Rural Health Care Coordination Network Partnership Program
This announcement solicits applications for the Rural Health Care Coordination Network Partnership Program (Care Coordination Program).
The purpose of the Rural Health Care Coordination Network Partnership Program is to support the development of formal, mature rural health networks that focus on care coordination activities for the following chronic conditions: diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient¿s care to achieve safer and more effective care. Rural Americans are unhealthier, with higher rates of chronic illnesses, such as diabetes, CHF, and COPD and have higher rates of high-risk behaviors such as smoking, physical inactivity, and poor nutrition.[1],[2],[3],[4] These high-risk behaviors cause many of the illnesses, suffering and deaths due to chronic diseases and conditions.[5] The increasing prevalence of chronic diseases and the high cost of health care in the U. S. bring treatment of the ¿whole¿ person to the forefront, especially as there are often psychosocial (psychological and social) issues related to chronic diseases; for example, there is a link between diabetes and depression. In addition, more mental health problems are seen in the primary care setting than other health care settings; thus, integrating behavioral health care into primary care helps address both the physical and psychosocial aspects of health and wellness. Reviews and reports from the Agency for Healthcare Quality and Research (AHRQ) have shown a positive impact from integrating a team approach to care for a variety of disease conditions.[6] Health care coordination for people living with chronic conditions is vital to providing high quality care, especially in rural areas where access to health care is an issue. The main goal of care coordination is to meet patients¿ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient¿s needs and preferences are known ahead of time and communicated at the right time to the right people; this information is used to provide safe, appropriate, and effective care to the patient. Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone:
patients, providers, and payers.[7] Care coordination is especially important in the changing health care landscape where payments increasingly focus on value. The ultimate goal of the program is to promote the delivery of coordinated care in the primary care setting.
There are numerous developments in state health policy that support the adoption of care coordination models, including patient centered medical homes (PCMH), accountable care organizations (ACO), and enhanced health information technology (HIT) such as electronic health records (EHR) and telehealth capabilities. Care coordination strategies can be tailored for a rural community¿s resources and challenges. Strategies may include a special emphasis on:
recruiting or training personnel to assume care coordination responsibilities or supporting other staff, such as, community health workers, in taking on this role; developing new or making creative use of existing resources, such as co-locating available behavioral and primary health care services; and addressing quality improvement through innovations like telehealth or system redesign using models such as, Six Sigma or the Lean Model, for example.[8] Applicants shall develop creative and innovative approaches to address outcomes in one or more of the three pre-specified disease states, diabetes, CHF, and/or COPD, through application of care coordination strategies.
Applicants shall disseminate the information regionally or nationally, including efforts by grassroots, faith-based or community-based organizations.
The proposed projects should demonstrate improved outcomes.
Applicants may address the prevalence and management of diabetes, CHF, and COPD conditions using innovative or evidence-based care coordination strategies, relevant to their community needs. At a minimum, networks will be asked to report on four outcome measures for each chronic condition (Type 2 Diabetes, CHF and COPD).
In addition to reporting on these outcome measures, networks will be also asked to report at least three care coordination measures.
Performance on those measures will be aggregated across the funded sites to measure program impact.
To review the outcome measures for each chronic condition, please refer to Section IV:
Application and Submission Information.
To the extent possible, grantees are encouraged to bill for third party reimbursement for covered services and participate in pay-for-performance and other incentive programs[9],[10] in order to aid in the sustainability of the project. By thinking beyond the day-to-day activities and services and planning for sustainability early in the grant cycle, organizations can better position their programs for long-term sustainability and leverage the investment of federal grant dollars to maintain successful programs that improve the health of rural Americans.
[1] Downy LH.
(2013).
Rural Populations and Health:
Determinants, Disparities, and Solutions [book review].
Preventing Chronic Disease; 10:13009 7. Available at: http://www.cdc.gov/pcd/issues/2013/13_009 7. htm.
[2] Why Rural America Needs Health Reform.
National Rural Health Association.
Available at: http://www.ruralhealthweb.org/index.cfm?objectid=A771071A-3048-651A-FEAB6199CED39F8E.
[3] Dallas ME.
(2012).
COPD Deaths Highest in Rural, Poor Areas:
CDC.
HealthDay News.
Available at: http://consumer.healthday.com/diseases-and-conditions-information-37/misc-diseases-and-conditions-news-203/copd-deaths-highest-in-rural-poor-areas-cdc-66969 2. html.
[4] American College of Chest Physicians.
(2012).
Poverty, rural living linked to increased COPD mortality in the US.
Science Daily.
Available at: http://www.sciencedaily.com/releases/2012/10/12102208065 5. htm.
[5] Chronic Diseases and Health Promotion.
(2014).
