ALABAMA Bayou Clinic, Inc. DBA Bayou La Batre Rural Health Clinic

Transcription

ALAB AMA
Bayou Clinic, Inc.
DBA Bayou La Batre Rural Health Clinic
Grant Number: D04RH00794
Program Director
TOPIC AREAS
Health promotion/disease prevention (general), Depression,
Alcohol/Substance abuse
PROJECT PERIOD
May 1, 2003 – April 30, 2005
R EGINA B ENJAMIN
B AYOU C LINIC, I NC.
DBA B AYOU L A B ATRE R URAL
H EALTH C LINIC
13833 TAPIA L ANE
B AYOU L A B ATRE , ALABAMA 36509
PHONE : (251) 824-4985
F AX : (251) 626-2200
FUNDING LEVEL EXPECTED PER YEAR
 Year 1 - 200,000.00
 Year 2 - 200,000.00
 Year 3 - 200,000.00
PARTNERS TO THE PROJECT
T he network partners are the Bayou La Batre Rural Health Clinic, the
lead applicant, Catholic Social Services, the Mayor and City Council
of Bayou La Batre, Mid-South Home Health, Mobile County Public
Health Department, Mobile County Public School Systems, Mobile
Mental Health Center, Mostellar Medical Center, Providence
Hospital; and the Dartmouth COOP Project, Dartmouth Medical
School.
B AYOU C LINIC, I NC.
DBA B AYOU L A B ATRE R URAL
H EALTH C LINIC
B AYOU L A B ATRE , AL 36509
AREAS SERVED
Bayou La Batre is designated as a Health Professional Shortage Area
ORHP Contact:
TARGET POPULATION SERVED
T he target population for the BOSS project is the multi-generational
residents and medically indigent of Bayou La Batre and the
surrounding communities in Alabama and Mississippi.
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
R OCKVILLE , MD 20857
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Bayou Outreach and Support Services (BOSS) project will serve Bayou La Batre, one of only two
rural zip codes in Mobile County, Alabama. Planned services include increased awareness of available
services among residents and those who serve them through coordination and planning as a network; the
development of a single intake and referral process among network members; the reduction in the
prevalence of obesity in Bayou La Batre through a city-wide exercise and weight reduction challenge;
expansion of basic medical screening and educational programs for residents; and the use of Web
technology to educate the public about health promotion and wellness, collect health status information
on areas residents, and monitor the population’s health status.
Bayou La Batre, a shrimping village of 2,500 persons 35 miles from Mobile, Alabama, is considered one
of the poorest areas in Alabama. Nearly 50 percent of the adult population in Bayou La Batre is
unemployed. T he prevalence of depression, alcohol and substance abuse, suicide, and unexplained
injuries is high in the community. T he target population for the BOSS project is the multi-generational
residents and medically indigent of Bayou La Batre and the surrounding communities in Alabama and
Mississippi. T he target population is 60 percent Caucasian, 30 percent Asian/Pacific Islander
ALAB AMA
Bayou Clinic, Inc.
DBA Bayou La Batre Rural Health Clinic
(predominantly Vietnamese, Cambodian, and Laotian refugees), 5 percent African American, and
5 percent Hispanic. Access barriers to services include geographic isolation and lack of public
transportation; lack of education and high rates of illiteracy; cultural and language barriers; community
denial (a sense of pride that prevents people from asking for government assistance); and a lack of health
care providers. Bayou La Batre is designated as a Health Professional Shortage Area.
T he network partners are the Bayou La Batre Rural Health Clinic, the lead applicant, Catholic Social
Services, the Mayor and City Council of Bayou La Batre, Mid-South Home Health, Mobile County
Public Health Department, Mobile County Public School Systems, Mobile Mental Health Center,
Mostellar Medical Center, Providence Hospital; and the Dartmouth COOP Project, Dartmouth Medical
School.
ALAB AMA
East Central Mental Health-Mental Retardation, Inc.
Program Director
TOPIC AREAS
Obesity
PROJECT PERIOD
May 1, 2005 – April 30, 2007
TERRY W ATKINS
EAST C ENTRAL MENTAL H EALTHMENTAL R ETARDATION, I NC.
200 C HERRY STREET
TROY , ALABAMA 36081-2044
PHONE : (334) 670-5261
F AX : (334) 670-5256
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Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners consist of eight members of the Pike County
Consortium, including East Central Mental Health-Mental
Retardation; four members of the Bullock County Consortium; and
community supporters in both counties.
AREAS SERVED
Rural Pike and Bullock counties.
T he 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. T he target populations will be multicultural, representing
all racial, social, and economic backgrounds in the two counties.
EAST C ENTRAL MENTAL H EALTHMENTAL R ETARDATION, I NC.
TROY , AL 36081-2044
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
East Central Mental Health-Mental Retardation, Inc., has initiated a partnership of community agencies
committed to the development and implementation of a comprehensive, countywide health risk
prevention and outreach project. T he 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.
T he 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. T he 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.
ALAB AMA
East Central Mental Health-Mental Retardation, Inc.
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.
T he network partners consist of eight members of the Pike County Consortium, including East Central
Mental Health-Mental Retardation; four members of the Bullock County Consortium; and community
supporters in both counties.
ALAB AMA
Sylacauga Alliance for Family Enhancement, Inc.
Program Director
TOPIC AREAS
Heart disease, Chronic Obstructive Pulmonary Disease, Diabetes,
Hypertension, Disease management, Faith-based health advocacy
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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MARGARET MORTON, ED.S.,
EXECUTIVE D IRECTOR
SYLACAUGA ALLIANCE FOR F AMILY
ENHANCEMENT, I NC.
P.O. B OX 1122
SYLACAUGA, ALABAMA 35150
PHONE : (256) 245-4343
F AX : (256) 245-3675
MORTONM@ SAFESYLACAUPA. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Parish Nurse Disease Management Program
AREAS SERVED
T he target population of under and uninsured residents of T alladega
County, Alabama with chronic diseases of Congestive Heart Failure
(CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes
and/or Hypertension.
T he 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.
SYLACAUGA ALLIANCE FOR F AMILY
ENHANCEMENT, I NC.
SYLACAUGA, AL 35150
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he 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 T alladega County, Alabama with chronic diseases of Congestive
Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes and/or Hypertension.
T he 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. T his project builds on existing research on the
ALAB AMA
Sylacauga Alliance for Family Enhancement, Inc.
relationship between spirituality and health, the effectiveness of lay community health workers, and
enabling technology. T he 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.
ALAB AMA
Tombigbee Healthcare Authority
Program Director
TOPIC AREAS
Health care
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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ANTOINETTE L ANKSTER, R.N., B.S.N.
TOMBIGBEE H EALTHCARE AUTHORITY
B RYAN W. W HITFIELD MEMORIAL
H OSPITAL
105 H IGHWAY 80 EAST
D EMOPOLIS , AL 36732
PHONE : (334) 287-2579
F AX : (334) 287-2594
Year 1 - 124,122.00
Year 2 - 123,292.00
Year 3 - 100,000.00
Rural Assistance Program for Churches and Schools (RAPCS).
AREAS SERVED
Green, Sumter, and Marengo Counties. T hese counties are rural,
medically underserved, and have a large African American
population.
T he 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.
TOMBIGBEE H EALTHCARE AUTHORITY
D EMOPOLIS , AL 36732
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he Rural Assistance Program for Churches and Schools (RAPCS) will provide access to health care for
disadvantaged populations in Green, Sumter, and Marengo Counties. T hese counties are ranked among
the poorest in the State and the Nation. T hey 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. T hose 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. T hese factors and others provide
insurmountable barriers to health care in this region of Alabama.
T he purpose of this project is two-fold: 1) T o 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
ALAB AMA
Tombigbee Healthcare Authority
access to health care, and 2) T o 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 communitybased organizations.
ALAB AMA
Coosa Board of Education
Program Director
TOPIC AREAS
Mental Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010
L UCY B ROWNING
C OOSA B OARD OF EDUCATION
P.O. B OX 37
R OCKFORD, AL
256-377-2385
F AX –256-377-2385
LBROWNING@ COOSASCHOOLS . K12. AL. US
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Year 1 - 139,785.00
Year 2 - 124,971.00
Year 3 - 99,993.00
T his 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. T he
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
C OOS A C OU N TY B OA R D OF
E D U C A TI ON
R OC K F OR D , AL 3 5 1 3 6 - 0 3 7 3
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
(301) 594-4438
KMARTINSEN@ HRSA. GOV
limited mental health services in our community as a problem
community as a problem, we formed the Coosa County Partnership for Youth.
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. T he 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
T he 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.
ALAS KA
Eastern Aleutian Tribes, Inc.
Program Director
TOPIC AREAS
Distance Education and T raining Health promotion/disease
prevention (general), Social services
PROJECT PERIOD
May 1, 2003 – April 30, 2005
N ANCY O’N EILL
EASTERN ALEUTIAN TRIBES , I NC.
1919 S. B RAGAW STREET
P.O. B OX 349
ANCHORAGE , ALASKA 99508
PHONE : (907) 497-3184
F AX : (907) 497-3186
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Year 1 - 147,500.00
Year 2 - 198,950.00
Year 3 - 178,399.00
T he network partners are the EAT , Chugachmiut, and ANC/CHAP
(Alaska Community Health Aide T raining Program).
AREAS SERVED
Serving six frontier communities of Akutan, False Pass, Nelson
Lagoon, Cold Bay, King Cove, and Sand Point whiech the entire area
is a Health Professional Shortage Area and Medically Underserved
Area, including mental health and dental.
In frontier and rural Alaska, primary health care is frequently
delivered by about 400 community health aides/practitioners
(CHA/Ps) who receive remote medical supervision from a physician.
EASTERN ALEUTIAN TRIBES , I NC.
ANCHORAGE , AK 99508
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
In frontier and rural Alaska, primary health care is frequently delivered by about 400 community health
aides/practitioners (CHA/Ps) who receive remote medical supervision from a physician. CHA/Ps are
selected from village residents and formally trained for about 16 weeks at 1 of 4 training centers in the
state. As a result of waiting lists for the training and travel distances to the training sites, frontier villages
have less medical coverage when the CHA/Ps are away for training. T he Rural Health Outreach project
proposes to develop a virtual training center for CHA/Ps to address the problems of access to training and
medical coverage of villages. T he project will establish a Distance Education and T raining Program over
existing Internet connections provided by the Alaska Federal Health Care Access Network (AFHCAN)
project. T he training program will eventually be available to the entire Rural Anchorage Service Unit.
T he permanent population served by the Eastern Aleutian Tribes, Inc. (EAT), the lead applicant, is
approximately 2,500 persons, with an increase of more than 8,500 persons during the peak fishing
seasons. T he permanent population of the rural villages served by the Chugachmiut tribal consortium is
7,489 persons. T he target populations are 41 percent Alaska Native, 24 percent Caucasian, 10 percent
Hispanic, and 25 percent other. Remoteness and isolation are the main access barriers to health care in
rural Alaska villages. Each of the communities served by the EAT is geographically isolated, and the
entire area is a Health Professional Shortage Area and Medically Underserved Area, including mental
health and dental. Efforts are under way to acquire the designations for the Chugachmiut villages.
ALAS KA
T he network partners are the EAT , Chugachmiut, and ANC/CHAP (Alaska Community Health Aide
T raining Program). EAT is the only health care “ safety net” provider in the 80,000 square mile Eastern
Aleutian region of Alaska, serving six frontier communities of Akutan, False Pass, Nelson Lagoon, Cold
Bay, King Cove, and Sand Point. Chugachmiut is the tribal consortium created to promote selfdetermination to the seven Native communities of the Chugach region.
ALAS KA
Bristol Bay Area Health Corporation
Program Director
TOPIC AREAS
Elderly, T elehealth
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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R OGER C LARK
PRESIDENT/C HIEF EXECUTIVE OFFICER
B RISTOL B AY AREA H EALTH
C ORPORATION
P.O. B OX 130
D ILLINGHAM, AK 99576
PHONE : (907) 842-5201
F AX : (907) 842-9409
E-MAIL: RCLARK@BBAHC. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Community Health Aide/Practitioners
AREAS SERVED
Alaska
T o 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.
B RISTOL B AY AREA H EALTH
C ORPORATION
D ILLINGHAM, AK 99576
ORHP Contact:
PROJECT SUMMARY
SHERILYN PRUITT
PROJECT OFFICER
T he service area of this proposed project is the 34 rural communities
HRSA/ORHP
within the Bristol Bay Area Health Corporation (BBAHC) medical
5600 F ISHERS L ANE
care system in Alaska. Some 8,072 people live in the area, of whom
6,865 are all or part Native. T he target population is the 555 persons
301-594-0819
SPRUITT@ HRSA. GOV
over the age of 62 that reside in the region. The most significant
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. T here 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. T elehealth 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. T his 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.
T he 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. T here are five
program goals: 1) T o increase access to specialized medical care for persons over the age of 62; 2) T o
ALAS KA
Bristol Bay Area Health Corporation
increase patient translation and advocacy services for persons over the age of 62; 3) T o increase provider
staff knowledge of geriatrics; 4) T o 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 FT E Patient
Advocate/T ranslators 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.
T he 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.
ALAS KA
Kenaitze Indian Tribe
Program Director
TOPIC AREAS
Colorectal cancer
PROJECT PERIOD
May 1, 2006 – April 30, 2008
D IANA TURNER
EXECUTIVE D IRECTOR
K ENAITZE I NDIAN TRIBE
P.O. B OX 988
K ENAI, AK 99611
PHONE : (907) 283-3633
E-MAIL: DTURNER@KENAITZE . ORG
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Kenaitze Indian T ribe (KIT), the Ninilchik T raditional Council, and
the Alaska Native T ribal Health Consortium (ANTHC).
AREAS SERVED
Rural Alaska communities of Kenai, Soldotna, Nikiski, Kasilof,
Sterling, Cooper Landing, Hope, Ninilchik, Anchor Point, and
Homer.
K ENAITZE I NDIAN TRIBE
K ENAI, AK 99611
ORHP Contact:
T he 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.
SHEILA W ARREN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0246
SWARREN@ HRSA. GOV
PROJECT SUMMARY
T his project will form a Colorectal Cancer Screening Consortium through the Kenaitze Indian T ribe
(KIT ), the Ninilchik Traditional Council, and the Alaska Native T ribal 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.
T he 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 ANT HC 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.
ALAS KA
Kenaitze Indian Tribe
T he consortium will monitor project progress, identify and problem-solve barriers, develop local capacity,
and seek ways to expand outreach, networking, and public education. ANT HC will provide intensive
training in flexible sigmoidoscopy procedures, as well as onsite follow-up and technical assistance with
both T ribes. T he two T ribes 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 T ribes 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 T ribe will implement public education and outreach.
T he 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 T ribal/rural providers.
ALAS KA
TOPIC AREAS
Hospice/Medicare
PROJECT PERIOD
May 1, 2007 – April 30, 2010
Program Director
L IAM C HRIS D EVLIN
3380 C STREET, SUITE 100
ANCHORAGE , AK
907-564-2501
F AX –907-277-1446
CHRISD@ EATRIBES . NET
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Eastern Aleutian T ribes, Providence Hospice, Aleutian Pribilof Islands
Association, and Alaska Native T ribal Health Consortium this
demonstration will allow Eastern Aleutian T ribes (EAT ) to expand
access to hospice services for rural Alaskan residents by using its midlevel practitioners and health aides to provide in-home hospice services.
AREAS SERVED
Both tribal and non-tribal members, who reside within the Eastern
Aleutian T ribes and Aleutian Pribilof Islands Association service area.
R U R A L AL A S K A H OS P I C E
O U TR E A C H P R OJ E C T
AN C H OR A GE , AK 9 9 5 0 3 - 3 4 4 0
ORHP Contact:
JACOB L ONG R UEDA III, PH.D., M.P.H.,
MED
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0649
JRUEDA@ HRSA. GOV
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
T ribes for Eastern Aleutian T ribes, April 2006). T here were a total of 1,120 reported cancers in Alaska
Natives in the Anchorage Service Unit. T he 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 T ribes, April 2006).
PROJECT SUMMARY
T he 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. T ribal 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.
ALAS KA
ARIZONA
Mt. Graham Regional Medical Center
Program Director
TOPIC AREAS
Diabetes, Health promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
K AREN D OTY
MT. GRAHAM R EGIONAL MEDICAL
C ENTER
1600 20TH AVENUE
SAFFORD, ARIZONA 85546
PHONE : (928) 348-4197
F AX : (928) 348-4189



