96 percent) from Appalachian or Melungeon heritage. For the estimated 19,679 low-income individuals residing in the area, chronic illness is a way of life. Southwest Virginians age 35 to 54 die from diseases such as chronic liver disease, diabetes, and heart disease at nearly twice the rate of residents from other parts of the state, and they are 67 percent more likely to commit suicide. Significant barriers to service include socioeconomic conditions such as poverty and lack of health insurance, high unemployment, and low education, coupled with geographic isolation and lack of transportation. The service area includes officially designated Health Professional Shortage Areas or Medically Underserved Communities or Populations. All counties to be served through the project are designated Medically Underserved Areas.

Consortium members include People Incorporated of Southwest Virginia, the lead applicant; Mt. Rogers Health District; CHIP of Virginia; and two private physicians.

Topic Areas

Health promotion/disease prevention (general)

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 147,318.00

· Year 2 - 114,436.00

· Year 3 - 99,954.00

Partners to the Project

The Rural Health Outreach Consortium, A Bath County Community Hospital (BCCH) health care team of four—a nurse practitioner, a registered nurse, a medication assistance coordinator, and a program coordinator.

Areas Served

Bath County, Virginia

Target Population Served

Program Director

Debbie Lipes

Chief Executive Officer

Bath County Community Hospital

P.O. Drawer Z

Hot Springs, VA 24445

Phone: (540) 839-7059

E-mail: bcchdl@bcchospital.org

Bath County Community Hospital

Hot Springs, VA 24445

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0837

lsmith3@hrsa.gov

Project Summary

The Rural Health Outreach Consortium, a consortium of health and human service agencies in Bath County, Virginia, has formed to sponsor a community wellness program for county residents. Bath County is a rural, sparsely populated county of 5,073 people nestled in the Allegheny Mountains on the western border of central Virginia. By providing free access to health screenings, the community-based and employer-based HealthConnection Screening reaches out to those whose access to health care has been limited by geographic isolation, costs of health services, and fear or difficulty in seeing a physician. A Bath County Community Hospital (BCCH) health care team of four—a nurse practitioner, a registered nurse, a medication assistance coordinator, and a program coordinator—will visit employer sites and community centers where neighbors, fire and rescue volunteers, and community leaders gather to learn their “health numbers.” These numbers are blood pressure, blood sugar, cholesterol, height, weight, and body mass index. Patients will be advised of appropriate follow-up to primary care providers and can come back to the next HealthConnection Screening to check their progress. All tests will be provided by the Bath County Community Hospital at no charge to the participants.

For ongoing wellness care, residents will be encouraged to enroll in HealthConnection Prevention, a preventive health care package offering exams, appropriate ancillary services, such as mammograms, and tracking of health care indicators for follow-up and recall care. Patients will have the opportunity to change risky behaviors and develop healthy habits at each visit with the nurse practitioner or participating physician. Chronic care management, medication assistance, and transportation help are all part of the package.

These services are especially targeted to people for whom the cost of a medical exam is a barrier, primarily those who are uninsured (15-20 percent of the population) or underinsured, and whose incomes fall below 300 percent of the poverty level. Free or minimum fees will apply to those under 200 percent of poverty (26 percent of population), and discounts up to 300 percent. All exams and tests will be reasonably priced for out-of-pocket payment. Free or reduced price medicines are available to eligible persons upon enrollment with the medication assistance coordinator. Other medication assistance may be available to those over the 200 percent income level.

It is anticipated that 10 percent of the Bath County population of 5,073 will be helped during the first through third years of the project. Recording and tracking the health indicators to remind and encourage residents to receive preventive health care is a goal of the applicant, Bath County Community Hospital (BCCH). By joining efforts with a consortium of community partners (called the Rural Health Outreach Consortium)—such as the Bath County Administration, the Bath County Health Department, the Bath County Department of Social Services, members of the Bath County Fire and Rescue Squads, Bath County Health Care Providers, the Allegheny Highlands Free Clinic, and the Valley Program for Aging, Bath County Community Hospital—the project hopes to see improved health behaviors in county residents.