Atlanta, GA:
U. S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/chronicdisease/overview/.
[6] Jortberg BT, Miller BF, Gabbay RA, Sparling K, Dickinson WP.
(2012).
Patient-Centered Medical Home:
How it Affects Pyschosocial Outcomes for Diabetes.
Current Diabetes Reports;12:721-72 8. [7] Care Coordination.
(2014).
Rockville, MD:
U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html.
[8] Stanek M, Hanlon C, Shiras T.
(2014).
Realizing Rural Care Coordination:
Considerations and Action Steps for State-Policy Makers.
Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf41205 8. [9] Pay-for-performance programs can either be from the private-sector such as, the California Pay for Performance Program or from the public-sector such as, the Medicare Hospital Value-Based Purchasing Program. An example of an incentive program is the Medicare and Medicaid EHR Incentive Programs, which provides financial incentives for the meaningful use of certified EHR technology to improve patient care. [10] James J.
(2012).
Health Policy Brief:
Pay-for- Performance.
Health Affairs.
Available at: http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_7 8. pdf.
The purpose of the Rural Health Care Coordination Network Partnership Program is to support the development of formal, mature rural health networks that focus on care coordination activities for the following chronic conditions: diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient¿s care to achieve safer and more effective care. Rural Americans are unhealthier, with higher rates of chronic illnesses, such as diabetes, CHF, and COPD and have higher rates of high-risk behaviors such as smoking, physical inactivity, and poor nutrition.[1],[2],[3],[4] These high-risk behaviors cause many of the illnesses, suffering and deaths due to chronic diseases and conditions.[5] The increasing prevalence of chronic diseases and the high cost of health care in the U. S. bring treatment of the ¿whole¿ person to the forefront, especially as there are often psychosocial (psychological and social) issues related to chronic diseases; for example, there is a link between diabetes and depression. In addition, more mental health problems are seen in the primary care setting than other health care settings; thus, integrating behavioral health care into primary care helps address both the physical and psychosocial aspects of health and wellness. Reviews and reports from the Agency for Healthcare Quality and Research (AHRQ) have shown a positive impact from integrating a team approach to care for a variety of disease conditions.[6] Health care coordination for people living with chronic conditions is vital to providing high quality care, especially in rural areas where access to health care is an issue. The main goal of care coordination is to meet patients¿ needs and preferences in the delivery of high-quality, high-value health care. This means that the patient¿s needs and preferences are known ahead of time and communicated at the right time to the right people; this information is used to provide safe, appropriate, and effective care to the patient. Care coordination is identified by the Institute of Medicine as a key strategy that has the potential to improve the effectiveness, safety, and efficiency of the American health care system. Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone:
patients, providers, and payers.[7] Care coordination is especially important in the changing health care landscape where payments increasingly focus on value. The ultimate goal of the program is to promote the delivery of coordinated care in the primary care setting.
There are numerous developments in state health policy that support the adoption of care coordination models, including patient centered medical homes (PCMH), accountable care organizations (ACO), and enhanced health information technology (HIT) such as electronic health records (EHR) and telehealth capabilities. Care coordination strategies can be tailored for a rural community¿s resources and challenges. Strategies may include a special emphasis on:
recruiting or training personnel to assume care coordination responsibilities or supporting other staff, such as, community health workers, in taking on this role; developing new or making creative use of existing resources, such as co-locating available behavioral and primary health care services; and addressing quality improvement through innovations like telehealth or system redesign using models such as, Six Sigma or the Lean Model, for example.[8] Applicants shall develop creative and innovative approaches to address outcomes in one or more of the three pre-specified disease states, diabetes, CHF, and/or COPD, through application of care coordination strategies.
Applicants shall disseminate the information regionally or nationally, including efforts by grassroots, faith-based or community-based organizations.
The proposed projects should demonstrate improved outcomes.
Applicants may address the prevalence and management of diabetes, CHF, and COPD conditions using innovative or evidence-based care coordination strategies, relevant to their community needs. At a minimum, networks will be asked to report on four outcome measures for each chronic condition (Type 2 Diabetes, CHF and COPD).
In addition to reporting on these outcome measures, networks will be also asked to report at least three care coordination measures.
Performance on those measures will be aggregated across the funded sites to measure program impact.
To review the outcome measures for each chronic condition, please refer to Section IV:
Application and Submission Information.
To the extent possible, grantees are encouraged to bill for third party reimbursement for covered services and participate in pay-for-performance and other incentive programs[9],[10] in order to aid in the sustainability of the project. By thinking beyond the day-to-day activities and services and planning for sustainability early in the grant cycle, organizations can better position their programs for long-term sustainability and leverage the investment of federal grant dollars to maintain successful programs that improve the health of rural Americans.