Year 1 - 199,992.00
Year 2 - 199,995.00
Year 3 - 199,999.00
T he network partners are the Mt. Graham Regional Medical Center,
the lead applicant, Graham County Health Department, and the
University of Arizona’s Rural Health Office.
AREAS SERVED
Graham and Greenlee counties in southeastern Arizona
T he target populations are persons at risk for diabetes, persons with
diabetes and their family and friends, health care providers and staff,
and elementary school youth.
MT. GRAHAM R EGIONAL MEDICAL
C ENTER
SAFFORD, AZ 85546
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Graham Greenlee Diabetes Prevention and Control Program
(GGDPCP) is a comprehensive approach to address diabetes in
Graham and Greenlee counties in southeastern Arizona. T he
GGDPCP will expand existing resources and develop new services and resources through a network
partnership. Services will include early detection screenings; support and education classes; in-home
visits and the option of monitoring and support through telemedicine; health care provider education;
printed materials; educational resources for health care providers and community members; supplies for
testing and monitoring diabetes; prevention education in elementary schools; and outreach and awareness
campaigns.
Graham and Greenlee counties have a disproportionately high number of people who are unemployed and
uninsured and a high rate of Hispanics (45 percent) and Native Americans (8 percent), groups that are at
increased risk of diabetes (the remaining population is 44 percent Caucasian, 2 percent African American,
and 1 percent Asian/Pacific Islander/Alaska Native). T he target populations are persons at risk for
diabetes, persons with diabetes and their family and friends, health care providers and staff, and
elementary school youth. Access barriers to services include a large uninsured population, lack of a
public transportation system, fear and denial of diabetes diagnosis, lack of diabetes educators, lack of time
for adequate information, and shifting priorities in schools. Greenlee County is designated as a Health
Professional Shortage Area.
T he network partners are the Mt. Graham Regional Medical Center, the lead applicant, Graham County
Health Department, and the University of Arizona’s Rural Health Office. T he Mt. Graham Regional
ARIZONA
Mt. Graham Regional Medical Center
Medical Center provides medical services for Graham and Greenlee counties. T he Graham County
Health Department is a division of county government dedicated to the prevention of disease, illness, and
injury. T he University of Arizona’s Rural Health Office will provide technical assistance in program
development and evaluation expertise.
ARIZONA
Hardrock Council on Substance Abuse, Inc.
Program Director
TOPIC AREAS
Substance abuse prevention/treatment
PROJECT PERIOD
May 1, 2006 – April 30, 2008



L ARRY YAZZIE , PRESIDENT
H ARDROCK C OUNCIL ON SUBSTANCE
ABUSE , I NC.
P.O. B OX 26
K YKOTSMOVI VILLAGE , AZ 86039
PHONE : (928) 725-3501
F AX : (928) 725-3731
E-MAIL: MBEGAY 523@YAHOO. COM
Year 1 - 149,996.00
Year 2 - 125,000.00
Year 3 - 99,996.00
T he 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.
AREAS SERVED
Navajo Nation and is part of Navajo County in northeastern Arizona.
1) T o 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) T o 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.
H ARDROCK C OUNCIL ON SUBSTANCE
ABUSE , I NC.
K YKOTSMOVI VILLAGE , AZ 86039
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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.
T he 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.
ARIZONA
Hardrock Council on Substance Abuse, Inc.
T he 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.
T he Hardrock Youth and Wellness Program has two main goals: 1) T o 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) T o 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.
T he 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 communitybased intervention and treatment services.
ARIZONA
Sulphur Springs Valley Health Care Consortium
TOPIC AREAS
Oral Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010



Program Director
JENNIFER “GINGER” R YAN
C HIRICAHUA C OMMUNITY H EALTH
C ENTERS , I NC.
10566 H IGHWAY 191
P.O. B OX 263
ELFRIDA, AZ
520-642-2222
F AX –520-642-3591
GRYAN@CCHCI. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
Children in the remote and sparsely populated Sulphur Springs Valley
of southeastern Cochise County.
C H I R I C A H U A C OMMU N I TY
H E A L TH C E N TE R S
E L F R I D A , AZ 8 5 6 1 0
ORHP Contact:
PROJECT SUMMARY
L ILLY SMETANA
PROJECT OFFICER
T he Sulphur Springs Valley Health Care Consortium is a group of rural
HRSA/ORHP
school districts (Elfrida, Double Adobe, Ash Creek, Cochise, McNeal
5600 F ISHERS L ANE
and Pearce) and a federally qualified community health center
(Chiricahua Community Health Centers) dedicated to providing
301-443-6884
LSMETANA@ HRSA. GOV
primary dental and medical care to the students and their families. T he
plan is to dace CCHCI’s Mobile Dental Unit at each school to provide full dental treatment plans for
eligible students. T he 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.
T he 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.
T he unit is equipped to provide both dental and medical services.
T he 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.
ARIZONA
Sulphur Springs Valley Health Care Consortium
ARKANS AS
Mainline Health Systems, Inc.
TOPIC AREAS
Primary Care, Health promotion/disease prevention (general), Social
services
PROJECT PERIOD
May 1, 2003 – April 30, 2005
Program Director
B ETTY GAY SHULER
MAINLINE H EALTH SYSTEMS , I NC.
P.O. B OX 100
PORTLAND, ARKANSAS 71663
PHONE : (870) 737-2737
F AX : (870) 737-4337



Year 1 - 200,000.00
Year 2 - 199,699.00
Year 3 - 200,000.00
T he network partners are Mainline Health Systems, Inc, the lead
applicant, Baptist Health, Ashley County Medical Center, Delta
Counseling Services, Ashley County Health Department, SeArk
Abuse Center, Delta Health Education Commission, Ashley County
Department of Human Services, and the Area Agency on Aging.
AREAS SERVED
Ashley County is a Medically Underserved Area, and Fountain Hill is
a Health Professional Shortage Area
MAINLINE H EALTH SYSTEMS , I NC.
PORTLAND, AR 71663
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he target population is all residents of Ashley County, from infants
through geriatric, with a focus on low-income, uninsured, and elderly residents as well as the growing
Hispanic population; more than 50 percent of the target population is uninsured).
PROJECT SUMMARY
T he Outreach project for Ashley County will provide comprehensive health services to residents of
Ashley County, Arkansas, one of the poorest counties in the United States. T he services include acute
and chronic medical care, disease screening, laboratory services, X-ray, preventative services, education,
socioeconomic assistance, and outreach. T he target population is all residents of Ashley County, from
infants through geriatric, with a focus on low-income, uninsured, and elderly residents as well as the
growing Hispanic population; more than 50 percent of the target population is uninsured). Fountain Hill,
the location of the Mainline Clinic, has had no physician for more than 20 years, and the area is in
desperate need of accessible and affordable medical and dental care. T he target population in Ashley
County is 70 percent Caucasian, 29 percent African American, and 1 percent Hispanic. T he service area
has a poverty rate of 21 percent.
Access barriers include lack of public transportation, language barriers for the Hispanic population,
cultural barriers, a large uninsured population, a high poverty rate, and disparity in oral services between
the rural area and the general population. Ashley County is a Medically Underserved Area, and Fountain
Hill is a Health Professional Shortage Area.
T he network partners are Mainline Health Systems, Inc, the lead applicant, Baptist Health, Ashley County
Medical Center, Delta Counseling Services, Ashley County Health Department, SeArk Abuse Center,
ARKANS AS
Mainline Health Systems, Inc.
Delta Health Education Commission, Ashley County Department of Human Services, and the Area
Agency on Aging.
ARKANS AS
Stuttgart Regional Medical Center
Program Director
TOPIC AREAS
Childhood development
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JANA C OLEMAN
STUTTGAR T R EGIONAL MEDICAL
C ENTER
P.O. B OX 1905
STUTTGAR T, ARKANSAS 72160
PHONE : (870) 672-6841
F AX : (870) 672-6821