Topic Areas

Elder Care

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 149,914.00

· Year 2 - 124,999.00

· Year 3 - 99,999.00

Partners to the Project

Shenandoah Memorial Hospital (SMH), Shenandoah Area Agency on Aging (AAA), Shenandoah County Free Clinic, United Way of Northern Shenandoah Valley, Valley Health Systems (VHS), and Our Health, Inc.

Areas Served

Rural Shenandoah County, Virginia

Target Population Served

It will specifically serve the health needs of older adults and seniors, children and underserved minority residents.

Program Director

Floyd Heater

Shenandoah Memorial Hospital

759 South Main Street,

Woodstock, VA

Phone: (540) 459-1100

Fax: (540) 459-1121

E-mail: fheater@valleyhealthlink.com

Shenandoah Memorial Hospital

Woodstock, VA 22664

ORHP Contact:

Nisha Patel

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

(301) 443-6894

npatel@hrsa.gov

Project Summary

The “Community Health Connections” project will provide disadvantaged persons in rural Shenandoah County, Virginia with enhanced access to health services utilizing a variety of education, outreach and coordination of care activities. It will specifically serve the health needs of older adults and seniors, children and underserved minority residents. The goals of the project are to: 1) Improve the health of chronically ill older adults living in remote areas through innovative health care delivery methods; 2) Assist low-income and disadvantaged persons living in obtaining access to key health and human services; 3) Make communities in the region more aware of rural health issues through extensive network community outreach/marketing and public relations; and, 4) Stimulate partnership and collaborations among providers so that a well-coordinated approach to meeting rural health needs is in Activities that will be carried to fulfill these goals include: having nurses go into homes of immobile chronically ill seniors to provide treatment; providing case management services low-income persons so they can access affordable health and human services, operating a transportation program that connections citizens with health providers, and conducing a variety of education, public relations and outreach activities so citizens know how to access affordable health care. The project will be operated by a consortium of six partner organizations in collaboration with numerous local public, private, non-profit and faith-based organizations. It will serve an estimated 2,475 persons and provide approximately 14,200 health encounters over a three year period. The year one federal budget request it $149,914, with an estimated $55,937 in cash and in-kind resources being provided by the consortium members (a 37 percent match).

Topic Areas

Mental Health

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

Carilion Giles Memorial Hospital (CGMH), the Free Clinic of the New River Valley (FCNRV), the Mental Health Association of the New River Valley (MHANRV), and the Virginia Rural Health Resource Center (VRHRC).

Areas Served

Rural Giles County, Virginia

Target Population Served

Services will be provided to Giles County residents who are low income (at or below 125 percent of the poverty guidelines) and have no health insurance.

Program Director

Tammy Blankenship

Carilion Giles Memorial Hospital

1 Taylor Avenue

Pearisburg, VA

Phone: (540) 921-6877

Fax: (540) 921-6858

E-mail: thblankenship@carilion.com

Carilion Giles Memorial Hospital

Pearisburg, VA 24134

ORHP Contact:

Kristi Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen @hrsa.gov

Project Summary

Giles County, in far Southwestern Virginia, is experiencing a dire need for health care services, including mental health care and oral care. This need is created by the unusually high number of uninsured, unemployed, and low-income families living in this area, along with significant geographic barriers that make travel difficult. The need is evidenced by the high proportion of emergency room visits for non-emergency medical, dental and mental health issues. Giles County is categorized as a Medically Underserved Population (MUP) and the County is in the process of obtaining designation as a Health Professional Shortage Area (HPSA). The program headquarters and clinic will be located in Giles County which is in an officially designated rural census tract.

The proposed solution, the Giles Community Health Access Project (G-CHAP), will be a new, innovative, and collaborative approach to the delivery of health care for Giles County residents. Comprehensive and holistic care including medical, dental, mental health, and pharmacy services will be delivered collaboratively through four Network Consortium members: Carilion Giles Memorial Hospital (CGMH), the Free Clinic of the New River Valley (FCNRV), the Mental Health Association of the New River Valley (MHANRV), and the Virginia Rural Health Resource Center (VRHRC). Each member will promote rural health service outreach by expansion of existing services, creation of new services, sharing of resources and evaluation of program impact. The G-CHAP Program will coordinate current and new safety net services for individuals previously unable to seek medical treatment because of lack of finances or insurance.