[1] Downy LH.
(2013).
Rural Populations and Health:
Determinants, Disparities, and Solutions [book review].
Preventing Chronic Disease; 10:13009 7. Available at: http://www.cdc.gov/pcd/issues/2013/13_009 7. htm.
[2] Why Rural America Needs Health Reform.
National Rural Health Association.
Available at: http://www.ruralhealthweb.org/index.cfm?objectid=A771071A-3048-651A-FEAB6199CED39F8E.
[3] Dallas ME.
(2012).
COPD Deaths Highest in Rural, Poor Areas:
CDC.
HealthDay News.
Available at: http://consumer.healthday.com/diseases-and-conditions-information-37/misc-diseases-and-conditions-news-203/copd-deaths-highest-in-rural-poor-areas-cdc-66969 2. html.
[4] American College of Chest Physicians.
(2012).
Poverty, rural living linked to increased COPD mortality in the US.
Science Daily.
Available at: http://www.sciencedaily.com/releases/2012/10/12102208065 5. htm.
[5] Chronic Diseases and Health Promotion.
(2014).
Atlanta, GA:
U. S. Department of Health and Human Services, Centers for Disease Control and Prevention.
Available at: http://www.cdc.gov/chronicdisease/overview/.
[6] Jortberg BT, Miller BF, Gabbay RA, Sparling K, Dickinson WP.
(2012).
Patient-Centered Medical Home:
How it Affects Pyschosocial Outcomes for Diabetes.
Current Diabetes Reports;12:721-72 8. [7] Care Coordination.
(2014).
Rockville, MD:
U. S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html.
[8] Stanek M, Hanlon C, Shiras T.
(2014).
Realizing Rural Care Coordination:
Considerations and Action Steps for State-Policy Makers.
Robert Wood Johnson Foundation. Available at: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf41205 8. [9] Pay-for-performance programs can either be from the private-sector such as, the California Pay for Performance Program or from the public-sector such as, the Medicare Hospital Value-Based Purchasing Program. An example of an incentive program is the Medicare and Medicaid EHR Incentive Programs, which provides financial incentives for the meaningful use of certified EHR technology to improve patient care. [10] James J.
(2012).
Health Policy Brief:
Pay-for- Performance.
Health Affairs.
Available at: http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_7 8. pdf.
Related Programs
Rural Health Care Services Outreach and Rural Health Network Development Program
Department of Health and Human Services
Agency: Department of Health and Human Services
Office: Health Resources and Services Administration
Estimated Funding: $1,600,000
Office: Health Resources and Services Administration
Estimated Funding: $1,600,000
Relevant Nonprofit Program Categories
Obtain Full Opportunity Text:
Not Available
Additional Information of Eligibility:
a) Ownership and Geographic Requirements: Applicants for the Rural Health Care Coordination Network Partnership Program must meet the ownership and geographic requirements stated below.
(Note: If an incorporated network does not apply on behalf of its members, the award will be made to only one member of the network that will be the grantee of record and only that organization needs to meet the eligibility criteria: 1) The lead applicant organization must be a public or private non-profit entity located in a rural area or in a rural census tract of an urban county, and all services provided by a HRSA grant awarded under this FOA must be provided in a rural county or census tract. The applicant¿s Employer Identification Number (EIN) provided by the Internal Revenue Service will verify it is a rural entity. To ascertain rural eligibility, please refer to: http://datawarehouse.hrsa.gov/RuralAdvisor/ and enter the applicant organization¿s state and county. An application that proposes a network serving rural communities where the applicant organization is not in a designated rural area will not be considered for funding under this announcement. Rural faith-based and community-based organizations, Tribes, and tribal organizations are eligible to apply.
2) In addition to the States listed on the Rural Advisor (link above) only Guam, the Commonwealth of Puerto Rico, the Northern Mariana Islands, American Samoa, the U. S. Virgin Islands, the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau may apply.
Applications submitted from organizations located outside the 50 states, must meet the rural eligibility requirements.
One of the following documents must be included in Attachment 3 to prove non-profit status (not applicable to State, local, and Tribal government entities; Tribal organizations, however, must provide one of the following):
Full Opportunity Web Address:
Contact:
Department of Health and Human Services, Health Resources and Services Administration, HRSA Grants Application Center, 910 Clopper Road, Suite 155 South, Gaithersburg, MD, 20878SAfayee@hrsa.gov
Agency Email Description:
Contact Sara Afayee at ((30)1) -945- Ext. 4169 or email SAfayee@hrsa.gov
Agency Email:
SAfayee@hrsa.gov
Date Posted:
2015-02-05
Application Due Date:
2015-04-06
Archive Date:
2015-06-05
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