Year 1 - 199,713.00
Year 2 - 199,713.00
Year 3 - 190,717.00
T he network partners are the Stuttgart Regional Medical Center, the
lead applicant, Easter Seals of Arkansas, and the Arkansas County
Department of Health. T he Stuttgart Regional Medical Center will
operate the sick childcare center. Easter Seals offers pediatric
outpatient services at the Stuttgart Regional Medical Center. T he
Arkansas County Department of Health will assist with
developmental screenings for children.
AREAS SERVED
Corner of Arkansas and includes the counties of Arkansas, Jefferson,
Lonoke, Monroe, Phillips, and Prairie which are designated as a
Health Professional Shortage Area.
STUTTGAR T R EGIONAL MEDICAL
C ENTER
STUTTGAR T, AR 72160
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he Early Childhood Development Center of Southeast Arkansas will
promote early identification of children at risk for developmental delays or children who may not be
developing appropriately, and will provide health care access to therapies that will help children reach
developmental milestones to the best of their abilities.
PROJECT SUMMARY
T he Early Childhood Development Center of Southeast Arkansas will promote early identification of
children at risk for developmental delays or children who may not be developing appropriately, and will
provide health care access to therapies that will help children reach developmental milestones to the best
of their abilities. T he Early Childhood Development Center will serve children age 6 weeks to 5 years
(children with and without disabilities, children with mild illnesses, and children who need childcare
services outside the traditional hours provided at childcare facilities). T he children in the service area,
which is the southeast corner of Arkansas and includes the counties of Arkansas, Jefferson, Lonoke,
Monroe, Phillips, and Prairie, are at higher risk for developmental delays that in other parts of the state as
the result of high teen fertility rates, lack of first trimester care, and low birth weight babies. T he target
population is 75.2 percent Caucasian, 23.4 percent African American, 0.8 percent Hispanic, 0.4 percent
Asian/Pacific Islander/Alaska Native, and 0.2 percent American Indian.
Access barriers to services include poverty (approximately 1 in 5 in the service area lives below the
poverty level), low educational levels, and indicators for potential disabilities and developmental
problems. T he service area is designated as a Health Professional Shortage Area.
ARKANS AS
Stuttgart Regional Medical Center
T he network partners are the Stuttgart Regional Medical Center, the lead applicant, Easter Seals of
Arkansas, and the Arkansas County Department of Health. T he Stuttgart Regional Medical Center will
operate the sick childcare center. Easter Seals offers pediatric outpatient services at the Stuttgart Regional
Medical Center. T he Arkansas County Department of Health will assist with developmental screenings
for children.
ARKANS AS
Arkansas River Valley Rural Health Cooperative, Inc.
TOPIC AREAS
Health promotion/disease prevention (general), Pharmaceutical
services, T elemedicine technology, Chronic pain management
PROJECT PERIOD
May 1, 2003 – April 30, 2005
Program Director
B OB R EDFORD
ARKANSAS R IVER VALLEY R URAL
H EALTH C OOPERATIVE , I NC.
P.O. B OX 208
R ATCLIFF, ARKANSAS 72951
PHONE : (479) 635-4400
F AX : (479) 635-0561



Year 1 - 200,000.00
Year 2 - 181,863.00
Year 3 - 139,355.00
T he network partners are the Arkansas River Valley Health
Cooperative, Inc., the lead applicant, and four rural hospitals in the
tri-county area: Mercy Hospital, North Logan Mercy Hospital,
Booneville Community Hospital, and Mercy Hospital of Scott
County.
AREAS SERVED
Franklin, Logan, and Scott counties in west-central Arkansas.
T o improve the health and quality of life for residents.
ARKANSAS R IVER VALLEY R URAL
H EALTH C OOPERATIVE , I NC.
R ATCLIFF, AR 72951
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Arkansas River Valley Rural Health Cooperative was established
to improve the health and quality of life for residents of Franklin, Logan, and Scott counties in westcentral Arkansas through improved access to health care services, health education, and chronic disease
management. T he Cooperative has developed a model program for rural community-based health care
(Community HealthLink Program) that includes a Health Care Access Program; Prescription Drug
Assistance Program; Health Education and Promotion Program; Telecommunications Programs; and
Chronic Disease Management Program.
T he target population of adults is 96 percent Caucasian, 1.5 percent Hispanic, 1 percent African
American, and 1 percent American Indian. Approximately 20 percent of the residents live on incomes
below the Federal poverty level, and about one-half live on incomes below 200 percent of the poverty
level. Access barriers to services include lack of insurance among non-elderly adults (23 percent); four
regional hospitals that are struggling to keep their doors open; an inability to obtain needed prescription
drugs, which affects the elderly and non-elderly; a high rate of chronic disease; and a great need for health
education and promotion services to encourage healthy lifestyles. T he entire tri-county area has been
designated a Medically Underserved Area, and two of the three counties (Logan and Scott) are designated
Health Professional Shortage Areas.
T he network partners are the Arkansas River Valley Health Cooperative, Inc., the lead applicant, and four
rural hospitals in the tri-county area: Mercy Hospital, North Logan Mercy Hospital, Booneville
Community Hospital, and Mercy Hospital of Scott County.
ARKANS AS
Arkansas River Valley Rural Health Cooperative, Inc.
ARKANS AS
White River Rural Health Center, Inc.
Program Director
TOPIC AREAS
Chronic illness, Diabetes
PROJECT PERIOD
May 1, 2005 – April 30, 2007
STEVEN F. C OLLIER
W HITE R IVER R URAL H EALTH
C ENTER, I NC.
P.O. B OX 497
AUGUSTA, ARKANSAS 72006-0497
PHONE : (870) 347-2534
F AX : (870) 347-2882



Year 1 - 162,765.00
Year 2 - 167,648.00
Year 3 - 172,677.00
T he 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.
Expand an existing chronic illness self-management education
program to focus on the elderly
W HITE R IVER R URAL H EALTH
C ENTER, I NC.
AUGUSTA, AR 72006-0497
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
EHOLLORAN@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he 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. T he 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. T he 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. T he 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
ARKANS AS
White River Rural Health Center, Inc.
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.
T he 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.
ARKANS AS
Ozark Mountain Health Network: Faith and School Rural Outreach:
Reach Out and Connect
Program Director
TOPIC AREAS
Chronic Disease
PROJECT PERIOD
May 1, 2007 – April 30, 2010



C INDY MILLER
OZARK H EALTH F OUNDATION
P.O. B OX 74
2500 H IGHWAY 65 SOUTH
C LINTON, AR
501-510-7004, EXT. 102
F AX –501-745-4203
CINDY . MILLER@ MYOZARKHEALTH. COM
Year 1 - 150,000.00
Year 2 - 181,944.00
Year 3 - 115,297.00
T he 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.
Community health center, rural health clinics, federally qualified
health center, nursing shortage area, state, and local health
departments.
O Z A R K M OU N TA I N H E A L TH
N E TW OR K
C L I N TON , AR 7 2 0 3 1
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
EILEEN. HOLLORAN@ HRSA. HHS . GOV
PROJECT SUMMARY
T he project focuses on primary care and wellness and disease
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.
T he 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. T hese 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.
CALIFORN IA
Lake County Tribal Health, Inc.
Program Director
TOPIC AREAS
Diabetes, Health promotion/disease prevention (general),
T elemedicine technology
PROJECT PERIOD
May 1, 2003 – April 30, 2005
ANNIE B ARNES
L AKE C OUNTY TRIBAL H EALTH, I NC.
925 B EVINS C OURT
P.O. B OX 1950
L AKEPORT, C ALIFORNIA 95453
PHONE : (707) 263-8382, EXT. 134
F AX : (707) 263-0329



Year 1 - 170,000.00
Year 2 - 170,000.00
Year 3 - 170,000.00
T he network partners are Lake County T ribal Health Consortium,
Inc., the lead applicant, the California Human Development
Corporation, Latino Coalition, and Middletown United Methodist
Church.
AREAS SERVED
T he service area is a designated Health Professional Shortage Area.
Lake County has been designated as one of the 786 most Medically
Underserved Areas in the United States.
L AKE C OUNTY TRIBAL H EALTH, I NC.
L AKEPORT, CA 95453
ORHP Contact:
T o provide access for farmworkers and at risk for type 2 diabetes and
their families (Native American, Latino, and African American/Older
Anglo). All other low-income uninsured or underinsured Lake
County residents identified with type 2 diabetes, especially older
Anglos.
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he “ Reach Out” project is a multi-cultural program designed to assist the residents of Lake County,
California in managing type 2 diabetes with education on nutrition, exercise, medication, case
management, and regular check-ups. T he “ Reach Out” project will have a mobile clinic unit to provide
access for farmworkers and will hire three promotores for each of the target populations identified with or
at risk for type 2 diabetes and their families (Native American, Latino, and African American/Older
Anglo). All other low-income uninsured or underinsured Lake County residents identified with type 2
diabetes, especially older Anglos, also will be recruited for the project. A telehealth unit will be added to
the project in Year 2.
Diabetes is the most common health problem in the African American, Latino, and Native American
population of Lake County, increasing from 9 percent to 15 percent in 2001. The population of Lake
County has a number of unmet needs. Approximately one-third of all children under age 5 reside in
families living under the poverty level. In addition, Lake County has double-digit unemployment, a high
rate of alcohol and substance abuse, and a high rate of crime, including a disproportionate number of
tribal children who are the victims of child abuse. T he target population for the “Reach Out” project in
Lake County is 34 percent American Indian, 33 percent African American, and 33 percent Hispanic.
CALIFORN IA
Lake County Tribal Health, Inc.
Access barriers to services in Lake County include poverty, rural isolation, lack of transportation,
language and communication barriers, distrust of government and state agencies and services, and a high
rate of residents who are uninsured or underinsured (60 percent). T he service area is a designated Health
Professional Shortage Area. Lake County has been designated as one of the 786 most Medically
Underserved Areas in the United States.
T he network partners are Lake County T ribal Health Consortium, Inc., the lead applicant, the California
Human Development Corporation, Latino Coalition, and Middletown United Methodist Church.
CALIFORN IA
Northern Sierra Rural Health Network
Program Director
TOPIC AREAS
Anger management/behavioral health, Chronic pain management,
T elemedicine technology, Social services
PROJECT PERIOD
May 1, 2003 – April 30, 2005
L IZ MANTLE
N ORTHERN SIERRA R URAL H EALTH
N ETWORK
700 Z ION STREET, SUITE E
N EVADA C ITY , C ALIFORNIA 95959
PHONE : (530) 470-9091
F AX : (530) 470-9094



Year 1 - 194,630.00
Year 2 - 194,051.00
Year 3 - 181,186.00
T he network partners are the Northern Sierra Rural Health Network,
the lead applicant, T rinity Hospital Primary Care Clinic, Big Valley
Health Center, and Plumas District Hospital Rural Health Clinic.
AREAS SERVED
Residing in the three frontier communities of Bieber (Lassen County),
Quincy (Plumas County), and Weaverville (Trinity County) in
northeastern California.
T he target population for project services is seniors with behavioral
health problems (1,775) and persons with chronic pain (2,000).
N ORTHERN SIERRA R URAL H EALTH
N ETWORK
N EVADA C ITY , CA 95959
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Regional Quality of Life Project seeks to improve the health
status and the quality of life for seniors with behavioral health
problems and for persons with chronic pain by expanding their access
to integrated behavioral health care services (behavioral health problems range from diagnosable mental
illness to the need to improve health through a change in lifestyle such as obesity, smoking or chronic
disease management). To accomplish project goals, the network will place behavioral health consultants
at each of the network member sites; use its existing telehealth network to conduct clinical training for
primary care providers and behavioral health consultants and provide psychiatric services to the target
population; and provide training and technical assistance to the primary care sites.
T he target population for project services is seniors with behavioral health problems (1,775) and persons
with chronic pain (2,000) residing in the three frontier communities of Bieber (Lassen County), Quincy
(Plumas County), and Weaverville (Trinity County) in northeastern California. The target population is
82 percent Caucasian, 10 percent Hispanic, 7 percent African American, 0.8 percent Asian/Pacific
Islander/Alaska Native, and 0.2 percent American Indian. Access barriers to services include the lack of
trained behavioral health providers, the lack of mental health resources, and the lack of coordination
between county services and the primary care providers. Weaverville is designated a Mental Health
Professional Shortage Area and a Dental Health Professional Shortage Area. Lassen County is designated
a Health Manpower Shortage Area with a Medically Underserved Population.
CALIFORN IA
Northern Sierra Rural Health Network
T he network partners are the Northern Sierra Rural Health Network, the lead applicant, T rinity Hospital
Primary Care Clinic, Big Valley Health Center, and Plumas District Hospital Rural Health Clinic.
CALIFORN IA
Mendocino County Health Department
Program Director
TOPIC AREAS
Substance Abuse, Prevention Education
PROJECT PERIOD
May 1, 2005 – April 30, 2007
N ED W ALSH
MENDOCINO C OUNTY H EALTH
D EPARTMENT
1120 SOUTH D ORA STREET
U KIAH, C ALIFORNIA 95482-6340
PHONE : (707) 472-2637
F AX : (707) 472-2658



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Adolescent Drug Abuse Prevention and T reatment Project (ADAPT)
AREAS SERVED
Mendocino County, which is designated as a Medically Underserved
Population.
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.
MENDOCINO C OUNTY H EALTH
D EPARTMENT
U KIAH, C A 95482-6340
ORHP Contact:
K RISTIN MARTINSEN
PROJECT SUMMARY
PROJECT OFFICER
T he Mendocino County Health Department and its partners
HRSA/ORHP
developed the Adolescent Drug Abuse Prevention and T reatment
5600 F ISHERS L ANE
Project (ADAPT) in response to the need for substance abuse
301-594-4438
prevention and treatment services for rural youth in northern
California. ADAPT will team a substance abuse therapist ADAPT
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. T he 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 highrisk 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
CALIFORN IA
Mendocino County Health Department
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.
CALIFORN IA
Tulare Local Healthcare District
Program Director
TOPIC AREAS
Mobile clinic, T elehealth technology, Primary care services,
Specialist consultation
PROJECT PERIOD
May 1, 2006 – April 30, 2008
D AWN K. W ELLS
TULARE L OCAL H EALTHCARE D ISTRICT
869 N. C HERRY STREET
TULARE , CA 93274
PHONE : (559) 685-3424
F AX : (559) 685-3835
E-MAIL: DWELLS @TDHS . ORG