CGMH will contribute the program’s clinic building located in central Giles County. The clinic will operate every weekday. A paid staff of a half-time Nurse Practitioner and full-time Program Assistant will be bolstered by the participation of health care student interns from four regional colleges and local volunteers. The G-CHAP clinic will function as a satellite of the FCNRV. Dental services will be provided by the FCNRV’s Dental Program. FCNRV will also contribute the use of its licensed pharmacy for free medication access. Mental health services will be provided by the award-winning ARMS Reach Project of the MHANRV. Specialty clinics for patients with chronic conditions such as diabetes and heart disease will be established to provide continuity of care with a strong focus on health education/literacy.

Process and outcome evaluation of the G-CHAP Program will be conducted by the Virginia Rural Health Resource Center. Program design will be culturally compatible with the Appalachian heritage of the target population, and service delivery will be culturally informed in all aspects.

Services will be provided to Giles County residents who are low income (at or below 125 percent of the poverty guidelines) and have no health insurance. To assure success of the project, the local community has been highly involved in the planning for the G-CHAP clinic. A local consumer survey was conducted to identify health needs and access issues. Meetings with local government officials, health care professionals, and agency directors were conducted to assure broad input and support for the project.

Topic Areas

Diabetes, Obesity/overweight, Migrant health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 124,893.00

· Year 3 - 100,000.00

Areas Served

Toppenish, Grandview, and Prosser, Washington

Target Population Served

The Salud en Sus Manos consortium will target Hispanic, low-income, and other underserved users with diabetes, obesity, and other nutrition-related medical conditions in the rural communities.

Project Summary

The goals of the Salud en Sus Manos (Health in Your Hands) project are to reduce disparities in diabetes, obesity, and other nutrition-related medical conditions; improve access to diabetes, obesity, and other nutrition-related health services; and improve the quality of diabetes, obesity, and other nutrition-related health services for Hispanic and rural residents in the Yakima Valley in Washington.

Program Director

Terri Trisler, R.D., C.D., M.S.

Yakima Valley Farm Workers Clinic

P.O. Box 190

Toppenish, WA 98948

Phone: (509) 248-8602

E-mail: territ@yvfwc.org

Yakima Valley Farm Workers Clinic

Toppenish, WA 98948

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

The strategies of the project are to educate outpatient users, participants, and community members on diabetes, obesity, and other nutrition-related medical conditions; build community capacity by recruiting and training diabetes self-management education staff and lay leaders; implement a chronic care model for diabetes, obesity, and other nutrition-related diagnoses and enhance the electronic registry for outpatient users with these conditions.

Yakima Valley Farm Workers Clinic (YVFWC) users with diabetes, obesity, and other nutrition-related medical conditions in a pilot project showed the following poor health status: 70.4 percent had HbAlc >7, 46.5 percent had total cholesterol >200, 51.5 percent had total triglycerides >150, 39.4 percent had HDL <40 (male), 67.7 percent had HDL <50 (female), 60.9 percent had LDL >100, and 84.6 percent had BMI >25.

The activities of the Salud en Sus Manos Project are as follows:

· YVFWC will provide medical nutrition education and nutrition self-management education, for outpatient users with diabetes, obesity, and other nutrition-related diagnoses.

· YVFWC and the Yakima Valley Memorial Hospital (YVMH) will recruit, train, and mentor Lay Leaders who will provide Tomando Control de su Salud (Taking Control of Your Health)/Chronic Disease Self Management Program (CDSMP) workshops for community participants.

· YVMH and Radio KDNA will provide weekly diabetes, obesity, and other nutrition and self-management education radio shows for community members, while Prosser Memorial Hospital will provide diabetes self-management education for community members.

· YVFWC will assign Cameron VanTassell MS, RD, CD to provide medical nutrition education services.

· YVFWC will hire a Coordinator to provide coordination of Tomando/CDSMP self-management education and contract with YVMH to attend the Tomando/CDSMP master trainer training.