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T ulare Local Healthcare District (Tulare District Hospital, T DH) is
the lead agency of a consortium composed of T ulare Community
Health Clinic (a Federally Qualified Health Center), public health
nurses from T ulare County Office of Education's Migrant Education
Program, T ulare 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 T ulare County, which is located in the
Central Valley of California.
T he purpose of the Mobile Clinic/T elehealth Outreach Project is to
provide primary health care services and specialist consults, including
dental services, to underserved residents in rural T ulare County
TULARE L OCAL H EALTHCARE D ISTRICT
TULARE , CA 93274
ORHP Contact:
SHERILYN PRUITT
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-0819
SPRUITT@ HRSA. GOV
PROJECT SUMMARY
T ulare Local Healthcare District (Tulare District Hospital, T DH) is the lead agency of a consortium
composed of T ulare Community Health Clinic (a Federally Qualified Health Center), public health nurses
from T ulare 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).
T hese partners formed this consortium to address the lack of basic healthcare available in the rural,
impoverished areas of Alta Vista and Pixley in T ulare County, which is located in the Central Valley of
California. T he purpose of the Mobile Clinic/T elehealth Outreach Project is to provide primary health
care services and specialist consults, including dental services, to underserved residents in rural T ulare
County. T DH will visit each site once a week, on a set schedule, bringing health care directly to the
community in a Mobile Health Clinic. T elehealth Monitors placed at each school site will provide live
access to the nurse practitioner on the Mobile Clinic, Monday through Friday.
T he 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
CALIFORN IA
Tulare Local Healthcare District
Professional Shortage Areas. (Alta Vista is in an unincorporated region east of Porterville, MSSA
231/232.)
T he focus of the Mobile Clinic/T elehealth 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 T ulare Community Health Clinic. Public health nurses from T ulare 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.
T ulare 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. T he target population is
Hispanic agricultural workers and their families. T he 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 T ulare 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.
T he Mobile Clinic/T elehealth 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. T ulare 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.
CALIFORN IA
Lindsay Unified School District
Program Director
TOPIC AREAS
Health insurance enrollment, Primary care, Dental care, Case
management
PROJECT PERIOD
May 1, 2006 – April 30, 2008
JANIE ELSON
L INDSAY U NIFIED SCHOOL D ISTRICT
475 E. H ONOLULU
L INDSAY , CA 93247
PHONE : (559) 562-5974
E-MAIL: JCELSON@LINDSAY . KL2. CA. US



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Lindsay and Woodlake school district Healthy Start and Family
Resource Centers and the Children’s Health Initiative coalition
through First 5 T ulare 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.
T o provide a comprehensive continuum of health care service for
uninsured children.
L INDSAY U NIFIED SCHOOL D ISTRICT
L INDSAY , CA 93247
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he Rural Health Services Outreach Grant for T ulare County’s Children’s Health Initiative specifically
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 T ulare. Lindsay and
Woodlake school district Healthy Start and Family Resource Centers and the Children’s Health Initiative
coalition through First 5 T ulare 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.
T he T ulare 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.
CALIFORN IA
Lindsay Unified School District
T he 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.
T hese children will qualify for the new Healthy Kids program. Referral appointments from the school eDental 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 FT E Certifed 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
identifed by the e-Dental and other health providers to be accessed. First 5 T ulare County will subsidize
Healthy Kids premium costs for children ages 0-5.
CALIFORN IA
Avalon Medical Development Corporation
Program Director
TOPIC AREAS
Satellite clinic, Bilingual specialty services, T elemedicine technology,
Substance abuse treatment
PROJECT PERIOD
May 1, 2006 – April 30, 2008



D AWN SAMPSON
AVALON MEDICAL D EVELOPMENT
C ORPORATION
C ATALINA I SLAND MEDICAL C ENTER
100 F ALLS C ANYON R OAD
P.O. B OX 1563
AVALON, CA 90704
PHONE : (310) 510-0520
F AX : (310) 510-2381
Year 1 - 149,120.00
Year 2 - 124,238.00
Year 3 - 94,942.00
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 T wo Harbors Enterprises, will utilize creative outreach
models to bring primary care services through a satellite clinic to the
remote island community of T wo Harbors.
AREAS SERVED
City of Avalon
Services will especially benefit the medically fragile and low-income
island residents.
AVALON MEDICAL D EVELOPMENT
C ORPORATION
AVALON, CA 90704
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
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. T here are 3,127 year-round
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. T he current needs
to be addressed with this project are as follows:

T he 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. T o reach
CIMC, located in the main city of Avalon for primary care, residents of the West End must travel the
CALIFORN IA
Avalon Medical Development Corporation


23 mile, 1.25-hour trip over mountainous terrain and partially paved roads. T o reach a mainland
facility they must travel at least 1 hour by boat, then find ground transportation. T he 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).
T here 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 lowincome 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
T wo Harbors Enterprises, will utilize creative outreach models to bring primary care services through a
satellite clinic to the remote island community of Two Harbors. T he 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.
CALIFORN IA
Sickness Prevention Achieved Through Regional Collaboration, Inc.
TOPIC AREAS
Geriatric care, Health screening, Health promotion/disease
prevention (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
R ICHARD B ENSER
SICKNESS PREVENTION ACHIEVED
THROUGH R EGIONAL
C OLLABORATION, I NC.
318 MAIN STREET
P.O. B OX 746
L AKEVILLE , C ONNECTICUT 06039
PHONE : (860) 435-2896
F AX : (860) 435-8193
Year 1 - 198,476.00
Year 2 - 196,259.00
Year 3 - 194,883.00
T he network partners are the Sickness Prevention Achieved through
Regional Collaboration, Inc., the lead applicant, the Community
Health Center of the Berkshires, Charlotte Hungerford Hospital,
Dutchess County Department of Health, Torrington Health District
Public Health Agency, Sharon Hospital, and Lee Regional Visiting
Nursing Agency.
AREAS SERVED
Berkshire County, Massachusetts; Dutchess County, New York; and
Litchfield County, Connecticut
T he target population is dedicated to increasing the delivery of
primary prevention services for residents above 50 in a rural threecounty New England area.
PROJECT SUMMARY
T he Sickness Prevention Achieved through Regional Collaboration
(SPARC) network is dedicated to increasing the delivery of primary
prevention services for residents above 50 in a rural three-county
SICKNESS PREVENTION ACHIEVED
THROUGH R EGIONAL
C OLLABORATION, I NC.
L AKEVILLE , CT 06039
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
New England area. Interventions include flu shots, pneumococcal immunizations (PPV), mammograms,
colorectal cancer (CRC) screening, and screening for cardiovascular disease. T he goal of the project is to
develop a preventive service model that increases the delivery of the interventions while reinforcing the
need for follow-up at the medical home.
T he target population is men and women age 50 and older residing in Berkshire County, Massachusetts;
Dutchess County, New York; and Litchfield County, Connecticut. T he region’s population is
approximately 130,000, of whom 25 percent are older than age 50. T he racial mix of the region is
Caucasian (97 percent), African American (2 percent), and Hispanic (1 percent). Access barriers to
services include uncertainty among community residents of the benefits and availability of immunization
and disease screening; disagreement among providers regarding current guidelines for preventive service
delivery; a smaller number of physicians per 100,000 population than elsewhere in Connecticut; increased
distance between medical practitioners and patients; a relative lack of public transportation; a thinner
network of social support; and inclement weather that isolates the elderly and the frail during flu shot
CALIFORN IA
Sickness Prevention Achieved Through Regional Collaboration, Inc.
season.
T he network partners are the Sickness Prevention Achieved through Regional Collaboration, Inc., the lead
applicant, the Community Health Center of the Berkshires, Charlotte Hungerford Hospital, Dutchess
County Department of Health, Torrington Health District Public Health Agency, Sharon Hospital, and
Lee Regional Visiting Nursing Agency.
CONNECTIC UT
Save Smiles Oral Health Project
Program Director
TOPIC AREAS
Oral Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010



D R. MARGARET ANN SMITH, DMD
GENERATIONS F AMILV H EALTH C ENTER.
I NC.
1315 MAIN STREET - SUITE 2
W ILLIMANTIC, CT 06226-1953
860-450-7471, EXT. 132
F AX – 860-450-7475
MARGARET. ANN. SMITH@ PENERNCO. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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.
Preschool/school-aged children and young pregnant women.
G E N E R A TI ON S F A MI L V H E A L TH
C E N TE R . I N C .
W I L L I MA N TI C , C T 0 6 2 2 6 - 1 9 5 3
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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
county in Connecticut. Windham’s population is 55% Hispanic; 45% of the Hispanic population is
uninsured. T hirty-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. T here are no pediatric or dental specialists in
the area who accept Medicaid. Since 1994, Windham has been a designated dental shortage area.
T he 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;
CONNECTIC UT
Save Smiles Oral Health Project






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.
D ELAWARE
La Red Health Center
Program Director
TOPIC AREAS
Prenatal Services
PROJECT PERIOD
May 1, 2005 – April 30, 2007
B RIAN OLSON
L A R ED H EALTH C ENTER
505-A W EST MARKET STREET
GEORGETOWN, D ELAWARE 199472321
PHONE : (302) 855-1233
F AX : (302) 855-1020



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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
T he target population includes underserved and vulnerable pregnant
women.
L A R ED H EALTH C ENTER
GEORGETOWN, D ELAWARE 199472321
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
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 management model developed to
facilitate access to medical care in underserved communities. T he 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.
T he 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. T he entire county is federally designated as a Medically
Underserved Area, a low-income Health Professional Shortage Area (HPSA), and a dental HPSA. T he
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. T his trend, combined with limited provider
availability, compounds the problem of early access to care. T hus, there is a tremendous need for
LRHC’s prenatal services.
T o 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
D ELAWARE
La Red Health Center
capacity for the prenatal program will be doubled and complemented by an aggressive campaign of
community education urging early entry to care.
FLORIDA
Guidance Clinic of the Middle Keys
Program Director
TOPIC AREAS
Primary care, Mental health, Homeless
PROJECT PERIOD
May 1, 2005 – April 30, 2007
JAMIE THOMAS PIPHER
GUIDANCE C LINIC OF THE MIDDLE K EYS
3000 41ST STREET, OCEANSIDE
MARATHON, F LORIDA 33050
PHONE : (305) 289-6150
F AX : (305) 289-6158



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners are the Guidance Clinic of the Middle Keys,
Inc., the lead applicant, and a service organization that has been
providing mental health and substance abuse services in Monroe
County for almost 30 years, Catholic Charities of the Archdiocese of
Miami, Inc., and the Rural Health Network of Monroe County,
Florida, Inc.
AREAS SERVED
Monroe County
T he target population of homeless persons residing in Monroe
County.
GUIDANCE C LINIC OF THE MIDDLE K EYS
MARATHON, FL 33050
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he St. Clare’s Clinic program will provide an onsite mental health and primary care clinic for the
homeless population in Monroe County, Florida. As part of the program, the Guidance Clinic of the
Middle Keys will provide weekly, onsite psychiatric services at St. Clare’s Clinic in Key West, and the
Rural Health Network of Monroe County will provide outpatient primary care (three times per week) at
St. Clare’s Clinic.
T he target population of homeless persons residing in Monroe County is estimated at more than 2,000.
Of the total homeless population, it is estimated that 43 percent suffer from substance abuse, 23 percent
from mental health issues, 27 percent are dually diagnosed, 29 percent have a disability, and 55 percent
have health needs. T he target population is 78.3 percent Caucasian, 15.9 percent Hispanic, 4.5 percent
African American, 0.65 percent American Indian, and 0.65 percent Asian/Pacific Islander/Alaska Native.
Access barriers to services for the homeless population in Monroe County include the high cost of living
and housing that, when combined with low-paying service sector jobs, frequently results in evictions and
homelessness; the difficulty in securing qualified medical professionals to address the health care needs of
the homeless population; and the lack of health insurance. Monroe County has been designated by the
Florida Department of Health as a Medically Underserved Area with a Medically Underserved
Population.
FLORIDA
Guidance Clinic of the Middle Keys
T he network partners are the Guidance Clinic of the Middle Keys, Inc., the lead applicant, and a service
organization that has been providing mental health and substance abuse services in Monroe County for
almost 30 years, Catholic Charities of the Archdiocese of Miami, Inc., and the Rural Health Network of
Monroe County, Florida, Inc.
FLORIDA
Lake Okeechobee Rural Health Network
TOPIC AREAS
Geriatric, T elehealth, Pharmacy program
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
MOLLY F ERGUSON
L AKE OKEECHOBEE R URAL
H EALTH N ETWORK
185 US H IGHWAY 27 SOUTH
P.O. B OX 881
SOUTH B AY , F LORIDA 33493
PHONE : (561) 993-1269
F AX : (561) 993-1271
Year 1 - 199,870.00
Year 2 - 199,788.00
Year 3 - 199,751.00
T he network partners are the Lake Okeechobee Rural Health
Network, the lead applicant, Florida Community Health Centers, T he
Palm Beach County Health Department/C.L. Brumback Health
Center, Ameri-Tech Institute, T ele-Homecare, American Red Cross,
Western Palm Beach County Mental Health Clinic, Mobile Path
Services, Inc., and the Everglades Area Health Education Center, Inc.
AREAS SERVED
Lake Okeechobee in South Central Florida
T he senior population in five rural counties surrounding Lake
Okeechobee in South Central Florida.
L AKE OKEECHOBEE R URAL
H EALTH N ETWORK
SOUTH B AY , FL 33493
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Senior Health And Resource Partnership (SHARP) model program will serve the senior population in
five rural counties surrounding Lake Okeechobee in South Central Florida. Services. Project activities
include the development of (1) a pilot using mobile telemedical services and the Internet to improve local
access and relay information to physicians for diagnosis and treatment of diseases; (2) a Pharmacy
Assistance Program, which will increase the availability and use of medications; and (3) a system for
coordinating all senior services in the five-county area.
T he target population is 20,000 seniors (60+) in the five county service area of the Lake Okeechobee
Rural Health Network, of whom 70 percent are on some type of assistance through local, state or Federal
programs. T he target population is 40 percent African American, 25 percent Caucasian, 25 percent
Hispanic, 5 percent American Indian, and 5 percent Asian/Pacific Islander/Alaska Native. Access
barriers for the population include low income level, limited specialists of geriatric care, very limited
public transportation, limited access to pharmaceutical services, and a weak support system infrastructure
for senior citizens. T he service area is designated as a Health Professional Shortage Area.
T he network partners are the Lake Okeechobee Rural Health Network, the lead applicant, Florida
Community Health Centers, The Palm Beach County Health Department/C.L. Brumback Health Center,
Ameri-T ech Institute, T ele-Homecare, American Red Cross, Western Palm Beach County Mental Health
Clinic, Mobile Path Services, Inc., and the Everglades Area Health Education Center, Inc.
FLORIDA
Lake Okeechobee Rural Health Network
FLORIDA
Nassau County Health Department
Program Director
TOPIC AREAS
Primary care, Mental health, Consumer health education (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
E.J. N GO-SEIDEL
N ASSAU C OUNTY H EALTH
D EPARTMENT
P.O. B OX 517
F ERNANDINA B EACH, F LORIDA 32035
PHONE : (904) 277-7287 EXT. 230
F AX : (904) 277-7286