· YVMH will provide diabetes and obesity self-management education via weekly radio shows, and Prosser Memorial Hospital will contract a Diabetes Educator to develop and implement diabetes self-management education.

· YVFWC will participate in the Washington State Diabetes Collaborative.

· YVFWC will manage the Chronic Disease Electronic Management System.

The Salud en Sus Manos consortium will target Hispanic, low-income, and other underserved users with diabetes, obesity, and other nutrition-related medical conditions in the rural communities of Toppenish, Grandview, and Prosser, Washington. Compared to the population in Yakima County, YVFWC users with nutrition-related diagnoses are more likely to be Hispanic, older, poor, publicly insured, uninsured, and speak Spanish.

Topic Areas

Minority/Cultural/HL

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 144,887.00

· Year 2 - 113,077.00

· Year 3 - 99,693.00

Partners to the Project

In partnership with Mid Valley Hospital (MVH) and Okanogan County Public Health (OCPH) will form a consortium to provide health education and outreach to the Migrant and Seasonal Farmworker (MSFW) population in Okanogan County, a large rural region in north central Washington.

Areas Served

Rural Okanogan County

Target Population Served

Latino residents and MSFW and their families in rural Okanogan County.

Program Director

Heather Findlay

Family Health Centers

716 First Avenue South

Okanogan, WA

Phone: (509) 422-5700

Fax: (509) 422-7680

E-mail: hfindlay@myfamilyhealth.org

Family Health Centers

Okanogan, WA 98840

ORHP Contact:

Lakisha Smith

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

(301) 443-0837

lsmith3@hrsa.gov

Project Summary

Family Health Centers (FHC), the applicant agency, in partnership with Mid Valley Hospital (MVH) and Okanogan County Public Health (OCPH) will form a consortium to provide health education and outreach to the Migrant and Seasonal Farmworker (MSFW) population in Okanogan County, a large rural region in north central Washington. The Program will use the promotor(a) model (lay workers) to improve and expand culturally relevant health education for Latino residents and MSFW and their families in rural Okanogan County. Consortium members have worked together for nearly a decade and will use their strong existing relationships to conduct this work. This project was developed with the assistance and input from the Latino and MSFW communities. Family Health Centers ‘La Futura Mama y Su Salud’ (The Mother to be and Her Health’) has been an existing task force program between the consortium members. This pilot project has, on a small scale, done some outreach to the Latino community, and was funded through the local Health Department for two years, which ends in June 2007. This new Program will enable us to provide new and expanded services under the operation of Family Health Centers.

In Okanogan County, an agriculturally-based economy, mi-m ant workers are a key portion of the labor force. 14.4% of the county’s resident self-identify as being Latino. This number swells during summer and the fall, with transient migrant workers who come to harvest fruits, nuts and berries. Within Family Health Centers’ (FHC’s) patient population nearly 50% are Latino and 7% are Migrant and Seasonal Farmworkers. Providing culturally and linguistically appropriate healthcare to Latino patients is an ongoing challenge for local health care providers, because the community has a different language,

cultural and religious beliefs that affect willingness to access care and, there are immigration issues that prevent this population from seeking care. This project is designed to address these challenges.

We will: (1) Develop and implement a promotor(a) (lay educators) program so that health education can be taken to the orchards, agricultural camps, and other community events and locations. (2) Develop and broadcast education programs through a local Spanish language radio station. (3) Provide childbirth education by a bilingual certified Lamaze instructor; and (4) Train health care providers and others in the community about cultural competency and the practice of medicine. During this Program we anticipate providing services to 1,939 clients.

Topic Areas

Telepsychiatry

Project Period

May 1, 2007 – April 30, 2010

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 125,000.00

· Year 3 - 100,000.00

Partners to the Project

The proposed partnership-Inter Island Medical Center, two Compass Health facilities (one in San Juan County), and Regence Blue Shield (which will contribute technical data and consultation regarding service delivery)-will establish, run, and maintain a telemedicine service project that provides psychiatric evaluation and treatment to isolated patients in San Juan County.