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he service network includes the Nassau County Health Department,
two Jacksonville-based medical centers (Baptist Medical CenterNassau and St. Vincent’s Hospital of Jacksonville), and the county’s
only community mental health and substance abuse treatment agency
(Sutton Place Behavioral Health, Inc.).
AREAS SERVED
Rural Nassau County in the northeast corner of Florida.
Primary care and mental health services to chronically ill, lowincome, uninsured, and medically underserved adults.
N ASSAU C OUNTY H EALTH
D EPARTMENT
F ERNANDINA B EACH, FL 32035
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Western Nassau County Healthcare Linkages Project is a four-member partnership that proposes to
bring primary care and mental health services to chronically ill, low-income, uninsured, and medically
underserved adults in rural Nassau County in the northeast corner of Florida. A Health Professional
Shortage Area with only one hospital, the region’s population is 76 percent Caucasian, 11 percent African
American, and 10 percent Hispanic. Of the area’s households, 21 percent have an annual income under
$15,000. Nassau County’s mortality rates in 11 of the 12 leading causes of death exceed state averages,
and a significant number of deaths in the county are premature and preventable. Uninsured county
residents are often unemployed, do not use preventive health services, and lack access to transportation to
medical facilities. In addition, there is limited support for adult mental health services in the area to
address depression and substance abuse issues.
T he Western Nassau County Healthcare Linkages Project will expand the activities of the existing Rural
Health Outreach program, which has been in place since 1999, to additional outreach sites and services in
the western part of the county. Van-delivered primary care services will travel to the county’s more
remote population pockets. T he primary care, laboratory, pharmaceutical, and inpatient/outpatient
hospital components of the existing program will expand to include the new project. T he project aims to
address mental health, substance abuse, and chronic disease management; offer medical specialty
consultation and dental and vision services; and provide consumer health education, including
nutrition/weight management counseling and diabetes education. T elehealth technology also will be
FLORIDA
Nassau County Health Department
developed. T he service network includes the Nassau County Health Department, two Jacksonville-based
medical centers (Baptist Medical Center-Nassau and St. Vincent’s Hospital of Jacksonville), and the
county’s only community mental health and substance abuse treatment agency (Sutton Place Behavioral
Health, Inc.).
FLORIDA
Big Bend Rural Health Network
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2003 – April 30, 2005
R OB L OMBARDO
B IG B END R URAL H EALTH N ETWORK
9601-54 MICCOSUKEE R OAD
TALLAHASSEE , F LORIDA 32309
PHONE : (850) 877-6414
F AX : (850) 878-7677



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners are the Big Bend Rural Health Network, the
lead applicant, Gadsden Community Hospital, Doctor’s Memorial
Hospital, Madison County Memorial Hospital, Gadsden County
Health Department, Jefferson and Madison County Health
Departments, Taylor County Health Department, Wakulla County
Health Department, the Diabetes Center at TMH, Madison Memorial
Healthcare Center, and the Area Health Education Center.
AREAS SERVED
Gadsden, Jefferson, Madison, T aylor, and Wakulla, northern
T o provide a rural diabetes outreach and education program to reach
populations suffering from poverty, lack of insurance and regular
medical care, and high death rates attributed to diabetes.
B IG B END R URAL H EALTH N ETWORK
TALLAHASSEE , FL 32309
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Big Bend Rural Health Network will provide a rural diabetes outreach and education program to
reach populations suffering from poverty, lack of insurance and regular medical care, and high death rates
attributed to diabetes in five rural counties in northern Florida (Gadsden, Jefferson, Madison, T aylor, and
Wakulla). More than 7,000 persons with diabetes are estimated to live in the five counties, which have a
total population of 118,841 residents. T he target population is 50 percent Caucasian, 48 percent African
American, and 2 percent Hispanic. Medicare data indicate a significant disparity in access to treatment
for African Americans in the region.
Access barriers to services include rates of uninsurance that are higher than the state average, low per
capita income, lack of transportation (25 percent of the adult population does not have access to a car),
language and cultural differences that affect comprehension of the health education message, a lack of
sufficient educational or cultural reinforcement of the importance of regular medical care, and the absence
of trained diabetes educators or community diabetes education programs. All five counties in the service
area are designated as Health Professional Shortage Areas.
T he network partners are the Big Bend Rural Health Network, the lead applicant, Gadsden Community
Hospital, Doctor’s Memorial Hospital, Madison County Memorial Hospital, Gadsden County Health
Department, Jefferson and Madison County Health Departments, Taylor County Health Department,
FLORIDA
Big Bend Rural Health Network
Wakulla County Health Department, the Diabetes Center at T MH, Madison Memorial Healthcare Center,
and the Area Health Education Center.
FLORIDA
Rural Health Network of Monroe Co., FL, Inc.
Program Director
TOPIC AREAS
Primary care, Mental health services, Substance abuse treatment,
Dental care
PROJECT PERIOD
May 1, 2006 – April 30, 2008
MARK L EE SZUREK, PH.D.
R URAL H EALTH N ETWORK OF MONROE
C O., FL, I NC.
P.O. B OX 4966
K EY W EST, FL 33041



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
Comprehensive health care program targeted to the uninsured and
homeless.
R URAL H EALTH N ETWORK OF MONROE
C O., FL, I NC.
K EY W EST, FL 33041
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he 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.
T his 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.
FLORIDA
Rural Health Network of Monroe Co., FL, Inc.
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. T he 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. T his project is the first
merger of its kind in county history, bringing together a for-profit hospital/primary care service, not-forprofit mental health and substance abuse care and not-for-profit primary and dental care.
G EORGIA
Ware County Board of Health
Program Director
TOPIC AREAS
Pre/peri/postnatal care
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JOHN H OLLOWAY
W ARE C OUNTY B OARD OF H EALTH
1101 C HURCH STREET
W AYCROSS , GEORGIA 31501
PHONE : (912) 285-6002
F AX : (912) 284-2980



Year 1 - 198,798.00
Year 2 - 192,245.00
Year 3 - 192,877.00
T he network partners are the Ware County Health Department, the
lead applicant, the Health Departments for the six counties in the
network, the Appling HealthCare System, Bacon County Hospital
System, Coffee Regional Medical Center, Jeff Davis Hospital, Satilla
Health Services, Inc., McKinney Community Health Center, South
Central Primary Care Center, Inc., Memorial Health University
Medical Center, Savannah Perinatology, and Southeast Georgia
Regional Perinatal Health Planning Group.
AREAS SERVED
Appling, Atkinson, Bacon, Coffee, Jeff Davis, and Ware counties.
T he target population for the project is women, infants, and children,
who are at high risk of adverse health outcomes such as maternal and
infant mortality, low birth weight or very low birth weight, and
subsequent medical and developmental problems.
W ARE C OUNTY B OARD OF H EALTH
1101 C HURCH STREET
W AYCROSS , GA 31501
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Perinatal Health Partners project is designed to improve health outcomes in six rural Georgia
counties through a perinatal case management model that targets women and babies with more intensive
care coordination needs than categorical prenatal and perinatal care. Services include early identification
of high-risk prenatal births, intensive case management, home visits, onsite rural perinatology clinics and
telehealth services. T he target population for the project is women, infants, and children living in
Appling, Atkinson, Bacon, Coffee, Jeff Davis, and Ware counties who are at high risk of adverse health
outcomes such as maternal and infant mortality, low birth weight or very low birth weight, and
subsequent medical and developmental problems. The target population is 50 percent Caucasian,
25 percent African American, and 25 percent Hispanic.
Access barriers to services include a high unemployment rate (5.8 percent); a high rate of residents who
are uninsured (23.8 percent); low educational levels; significant cultural, linguistic, and legal barriers to
care for the region’s growing Hispanic population; and the lack of public transportation. Five of the six
counties are whole or partial Medically Underserved Areas and low-income or whole county primary care
Health Professional Shortage Areas, and all of the counties are Health Professional Shortage Areas for
mental health.
G EORGIA
Ware County Board of Health
T he network partners are the Ware County Health Department, the lead applicant, the Health Departments
for the six counties in the network, the Appling HealthCare System, Bacon County Hospital System,
Coffee Regional Medical Center, Jeff Davis Hospital, Satilla Health Services, Inc., McKinney
Community Health Center, South Central Primary Care Center, Inc., Memorial Health University Medical
Center, Savannah Perinatology, and Southeast Georgia Regional Perinatal Health Planning Group.
G EORGIA
TenderCare Clinic, Inc.
Program Director
TOPIC AREAS
Health screening, Geriatrics, Health Education
PROJECT PERIOD
May 1, 2003 – April 30, 2005
TEENA L ONG
TENDERC ARE C LINIC, I NC.
803 SOUTH MAIN STREET
GREENSBORO, GEORGIA 30642
PHONE : (706) 453-1200
F AX : (706) 453-1441



Year 1 - 199,540.00
Year 2 - 199,985.00
Year 3 - 199,432.00
T he network partners are T enderCare Clinic, Inc., the lead applicant;
T enderCare Preschool and Daycare Academy; Family Connections;
GMP Health Network; Medical College of Georgia; and University of
Georgia–Athens.
AREAS SERVED
Greene and Putnam counties. Both counties are designated Health
T he Coordinating Care to Achieve Lifestyle and Health Literacy
Modification for Improved Health program will provide culturally
sensitive health education and medical case management services to
target populations that have a low educational attainment level and
exhibit extremely high incidence of ambulatory care sensitive
conditions, including diabetes, hypertension/stroke, CVD/congestive
heart failure, asthma, and clinical depression.
TENDERC ARE C LINIC, I NC.
GREENSBORO, GA 30642
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Coordinating Care to Achieve Lifestyle and Health Literacy Modification for Improved Health
program will provide culturally sensitive health education and medical case management services to
target populations in Greene and Putnam counties that have a low educational attainment level and exhibit
extremely high incidence of ambulatory care sensitive conditions, including diabetes, hypertension/stroke,
CVD/congestive heart failure, asthma, and clinical depression. Services will include screening and
functional health literacy assessments, health education, case management, community health outreach,
health provider education, and social services.
T he target populations in Greene and Putnam counties (40 percent African American, 40 percent
Caucasian, and 20 percent Hispanic) have a number of unmet needs, including a high and persistent rate
of poverty among the indigenous poor, some of the highest unemployment rates in Georgia, the lack of
public transportation services, large numbers of people living in female-headed households, a
high percentage of people without a high school education, and a high rate of uninsured or underinsured
patient populations. Access barriers to services include the low educational attainment level of the target
population, dietary habits of the population, the lack of medical case management services in either
Putnam County or Greene County, and the lack of support groups for specific diseases to assist patients in
G EORGIA
TenderCare Clinic, Inc.
sharing with others challenged by a chronic disease. T he service area is a designated Health Professional
Shortage Area.
T he network partners are T enderCare Clinic, Inc., the lead applicant; TenderCare Preschool and Daycare
Academy; Family Connections; GMP Health Network; Medical College of Georgia; and University of
Georgia–Athens.
G EORGIA
Tanner Medical Foundation
Program Director
TOPIC AREAS
Diabetes, Hypertension, Pulmonary disease, Asthma
PROJECT PERIOD
May 1, 2004 – April 30, 2006
GINA B RANDENBURG
TANNER MEDICAL F OUNDATION
99 D OCTOR’ S D RIVE
C ARROLLTON, GEORGIA 30117
PHONE : (770) 836-9282
F AX : (770) 838-8110