Areas Served

Rural San Juan County, WA

Target Population Served

The project has two goals: 1) increasing access to psychiatric services for underserved populations, and 2) influencing third party payers to pay for such services in order to sustain services over the long-term.

Program Director

Beth Williams Gieger

Compass Health

4526 Federal Avenue (M/S 19)

Everett, WA 98213

Phone: (425) 349-6320

Fax: (425) 349-6325

E-mail: bethwg@interisland.net

Compass Health

Everett, WA 98213

ORHP Contact:

Kristin Martinsen

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-4438

kmartinsen @hrsa.gov

Project Summary

Inter Island Medical Center and its partners request a grant of $375,000 to establish, run, and maintain a telemedicine project that provides psychiatric services to isolated patients in rural San Juan County, WA. The project has two goals: 1) increasing access to psychiatric services for underserved populations, and 2) influencing third party payers to pay for such services in order to sustain services over the long-term. Telemedicine via videoconferencing has been found satisfactory to both patients and providers, and to be equal to in-person appointments for efficacy. Recent literature has called for initiatives aimed at influencing third party payers to pay for telepsychiatry services in rural areas with significant health care disparities.

San Juan County, consisting of a group of islands off the coast of Washington State, is designated as a rural area. It is medically underserved, has a lack of health professionals, and is isolated and costly to serve. Most full-time residents work in low paying service industry jobs or on farms. The alarming lack of health services, especially for mental illness, impacts all age categories, including children and older adults.

No psychiatrists or psychiatric nurse practitioners are available anywhere in the island county to provide evaluation and pharmacologic treatment. Patients must travel hundreds of miles and many hours, primarily by ferry, to access psychiatric services on the mainland. Few citizens can afford mental healthcare from their own funds, but neither Medicaid nor most commercial health plans pay for telepsychiatry services that would allow for virtual psychiatric evaluation, diagnosis, and treatment. Even those health plans that do pay for telepsychiatry in some instances do so reluctantly, impose a standard for service approval that in not imposed for in-person services, and allow insufficient fees to cover the cost of psychiatric service and necessary technology.

The project will address high rates of depression, reduce the incidence of untreated psychiatric illness, and examine the cost-offset and community health status effects of psychiatric service delivery. By significantly increasing access to psychiatric services, the project will result in the reduction of Global Health Burden of psychiatric illness in San Juan County - a condition that ranks second only to cardiovascular disease in health burden.

Topic Areas

Dementia Services

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 191,577.00

· Year 2 - 189,964.00

· Year 3 - 192,758.00

Partners to the Project

Consortium partners include the Alzheimer’s Association of Greater Wisconsin, the lead applicant; Wisconsin Alzheimer’s Institute; Northern Area Agency on Aging; and Northern Wisconsin Area Health Education Center.

Areas Served

Target Population Served

This project seeks to formulate a proactive rather than reactive approach to identified persons with Alzheimer’s disease at age 65 and older as well as a small number of persons between the ages of 35 and 65.

Program Director

Judith Durkee

Alzheimer’s Disease and Related Disorders Association, Inc.

203 Schiek Plaza

Rhinelander, Wisconsin 54501-3364

Phone: (715) 362-7779

Fax: (715) 362-1879

Alzheimer’s Disease and Related Disorders Association, Inc.

Rhinelander, WI 54501-3364

ORHP Contact:

Eileen Holloran

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-7529

eholloran@hrsa.gov

Project Summary

This partnership project seeks to improve dementia services and availability in northern Wisconsin. Alzheimer’s disease affects approximately 10 percent of the population age 65 and older as well as a small number of persons between the ages of 35 and 65. Because the incidence of Alzheimer’s disease appears to double every 5 years after age 65, it is believed to affect nearly half of all persons older than age 85. Population projections through the next 30 years indicate that the number of Wisconsin residents with Alzheimer’s disease will increase significantly. This project seeks to formulate a proactive rather than reactive approach to the identified number one health concern in Wisconsin—Alzheimer’s disease—and will focus on three major areas of activity: dementia care network development, rural educational outreach, and diagnostic efficacy and clinic support and development. Project efforts will link with local community health centers, rural health clinics, Indian Health Service sites, local public health departments, and primary medical care professionals. Impact of the project will increase the capacity of primary care physicians and their staff, as well as patient and care partner wellness and the prevention of care partner stress-related diseases processes. The project will not only build service capacity but will also affect service quality and availability.

The estimated total population of persons age 65 and older living in the service area is 62,345: 1,021 African Americans, 2,798 Hispanic, 1,144 Asian, and 11,688 Native American. The estimated population of persons with Alzheimer’s disease in the proposed service area is 9,438, and the number is expected to grow to 10,042 during 2010 and to 12,361 by 2020. The target population is older adults, especially those with Alzheimer’s disease.

This project will serve 16 counties in the rural and underserved areas of northern Wisconsin. Thirteen of the counties in the service area are Medically Underserved Communities. The project service area includes seven sovereign tribal nations. The area poses serious challenges and threats for persons affected by Alzheimer’s disease. Population centers are few and far between, and homes are scattered throughout the area.

While the service area is attractive to vacationers, the environment poses risks to travel, social, and service isolation, and a risk of wandering and death for persons with Alzheimer’s disease. In addition, a higher percentage of persons age 65 and older live alone in this area than in the state as a whole. Accessibility to medical and support services is hampered by stigma, geography, and availability. The counties served by this project are characterized by relatively low population densities, smaller average household sizes, and the clustering of resources outside this largely rural service area, all of which create significant challenges and barriers. Barriers to services include long, harsh winters with impassable road conditions; variable road systems, which make travel difficult; the potential for patients with Alzheimer’s becoming lost in the national forest or a deserted farm field; and lack of affordable transportation. Other barriers include low literacy and cultural differences experienced especially by Native Americans seeking treatment.

Topic Areas

Diabetes, Obesity

Project Period

May 1, 2005 – April 30, 2008

Funding Level Expected Per Year

· Year 1 - 189,902.00

· Year 2 - 184,220.00

· Year 3 - 188,762.00

Partners to the Project

Consortium partners include the Ho-Chunk Division of Health, Ho-Chunk Education Department, Ho-Chunk Social Services, and Tomah and Black River School Districts.

Areas Served

Tomah and Black River Falls areas.

Target Population Served

The target population is 400 Ho-Chunk youth age 6 to 18 and their parents.

Project Summary

An estimated 15 percent of children age 6 to 19 in the United States are overweight. The Ho-Chunk Nation data are even more alarming—59.5 percent of children age 5 to 14 and 48.1 percent of children age 15 to 19 are overweight or at risk for overweight.

Program Director

Linda Lowery

Ho-Chunk Nation

N6520 Guy Road

Black River Falls, Wisconsin 54615-5405

Phone: (715) 284-9851, ext. 5343

Fax: (715) 284-5150

Ho-Chunk Nation

Black River Falls, WI 54615-5405

ORHP Contact:

Vanessa Hooker

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-594-5105

vhooker@hrsa.gov

The ultimate goal of the Ho-Chunk Nation Youth Fitness Project (HYFP) is to prevent, or at least delay, the onset of type 2 diabetes among people of Ho-Chunk Nation, an already high-risk ethnic group. This project will bring together resources and personnel from an already successful Pediatric Fitness Clinic in a collaborative effort to modify the overweight risk factor through improved eating and activity habits. HYFP will expand the prior program to include the following components: (1) offer 90 minutes of fitness, nutrition, and wellness classes, twice a week, to all Ho-Chunk youth age 6 to 18, regardless of weight, for 16 weeks; (2) require parents of the youth participants to attend weekly nutrition and fitness classes; (3) have parents and youth meet weekly with a guidance counselor who will promote positive self-esteem and overall well-being; (4) offer the program to the Tomah/Wyeville area, which has not received these services; and (5) implement the new program in Black River Falls. The HYFP goal is to develop strategies for preventing and reducing childhood overweight through fitness, nutrition, and counseling that can be replicated in other communities and tribal organizations. Parental involvement will be encouraged because parent support is necessary in the success of the child’s weight loss.