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Members of the West Georgia Chronic Disease Initiative Consortium
include the T anner Medical Foundation (Applicant/lead agency),
Carroll, Haralson and Heard County Health Departments, Haralson,
Heard, Carrollton City and Bremen City Schools Systems, the Center
for Allergy and Asthma of West Georgia, Dr. Sandra Stone of the
State University of West Georgia, the American Lung Association of
Georgia, and the T allatoona Economic Opportunity Authority.
AREAS SERVED
T argeting citizens in Carroll, Haralson, and Heard counties in rural
West Georgia.
T he program will place a special emphasis on low-income, uninsured,
and underserved individuals, including the community’s growing
minority populations.
TANNER MEDICAL F OUNDATION
C ARROLLTON, GA 30117
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he West Georgia Chronic Disease Initiative (WGCDI) is a community-based treatment, management,
and prevention program targeting citizens in Carroll, Haralson, and Heard counties in rural West Georgia.
WGCDI was formed initially in 2001 as a broad partnership with more than 70 local participants and was
prompted in part by the results of two community health assessments, which indicated a prevalence of
risk factors associated with diabetes and hypertension. Currently, the Initiative has now formed a rural
health consortium to guide the program’s continued growth and development. T he consortium proposes
to expand existing protocol for patients with diabetes and hypertension, and add programs targeting
asthma and chronic obstructive pulmonary disease (COPD). Increases in county’s general population and
the “ aging” of the area’s population have led to an increased need for these services.
T he expanded West Georgia Chronic Disease Initiative will serve individuals who currently suffer from
diabetes, hypertension, asthma or COPD, or who are at risk for these diseases. T he program will place a
special emphasis on low-income, uninsured, and underserved individuals, including the community’s
growing minority populations. Specific target populations include 72 percent Caucasian, 25 percent
African American, 2 percent Hispanic, and less than 1 percent Asian.
G EORGIA
Tanner Medical Foundation
Members of the West Georgia Chronic Disease Initiative Consortium include the T anner Medical
Foundation (Applicant/lead agency), Carroll, Haralson and Heard County Health Departments, Haralson,
Heard, Carrollton City and Bremen City Schools Systems, the Center for Allergy and Asthma of West
Georgia, Dr. Sandra Stone of the State University of West Georgia, the American Lung Association of
Georgia, and the T allatoona Economic Opportunity Authority.
G EORGIA
Floyd County Board of Health
Program Director
TOPIC AREAS
Oral health care
PROJECT PERIOD
May 1, 2005 – April 30, 2007
PATRICIA TOWNLEY
F LOYD C OUNTY B OARD OF H EALTH
315 W EST 10TH STREET
R OME , GEORGIA 30165-2638
PHONE : (706) 802-5444
F AX : (706) 802-5445



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Consortium members include Floyd County Health Department,
Coosa Valley T echnical College, Floyd College Health Sciences
Division, Floyd Medical Center, Northwest Health District, and
Rome/Floyd County Commission on Children and Youth.
AREAS SERVED
T he five counties are located in the foothills of the Appalachian
Mountains.
T he 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. T he need for dental services among lowincome families in the target area is tremendous.
F LOYD C OUNTY B OARD OF H EALTH
R OME , GA 30165-2638
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he new Floyd County Dental Clinic will operate as a regional clinic, serving residents of a five-county
area in rural northwest Georgia. T he goal of the clinic is to increase access to oral health care for
residents in the region. T he 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. T he 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. T he 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.
T he five counties are located in the foothills of the Appalachian Mountains. T he 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. T he 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.
G EORGIA
Floyd County Board of Health
Access to oral health care is problematic for many residents in the target area, especially for those with
low income or who lack insurance. T he 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
Consortium members include Floyd County Health Department, Coosa Valley T echnical College, Floyd
College Health Sciences Division, Floyd Medical Center, Northwest Health District, and Rome/Floyd
County Commission on Children and Youth.
G EORGIA
East Central Georgia Regional Teen Wellness Coalition
Program Director
TOPIC AREAS
Health Education
PROJECT PERIOD
May 1, 2005 – April 30, 2007



MARY ANN K OTRAS
EAST C ENTRAL GEORGIA R EGIONAL
TEEN W ELLNESS C OALITION
L INCOLN C OUNTY C OMMISSION
P.O. B OX 68
L INCOLNTON, GEORGIA 30824-0068
PHONE : (706) 595-3112
F AX : (706) 595-3113
Year 1 - 198,810.00
Year 2 - 198,092.00
Year 3 - 198,896.00
T he East Central Georgia Regional T een 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, T aliaferro 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
T he rural underserved service area includes eight counties: Glascock,
Jenkins, Lincoln, McDuffie, Screven, T aliaferro, Warren, and Wilkes.
T he proposed East Central Georgia Regional T een 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.
EAST C ENTRAL GEORGIA R EGIONAL
TEEN W ELLNESS C OALITION
L INCOLNTON, GA 30824-0068
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
Experts agree that decisions youth make regarding lifestyle and personal behavior in adolescence have
tremendous future consequences. T hese 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). T he proposed East Central Georgia Regional T een 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
G EORGIA
East Central Georgia Regional Teen Wellness Coalition
they plan and coordinate an ongoing local health lifestyles education outreach campaign for youth in the
proposed service area.
T he rural underserved service area includes eight counties: Glascock, Jenkins, Lincoln, McDuffie,
Screven, T aliaferro, Warren, and Wilkes. T he 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.
T he East Central Georgia Regional T een 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, T aliaferro 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.
G EORGIA
Turner County Board of Education
Program Director
TOPIC AREAS
Dental clinic services, preventative dental care
PROJECT PERIOD
May 1, 2005 – April 30, 2007
B RENDA L EE
TURNER C OUNTY B OARD OF
EDUCATION
213 N ORTH C LEVELAND STREET
ASHBURN, GA 31714-0609
PHONE : (229) 567-9066
F AX : (229) 567-2877



Year 1 - 169,004.00
Year 2 - 160,198.00
Year 3 - 161,620.00
T he South Georgia Regional Dental Outreach Initiative comprises the
T urner 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, T urner County
Connection, Wilcox County Family Connection, and Worth County
Family Connection.
AREAS SERVED
T he service area is a five-county underserved area in rural southern
Georgia with a population of 67,463 individuals.
T he 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.
TURNER C OUNTY B OARD OF
EDUCATION
ASHBURN, GA 31714-0609
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T o 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.
T he 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,
G EORGIA
Turner County Board of Education
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. T here 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.
T he South Georgia Regional Dental Outreach Initiative comprises the T urner 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, T urner County Connection, Wilcox County Family Connection, and Worth County Family
Connection.
G EORGIA
Evans County Health Department
Program Director
TOPIC AREAS
Perinatal health
PROJECT PERIOD
May 1, 2006 – April 30, 2008



JANICE MASSEY
EVANS C OUNTY H EALTH D EPARTMENT
P.O. B OX 366
4 N ORTH N EWTON STREET
C LAXTON, GA 30417
PHONE : (912) 739-2088
E-MAIL:
JAMASSEY @ GDPH. STATE . GA. US
Year 1 - 148,994.00
Year 2 - 124,908.00
Year 3 - 100,000.00
Wayne Memorial Hospital, Evans Memorial Hospital, Candler
County Health Department, Tattnall County Health Department and
Wayne County Health Department.
AREAS SERVED
T wo of the counties, Candler and T attnall, 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.
Perinatal health program to improve health outcomes for women,
infants and children.
EVANS C OUNTY H EALTH D EPARTMENT
C LAXTON, GA 30417
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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,
T attnall, 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. T he 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.
T wo nurses will be hired to provide services to program participants under the direction of a project
director.
T he 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. T he population of the target area is 66 percent Caucasian, 28 percent Black, and 6 percent
Hispanic. Evans, Candler, and T attnall counties have seen tremendous growth in their Hispanic
G EORGIA
Evans County Health Department
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. T wo of the counties, Candler and T attnall, 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.
G EORGIA
Hospital Authority of Washington County, Inc.
Program Director
TOPIC AREAS
Physical activity/fitness, Obesity/overweight
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 149,969.00
Year 2 - 124,342.00
Year 3 - 99,968.00
GREG R OSSIDIVITO
H OSPITAL AUTHORITY OF W ASHINGTON
C OUNTY , I NC.
W ASHINGTON C OUNTY R EGIONAL
MEDICAL C ENTER
610 SPARTA R OAD
P.O. B OX 636
SANDERSVILLE , GA 31082
PHONE : (478) 240-2391
F AX : (478) 240-2390
E-MAIL: GROSSIDIVITO@HOTMAIL. COM
T he 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
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.
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.
H OSPITAL AUTHORITY OF W ASHINGTON
C OUNTY , I NC.
SANDERSVILLE , GA 31082
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
From 1991 to 1998, Georgia reported the greatest rate of increase in 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
G EORGIA
Hospital Authority of Washington County, Inc.
of multiple barriers, many of which are remediable.
T he 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). T his
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. T ransportation, 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. T he program will
include 75 obese/overweight children, 25 parents/primary caregivers, and 50 non-overweight peers and/or
adults. T o 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.
G EORGIA
Irwin County Board of Health
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008



L YNNE D. F ELDMAN, M.D., M.P.H.
I RWIN C OUNTY B OARD OF H EALTH
GEORGIA D EPARTMENT OF H UMAN
R ESOURCES
407 W. F OURTH STREET
OCILLA, GA 31774
PHONE : (229) 333-5290
E-MAIL:
LDFELDMAN@ GDPH. STATE . GA. US
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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.
AREAS SERVED
T he 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.
T he 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.
I RWIN C OUNTY B OARD OF H EALTH
OCILLA, GA 31774
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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.
G EORGIA
Irwin County Board of Health
T he 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. T he 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.
T he 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.
Grant funds will be used to hire a Nurse with a background in diabetes education as the Project
Coordinator and a Secretary. T he 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.
G EORGIA
Latinos Reduciendo el Diabetes (LaRED)
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2007 – April 30, 2010



ANDREA H INOJOSA
SOUTHEAST GEORGIA C OMMUNITIES
PROJECT
300 S. STATE
ST. L YONS , GA 30436
912-526-5451
F AX –912-526-0089
AHINOJOSA38@ AOL. COM
Year 1 - 138,947.00
Year 2 - 124,999.00
Year 3 - 100,000.00
Southeast Georgia Communities Project, East Georgia Healthcare
Center, Inc., and Meadows Wellness Center
AREAS SERVED
Appling, Candler, Emanuel, Evans, Long, T attnall and T oombs
counties in rural Southeast Georgia.
T he target population includes Latino families with one or more
members diagnosed with diabetes.
PROJECT SUMMARY
T he 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
services for diabetic program participants.
S OU TH E A S T G E OR GI A
C OMMU N I TI E S P R OJ E C T
ST. L YONS , GA 30436
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he 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.
T he 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. T oombs 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. T he 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, T exas 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. T he educational curricula and
G EORGIA
Latinos Reduciendo el Diabetes (LaRED)
materials will be adapted from Diabetes T oday, 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.
I DAHO
Idaho State University
Program Director
TOPIC AREAS
Education (Sexual and spousal abuse, Violence)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
K AREN H AYWARD
I DAHO STATE U NIVERSITY
921 SOUTH 8TH AVENUE
C AMPUS B OX 8046, 309 F INE ARTS
POCATELLO, I DAHO 83209
PHONE : (208) 282-2102
F AX : (208) 282-4476