The target population is 400 Ho-Chunk youth age 6 to 18 and their parents who reside in the Tomah and Black River Falls areas. The jurisdictional lands of the Ho-Chunk Nation, a federally recognized Indian Tribe, cover a 16-county area in central Wisconsin. The majority of the Ho-Chunk lands are located in rural areas that lack access to specialized health care services with the nearest being 50 miles.

The service area faces several other barriers to health care. Ho-Chunk tribal members do not always feel comfortable seeking non-tribal health services, especially with the stigma that often goes with obesity. Until the establishment of HYFP, there was no program addressing childhood overweight being offered within the Black River Falls area and currently there is not a program in Tomah. Treatment for obesity is not covered by most insurance plans, and many families lack financial resources to travel to special program service sites. Monroe and Jackson counties, where project services will be provided, are Medically Underserved Populations and Medically Underserved Areas. In addition, Ho-Chunk Health Care Center serves a Medically Underserved Community.

Consortium partners include the Ho-Chunk Division of Health, Ho-Chunk Education Department, Ho-Chunk Social Services, and Tomah and Black River School Districts.

Topic Areas

Minority health, Occupational health

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 150,000.00

· Year 2 - 200,000.00

· Year 3 - 200,000.00

Partners to the Project

The Alliance for Hispanic Outreach and Regional Awareness (AHORA) is a coalition formed by Wisconsin’s Wood County Health Department.

Areas Served

Clark, Lincoln, Marathon, Portage, and Wood counties.

Target Population Served

Will provide regional and cross systems coordination to better assess needs and identify priorities for future systems and service development. In addition, the sense of purpose created by unifying our goals and creating a common vision and shared outcomes will drive the development of quality services for the Hispanic population in north central Wisconsin for years to come.

Program Director

Karen Brewer

Wood County Health Department

184 N. 2°d Street

Wisconsin Rapids, WI 54494

Phone: (715) 421-8911

E-mail: kbrewer@co.wood.wi.us

Wood County Health Department

Wisconsin Rapids, WI 54494

ORHP Contact:

Sheila Warren

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-0246

swarren@hrsa.gov

Project Summary

Currently, services available to the Hispanic population are limited and fragmented across the four-county region. Reliable data on this population are poor due to fears that the Hispanic population has about accessing services and providing information due to their immigration status. The overarching goal of this proposal is to reduce health disparities in the Latino/Hispanic population in a four county area by increasing access to health care, providing health information and education, increasing direct health care services, improving occupational health and safety and developing community capacity and infrastructure to deliver culturally competent health care services.

The Alliance for Hispanic Outreach and Regional Awareness (AHORA) is a coalition formed by Wisconsin’s Wood County Health Department in September 2003 to assemble providers for discussion about regional strengths and weaknesses in meeting the needs of the rapidly growing Hispanic community in central Wisconsin. AHORA includes representatives from the counties of Clark, Lincoln, Marathon, Portage, and Wood. It has grown to include membership from 42 medical and service providers, non-profit organizations, faith-based groups, Latino service providers, and community volunteers both Hispanic and non-Hispanic.

The model that will be used to provide health and safety outreach for this proposed project is founded on the community health outreach model. The project is designed to address the health disparities and access issues in the Hispanic community in four counties in the north central heartland of Wisconsin. The counties are Wood, Marathon, Clark, and Lincoln counties. The community health outreach services focus on four primary and interrelated services including:

· Providing health information and referral using a community health outreach worker approach that includes a toll-free telephone help line and health navigators to assist Hispanic/Latino individuals to access and benefit from community resources to meet their needs;

· Provide health information to Hispanic families and children through a home visitation model, with bilingual staff that will use a curriculum to provide health information, but will also address individuals’ needs for information and support;

· Train bilingual health educators to provide services to women infants and children in the Hispanic community using a train the trainer model developed by the Wisconsin WIC program; and

· Provide occupational health and safety information to Hispanic workers and employers with a variety of educational interventions including health fairs at employer locations, with families, with children in schools, at churches, in the Spanish newspaper, in the AHORA newsletter, and at Hispanic events like the area soccer league.