Year 1 - 170,625.00
Year 2 - 138,153.00
Year 3 - 143,844.00
T he network partners are Idaho State University, the lead applicant,
Bannock Regional Medical Center, and Family Services Alliance of
Southeastern Idaho.
AREAS SERVED
Rural five-county region in southeastern Idaho.
Will primarily serve women in the region, will provide for the
development and implementation of a regional response to victims of
violence through the use of mobile services.
I DAHO STATE U NIVERSITY
POCATELLO, ID 83209
ORHP Contact:
VANESSA H OOKER
PROJECT SUMMARY
PROJECT OFFICER
T he purpose of the Regional Sexual Assault Nurse Examiner (SANE)
HRSA/ORHP
Sexual Assault T eam (SART ) project is to expand the national
5600 F ISHERS L ANE
SANE/SART model to provide direct outreach services to a rural
301-594-5105
five-county region in southeastern Idaho. The SANE/SART project,
VHOOKER@ HRSA. GOV
which will primarily serve women in the region, will provide for the
development and implementation of a regional response to victims of violence through the use of mobile
services. Education and training will focus on nurses (forensic evidence collection and the role of
SANE); law enforcement, prosecutors, judges and advocates (development and implementation of the
SANE/SART model); and community members. The provision of mobile services will ensure ongoing
mentorship to rural areas to foster a high standard of care to rape victims, including a comprehensive
exam necessary to support the conviction of the perpetrator.
T he target population for the project is 75 percent Caucasian and 25 percent Hispanic. Access barriers to
services are difficulties in accessing health care (access to health care is more challenging for Idahoans
than for nearly any other state); transportation and distance problems, particularly for rural women;
conservative rural values; the lack of resources; a cultural tradition of restricted and defined roles for
women; and the unique problems facing rural women who are raped, including the lack of trained nurses
and professionals to address their specific needs, the lack of established advocacy programs or shelters,
and the lack of consistency in caring for victims. The service area is a designated Health Professional
Shortage Area.
I DAHO
Idaho State University
T he network partners are Idaho State University, the lead applicant, Bannock Regional Medical Center,
and Family Services Alliance of Southeastern Idaho.
I DAHO
Terry Reilly Health Services
Program Director
TOPIC AREAS
Pediatric Obesity
PROJECT PERIOD
May 1, 2005 – April 30, 2007
ANN M. SANDVEN
TERRY R EILLY H EALTH SERVICES
211 16TH AVENUE , N ORTH
P.O. B OX 9
N AMPA, I DAHO 83653-0009
PHONE : (208) 467-4431
F AX : (208) 467-7684



Year 1 - 198,795.00
Year 2 - 178,071.09
Year 3 - 181,591.09
Healthy Families Active Youth partners include T erry Reilly Health
Services as the lead agency, Southwest District Health Department,
T reasure Valley Family YMCA, Homedale School District, and
Caldwell School District. All partners have participated in a broadbased community coalition of more than 15 organizations that began
in October 2003 to address childhood overweight.
AREAS SERVED
Rural Canyon and Owyhee counties.
T he target population is low-income elementary school children and
their families in two towns in rural Canyon and Owyhee counties.
TERRY R EILLY H EALTH SERVICES
N AMPA, ID 83653-0009
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
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
obesity. T he 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.
T he 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. T he 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. T he 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.
I DAHO
Terry Reilly Health Services
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.
Healthy Families Active Youth partners include T erry Reilly Health Services as the lead agency,
Southwest District Health Department, T reasure 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.
I DAHO
Gritman Medical Center/Adult Day Health Program
Program Director
TOPIC AREAS
Primary care, Social services, Elderly, Health promotion/disease
prevention (general)
PROJECT PERIOD
May 1, 2006 – April 30, 2008



B ARBARA MOHONEY
GRITMAN MEDICAL C ENTER/ADULT
D AY H EALTH PROGRAM
700 S. MAIN
MOSCOW , ID 83843
PHONE : (208) 883-6483
F AX : (208) 883-6489
E-MAIL:
BARBARA. MAHONEY @ GRITMAN. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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 T ransportation, 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.
T o increase access to medical care and social services for seniors.
PROJECT SUMMARY
T he 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 T ransportation, and Region II Area Agency on
Aging.
GRITMAN MEDICAL C ENTER/ADULT
D AY H EALTH PROGRAM
MOSCOW , ID 83843
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
T he 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
I DAHO
Gritman Medical Center/Adult Day Health Program
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 T ransportation will also work collaboratively
with Latah County to identify and train volunteer drivers to respond to requests in Latah County.
T hird, 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.
I LLINOIS
Saint Mary’s Hospital
Program Director
TOPIC AREAS
Primary care, T elehealth, Developmental disability
PROJECT PERIOD
May 1, 2003 – April 30, 2005
K EN B LAKELY
SAINT MARY ’ S H OSPITAL
400 N ORTH PLEASANT
C ENTRALIA, I LLINOIS 62801
PHONE : (618) 436-8291
F AX : (618) 436-8015



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners are St. Mary’s Hospital, the lead applicant,
Alternative Education Programs, which will oversee programs at Safe
Schools and alternative schools, B.C.M.W. Project Head Start and the
Kaskaskia Workshop, an organization that provides services to
adolescents and adults with developmental disabilities.
AREAS SERVED
Marion County is a designated Health Professional Shortage Area,
and Jefferson County has a Medically Underserved Population.
T he target population of preschool and school children age 3 through
18 and persons with developmental disabilities in the primary service
area of St. Mary’s Hospital.
SAINT MARY ’ S H OSPITAL
C ENTRALIA, IL 62801
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Outreach T elehealth project, which is modeled on a successful T eleKidcare program conducted by
the University of Kansas Medical Center, will serve a target population of preschool and school children
age 3 through 18 and persons with developmental disabilities in the primary service area of St. Mary’s
Hospital. (T he primary service area comprises 11 counties in southern Illinois; as 1 county is designated
“ metropolitan,” the 10 rural counties will be included in the project). Operation Telehealth will provide
telehealth medical examinations for children while at school and for persons with developmental
disabilities who attend an area workshop. Health status indicators for the service area point to a high rate
of low birth weight babies.
T he target population is 95 percent Caucasian, 2 percent African American, 2 percent Hispanic, and
1 percent Asian/Pacific Islander/Alaska Native. Access barriers to services include the lack of primary
care and specialty physicians and school nurses, the lack of transportation services, a high unemployment
rate, a high number of residents living below the poverty level, and the lack of insurance. Within the
service area, Marion County is a designated Health Professional Shortage Area, and Jefferson County has
a Medically Underserved Population. Marion and Jefferson counties will be the two counties focused on
in the first year of funding.
I LLINOIS
Saint Mary’s Hospital
T he network partners are St. Mary’s Hospital, the lead applicant, Alternative Education Programs, which
will oversee programs at Safe Schools and alternative schools, B.C.M.W. Project Head Start and the
Kaskaskia Workshop, an organization that provides services to adolescents and adults with developmental
disabilities.
I LLINOIS
OSF Saint James-John W. Albrecht Medical Center
Program Director
TOPIC AREAS
Children’s health, T elehealth/medicine, Health screening
PROJECT PERIOD
May 1, 2003 – April 30, 2005



K EN B EUTKE
ASSISTANT ADMINISTRATOR
OSF SAINT JAMES -JOHN W.
ALBRECHT MEDICAL C ENTER
2500 W EST R EYNOLDS STREET
PONTIAC, I LLINOIS 61764
PHONE : (815) 842-4922
F AX : (815) 842-4912
Year 1 - 196,000.00
Year 2 - 196,000.00
Year 3 - 162,000.00
T he network partners are OSF Saint James-John W. Albrecht Medical
Center, the lead applicant, Livingston County Special Services Unit,
Heartland Community College, and the Community Foundation of
Livingston County.
AREAS SERVED
In and around Livingston County.
T o address the unmet health needs of children in Livingston County,
Illinois.
OSF SAINT JAMES -JOHN W.
ALBRECHT MEDICAL C ENTER
PONTIAC, IL 61764
ORHP Contact:
PROJECT SUMMARY
VANESSA H OOKER
AdventureCare, a new Children’s Health/Childcare Center, is a
PROJECT OFFICER
collaborative effort that integrates new and existing children’s health
HRSA/ORHP
programs under one organizational structure to address the unmet
5600 F ISHERS L ANE
health needs of children in Livingston County, Illinois.
301-594-5105
Approximately 25 percent of Livingston County is considered at the
VHOOKER@ HRSA. GOV
poverty level, 12.8 percent of the county population is uninsured, and
800 county residents participate in the Women, Infants and Children (WIC) program. T he AdventureCare
program will include early intervention developmental therapies, audiology services, diabetes and asthma
screening, education and support, and three new essential programs of assistive technology, children’s
mental health, and specialized childcare. T he three new programs will be enhanced using video
teleconferencing and telemedicine. AdventureCare’s childcare program will be based on a family care
model and will have the capacity for 77 children. Children with disabilities and at-risk children will be
integrated to encourage children with different abilities to learn from each other.
T he target population of children from all nationalities and economic levels in and around Livingston
County is 90 percent Caucasian, 7 percent African American, 2.5 percent Hispanic, and 0.5 percent
Asian/Pacific Islander/Alaska Native. Access barriers to services include the lack of health care
personnel; geographic barriers, and transportation issues for the rural population in Livingston County
(50.8 percent); a high rate of poverty; lack of childcare facilities; and a lack of assistive technology for
health assessment and follow-up.
I LLINOIS
OSF Saint James-John W. Albrecht Medical Center
T he network partners are OSF Saint James-John W. Albrecht Medical Center, the lead applicant,
Livingston County Special Services Unit, Heartland Community College, and the Community Foundation
of Livingston County.
I LLINOIS
Provena United Samaritans Medical Center Foundation
TOPIC AREAS
Healthy lifestyle education
PROJECT PERIOD
May 1, 2003 – April 30, 2005
Program Director
JOYCE D EBOER
PROVENA U NITED SAMARITANS
MEDICAL C ENTER F OUNDATION
801 W EST F AIRCHILD STREET
D ANVILLE , I LLINOIS 61832
PHONE : (217) 442-6594
F AX : (217) 442-6821



Year 1 - 128,558.00
Year 2 - 148,176.00
Year 3 - 113,553.00
T he network partners are Provena United Samaritans Medical Center,
the lead applicant, the Vermilion County Health Department,
Danville Area Community College, Vermilion County Regional
Office of Education, and the Center for Children’s Services.
AREAS SERVED
Vermilion County
Access barriers to services include a lack of healthy
choice/preventative messages and program content for 9-12 grade
students, limited substance abuse prevention programs and programs
on sexuality for adolescents, and geographic barriers for those
residing outside of the Danville area.
MEDICAL C ENTER F OUNDATION
D ANVILLE , IL 61832
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he I Sing the Body Electric program challenges high school students
in Vermilion County, Illinois to use creative arts to develop effective
messages of healthy lifestyle choices for their peers. Services will
include support for the production of student arts-prevention projects in the area of drug abuse, suicide,
alcohol abuse/drinking and driving, and teen sexuality/teen pregnancy (phase 2, based on subjects
identified in a phase 1 survey), and a T our and Media Campaign (phase 3). T he target population for the I
Sing the Body Electric program is youth in grades 9–12 and youth in grades 5–8 in Vermilion County.
T he target population is 86 percent Caucasian, 11 percent African American, and 3 percent Hispanic.
Single females with children under age 18 head approximately 33 percent of the households in the county,
and 23 percent of Vermilion County’s children live below the poverty level, compared with a state
average of 17.5 percent. In addition, Vermilion County has had one of the highest teen pregnancy rates in
Illinois for more than 30 years. Access barriers to services include a lack of healthy choice/preventative
messages and program content for 9-12 grade students, limited substance abuse prevention programs and
programs on sexuality for adolescents, and geographic barriers for those residing outside of the Danville
area.
T he network partners are Provena United Samaritans Medical Center, the lead applicant, the Vermilion
County Health Department, Danville Area Community College, Vermilion County Regional Office of
Education, and the Center for Children’s Services.
I LLINOIS
Provena United Samaritans Medical Center Foundation
I LLINOIS
Warren Achievement Center, Inc.
TOPIC AREAS
Developmental screenings, Healthy lifestyle education
PROJECT PERIOD
May 1, 2004 – April 30, 2006
Program Director
SUSAN K. B LACKMAN
W ARREN ACHIEVEMENT C ENTER, I NC.
1220 EAST 2ND AVENUE
MONMOUTH, I LLINOIS 61462
PHONE : (309) 734-3131
F AX : (309) 734-7114