This activity also impacts the Healthy People 2010 goal addressing socioeconomic factors that influence health.

It is believed that the development of the partnerships created through this grant opportunity will provide regional and cross systems coordination to better assess needs and identify priorities for future systems and service development. In addition, the sense of purpose created by unifying our goals and creating a common vision and shared outcomes will drive the development of quality services for the Hispanic population in north central Wisconsin for years to come.

Topic Areas

Health promotion/disease prevention (general)

Project Period

May 1, 2006 – April 30, 2009

Funding Level Expected Per Year

· Year 1 - 149,886.00

· Year 2 - 124,944.00

· Year 3 - 99,994.00

Partners to the Project

Know Your Numbers, High School Peer Health Education, Manitowoc County Network for Child Passenger Safety, and Healthy Teeth Healthy Kids.

Areas Served

Manitowoc County

Target Population Served

This is an overarching project that touches many health care issues.

Project Summary

This project will enhance the efforts of Healthiest Manitowoc County 2010 (HMC2010) through the implementation of four initiatives. HMC2010 is a broad-based, community-driven coalition formed in 2004 to address the most critical health needs of Manitowoc County.

HMC2010 addresses six health priorities through seven Community

Program Director

Martin Schaller

Northeastern Wisconsin Area Health Education Center, Inc.

804 Jay Street, Ste. 201A

Manitowoc, WI 54220

Phone: (920) 652-0238

Fax: (920) 652-0617

E-mail: martys@newahec.org

Northeastern Wisconsin Area Health Education Center, Inc.

Manitowoc, WI 54220

ORHP Contact:

Sonja Taylor

Project Officer

HRSA/ORHP

5600 Fishers Lane

Rockville, MD 20857

301-443-1902

staylor@hrsa.gov

Health Improvement Committees (CHICs) and a Steering Committee. The six health priorities of HMC2010 are as follows: physical activity and nutrition; tobacco use; teen pregnancy and risky sexual behavior; injury prevention; oral health; and alcohol and other substance abuse. The First Initiative, Know Your Numbers, will build upon current HMC2010 activities and will provide outreach and a comprehensive health risk assessment to underserved adults, with follow-up counseling and referral to community resources.

This is an overarching project that touches many health care issues. For example, the rate of Manitowoc County adults at healthy weight is currently 34 percent, compared to 42 percent of Wisconsin residents. The Second Initiative, High School Peer Health Education, will train high school students at three high schools to creatively deliver key messages both to their peers and to junior high school students that will inform and foster healthy lifestyle choices regarding tobacco use, alcohol and drugs, risky sexual behavior, and physical activity & nutrition.

Manitowoc County’s (MC) teen pregnancy rate increased 33 percent between 1995 and 2002, compared to a 27 percent decrease statewide; MC’s rate for underage drinking arrests is 128 per 10,000 kids, compared to the state rate of 90 per 10,000; MC high school student smoking rate is 29 percent compared to 24 percent statewide; binge drinking among MC high school students is 30 percent compared to 28 percent statewide; the percentage of MC high school students achieving Healthy People 2010 nutrition (daily vegetable consumption) and exercise (vigorous physical activity) targets is 23 percent and 70 percent, respectively. The Third Initiative, Manitowoc County Network for Child Passenger Safety, will enhance the county-wide network for child passenger safety by ensuring there are an adequate number of certified child passenger safety technicians at both hospitals in the county to provide education to each family of newborns delivered at their hospital, and provide outreach and education to the community regarding child passenger seat safety. Need addressed: In the past 3 years, over 95 percent of child passenger safety seats presented for car seat checks in Manitowoc County were installed incorrectly. The Fourth Initiative, Healthy Teeth Healthy Kids, will provide comprehensive preventive and restorative dental services to 1,305 Medicaid and uninsured children in elementary and middle schools in the schools with the highest rate of poverty in the county.

Only 18 percent of Medicaid recipients in Manitowoc County received dental care in the past year, compared with 23 percent of Medicaid recipients statewide and 73 percent of the total Manitowoc County population. Only one Manitowoc County dentist accepts pediatric Medicaid patients.