Year 1 - 165,836.00
Year 2 - 157,055.00
Year 3 - 144,210.00
T he consortium, which includes the Warren Achievement Center, the
Knox County Health Department, the Henderson County Health
Department, the Knox-Warren Counties Special Education District,
the West Central Illinois Special Education Cooperative, and the
Henderson County Rural Health Center.
AREAS SERVED
Project All Aboard targets any preschool child not eligible for other
state or locally-funded services in Henderson, Knox, and Warren
counties, Illinois.
Preschool-age children in a three county rural area of western Illinois
are missing vital developmental services because parents and health
care providers are not aware of their value and availability.
W ARREN ACHIEVEMENT C ENTER, I NC.
MONMOUTH, IL 61462
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Preschool-age children in a three county rural area of western Illinois
are missing vital developmental services because parents and health care providers are not aware of their
value and availability. Additional children are denied services because their identified needs do not
conform to highly regulated eligibility criteria. Still other children fall in age ranges that force them out
of one program before they are eligible for another. Early diagnosis and treatment of children at risk for
developmental disorders prevents problems at school and offers huge economic benefits to both the child
and the community. Project All Aboard will identify these children through public awareness campaigns,
developmental screenings, and provider networking to provide intervention and other needed
developmental services to ensure every child has an opportunity to reach their potential.
Project All Aboard targets any preschool child not eligible for other state or locally-funded services in
Henderson, Knox, and Warren counties, Illinois. T he consortium, which includes the Warren
Achievement Center, the Knox County Health Department, the Henderson County Health Department,
the Knox-Warren Counties Special Education District, the West Central Illinois Special Education
Cooperative, and the Henderson County Rural Health Center, aims to reduce the average age children are
first screened for developmental delays from 20 months to 14 months, increase referrals of at-risk
children receiving services by 100 percent, and to ensure services to 10 children in the first year of the
program, 20 children in the second year, and to 30 children in the third year of the program, who are in
need of early intervention services but don’t qualify under current guidelines.
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Coles County Mental Health Association, Inc.
Program Director
TOPIC AREAS
Perinatal depression
PROJECT PERIOD
May 1, 2006 – April 30, 2008



K ATHLEEN R OBERTS
EXECUTIVE D IRECTOR
C OLES C OUNTY MENTAL H EALTH
ASSOCIATION, I NC.
1300 C HARLESTON AVENUE
MATTOON, IL 61938
PHONE : (217) 234-6405
F AX : (217) 258-6136,
E-MAIL: KROBERTS @CCMHC. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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.
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.
T his 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.
C OLES C OUNTY MENTAL H EALTH
ASSOCIATION, I NC.
MATTOON, IL 61938
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T his 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;
I LLINOIS
Coles County Mental Health Association, Inc.
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 T wo, and 500 in
Year T hree). 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. T he 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.
I NDIANA
Mother & Baby Care of Rush County, Inc.
Program Director
TOPIC AREAS
Health promotion/disease prevention, Health literacy
PROJECT PERIOD
May 1, 2003 – April 30, 2005



ANN C URTIS
MOTHER & B ABY C ARE OF R USH
C OUNTY , I NC.
F AMILY H EALTH SERVICES
509 H ARCOURT W AY
P.O. B OX 21
R USHVILLE , I NDIANA 46173
PHONE : (765) 932-3699
F AX : (765) 932-4164
Year 1 - 181,100.00
Year 2 - 191,650.00
Year 3 - 198,300.00
Mother & Baby Care of Rush County, Inc., the lead applicant, Family
Health Services, Medical Care and Outcomes, LLC, Hoosier Uplands
Economic Development Corporation, and the Indiana Rural Health
Association.
AREAS SERVED
Fayette, Rush, Franklin, Orange, and Crawford counties in Indiana.
T he target population includes rural residents served by health clinics
in the five counties, with a special emphasis on those living in poverty
(between 7 to 15 percent), those who are uninsured, the elderly, and
those with chronic diseases.
MOTHER & B ABY C ARE OF R USH
C OUNTY , I NC.
R USHVILLE , IN 46173
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Collaborative Model for Continuity of Care in Indiana Rural Health Clinics Outreach Program will
serve residents of all ages in Fayette, Rush, Franklin, Orange, and Crawford counties in Indiana. T he
program will implement follow-up services to patients at targeted health clinics in the counties that are
designed to (1) improve medication compliance of patients; (2) improve patient understanding regarding
health conditions; (3) increase improvement in overall health and well-being reports among patients;
(4) increase the continuity of care and communication among the patient, primary care provider, and other
health care professionals; and (5) improve documentation of medical outcomes throughout the continuum
of care.
T he target population includes rural residents served by health clinics in the five counties, with a special
emphasis on those living in poverty (between 7 to 15 percent), those who are uninsured, the elderly, and
those with chronic diseases. T he population in each of the targeted communities is predominately
Caucasian (more than 98 percent). Access barriers to services include low educational levels, low income
levels, a high rate of persons without insurance or those who are underinsured and limited transportation
options for low-income residents and the elderly. Each of the five counties has some level of Health
Professional Shortage Area (HPSA) or Medically Underserved Area (MUA) designation. T wo of the
counties are both a HPSA and MUA for the entire county, two counties are partial MUAs for specific
townships within the counties, and one county has a HPSA designation for all low-income residents.
I NDIANA
Mother & Baby Care of Rush County, Inc.
T he network partners are Mother & Baby Care of Rush County, Inc., the lead applicant, Family Health
Services, Medical Care and Outcomes, LLC, Hoosier Uplands Economic Development Corporation, and
the Indiana Rural Health Association.
I NDIANA
Rural Health Care Services Outreach Grant Program
Gibson General Hospital
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 124,476.00
Year 3 - 99,783.00
T he project brings together a consortium of local organizations—
Gibson General Hospital, the Gibson County Health Department, the
Pike County Health Department, T ulip 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.
JANET GRAVES , R.D., C.D.
GIBSON GENERAL H OSPITAL
R URAL H EALTH C ARE SERVICES
OUTREACH GRANT PROGRAM GIBSON
GENERAL H OSPITAL
1808 SHERMAN D RIVE
PRINCETON, IN 47670
PHONE : (812) 385-9220
F AX (812) 385-9415
E-MAIL:
JGRAVES @ GIBSONGENERAL. COM
OUTREACH GRANT PROGRAM GIBSON
GENERAL H OSPITAL
PRINCETON, IN 47670
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he 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 treatment services to the citizens of
Indiana’s Gibson and Pike Counties. T he 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 T ree 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.
I NDIANA
Rural Health Care Services Outreach Grant Program
Gibson General Hospital
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 selfmanagement. 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. T he Lifestyles Diabetes Project aims to provide the people of Gibson and Pike
Counties with this access to knowledge, resources, and support.
T he 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. T o
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.
I NDIANA
Dunn Center
Program Director
TOPIC AREAS
Mental Health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
K AY W HITTINGTON
D UNN C ENTER
630 EAST MAIN STREET
R ICHMOND, IN 47375
PHONE : (765) 983-8053
F AX : (765) 983-8686
E-MAIL: WHITTK@DUNNCENTER. ORG



Year 1 - 149,999.00
Year 2 - 124,999.00
Year 3 - 100,000.00
T he 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.
D UNN C ENTER
R ICHMOND, IN 47375
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
T o improve the health and wellness of low-income and elderly.
PROJECT SUMMARY
T he 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) 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. T hese 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.
T hese 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.
T hese challengers are inter-related. T he 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.
I NDIANA
Dunn Center
T he 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. T he 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.
I OWA
Substance Abuse Treatment Unit of Central Iowa
Program Director
TOPIC AREAS
Substance abuse treatment, Substance abuse education
PROJECT PERIOD
May 1, 2003 – April 30, 2005
VICKIE L EWIS
SUBSTANCE ABUSE TREATMENT U NIT
OF C ENTRAL I OWA
9 N ORTH 4TH AVENUE
MARSHALLTOWN, I OWA 50158
PHONE : (641) 752-5421
F AX : (641) 752-7211



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Substance Abuse T reatment Unit of Central Iowa (SAT UCI), the lead
applicant, Center Associates, the local mental health provider, and the
Youth and Violence Committee, Inc.
AREAS SERVED
Marshall County, Iowa
T he target population includes four goals: (1) provide comprehensive
substance abuse treatment services to all youth in the county who
need assistance; (2) provide substance abuse prevention education to
all students in grades K-12; (3) provide substance abuse information
and training to local service providers, community members, school
staff, and parents; and (4) improve substance abuse data collection
and reporting and assist community agencies in using the data in an
effective planning process.
SUBSTANCE ABUSE TREATMENT U NIT
OF C ENTRAL I OWA
MARSHALLTOWN, IA 50158
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Project Connect, a joint effort of more than 50 agencies in Marshall County, Iowa, will address 10 of the
12 substance abuse issues identified in the Marshall County Comprehensive Strategies Plan. T he network
members have designed 4 goals to address the 10 issues: (1) provide comprehensive substance abuse
treatment services to all youth in the county who need assistance; (2) provide substance abuse prevention
education to all students in grades K-12; (3) provide substance abuse information and training to local
service providers, community members, school staff, and parents; and (4) improve substance abuse data
collection and reporting and assist community agencies in using the data in an effective planning process.
Marshall County, which is located in rural north central Iowa, has a number of unmet needs relating to
youth and substance abuse issues. T here has been a significant increase in juvenile arrests, drug seizures,
and juvenile use of methamphetamines, tobacco, alcohol, and marijuana. U.S. News and World Report
described Marshall County as the methamphetamine distribution center of the Midwest. T he number of
youth living in poverty also has more than doubled over the last 11 years; if the trend continues, more
than one-half of the youth in the county will be living in poverty in the next 2 years.
T he target population for project services is 81 percent Caucasian, 15.5 percent Hispanic, and 3.3 percent
African American. Access barriers to services include the lack of sufficient services to meet the
I OWA
Substance Abuse Treatment Unit of Central Iowa
substance abuse prevention and treatment needs of all youth in the county, the lack of qualified bilingual
staff, and the elimination of prevention education/intervention groups offered by local school districts
because of budget cuts.
T he network partners are the Substance Abuse T reatment Unit of Central Iowa (SAT UCI), the lead
applicant, Center Associates, the local mental health provider, and the Youth and Violence Committee,
Inc.
I OWA
Decatur County Hospital
Program Director
TOPIC AREAS
Behavioral Health, youth
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JO SMITH
D ECATUR C OUNTY H OSPITAL
1405 NW C HURCH STREET
L EON, I OWA 50144
PHONE : (641) 446-2339
F AX : (641) 446-2201
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Year 1 - 199,261.00
Year 2 - 189,447.00
Year 3 - 198,196.00
T he network partners are Decatur County Hospital, the lead applicant,
Central Decatur Community School District, Lamoni Community
School District, Mormon T rail Community School District, LinevilleClio Community Schools District, Green Valley Area Education
Agency 14, Iowa Federation of Families for Children’s Mental
Health, Decatur County Community Services, and Decatur County
Human Services.
AREAS SERVED
Decatur County is a Medically Underserved Area, Governor’s Health
Professional Shortage Area and a proposed Mental Health Catchment
Area.
D ECATUR C OUNTY H OSPITAL
L EON, IA 50144
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he unmet behavioral health needs of 1,648 students in grades K-12
in Decatur County and in four school districts located in southern
Iowa along the Iowa/Missouri border.
PROJECT SUMMARY
T he Decatur County Behavioral Access4 Project will address the unmet behavioral health needs of 1,648
students in grades K-12 in Decatur County and in four school districts located in southern Iowa along the
Iowa/Missouri border. Project activities include school-based identification, problem solving, and
documentation of students with behavioral health problems; linkages of school-based children and their
families to intensive behavioral health services; and the provision of services to behavioral health at-risk
children and their families through community asset building activities using the Search Institute and
local mentorship resources.
Decatur County is Iowa’s poorest county, with almost twice the national average in a number of areas
related to income and education. For example, 25.2 percent of county residents are at 100 percent of
poverty (compared to a national average of 11.3 percent), and there are 74.5 percent of female households
with children in poverty (compared to a national average of 46.4 percent). Of county residents,
18.3 percent have a ninth grade education or less, compared to a national average of 7.5 percent. A 1999
state report also listed Decatur County as the ninth most severe county in Iowa for reported and confirmed
child abuse cases. T hese factors have negatively affected the mental and behavioral health of the
county’s children and youth, families, schools, and communities.
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Decatur County Hospital
T he target population of students and their families is 98.2 percent Caucasian, 1.2 percent Hispanic, and
0.6 percent African American. Access barriers to services include unstable family environments, the lack
of adequate financial resources, the lack of transportation, the lack of parental knowledge on how to
obtain behavioral health services for children in need and the stigma associated with mental health and
behavioral health in rural Decatur County. Decatur County is a Medically Underserved Area, Governor’s
Health Professional Shortage Area and a proposed Mental Health Catchment Area.
T he network partners are Decatur County Hospital, the lead applicant, Central Decatur Community
School District, Lamoni Community School District, Mormon T rail Community School District,
Lineville-Clio Community Schools District, Green Valley Area Education Agency 14, Iowa Federation of
Families for Children’s Mental Health, Decatur County Community Services, and Decatur County
Human Services.
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AgriWellness, Inc.
Program Director
TOPIC AREAS
Behavioral health, Education
PROJECT PERIOD
May 1, 2003 – April 30, 2005
MICHAEL R OSMANN
AGRIW ELLNESS , I NC.
1210 7TH STREET, SUITE C
H ARLAN, I OWA 51537
PHONE : (712) 235-6100
F AX : (712) 235-6105
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Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners are AgriWellness, Inc., the lead applicant and
nonprofit corporation that provides administrative support for the
Sowing the Seeds of Hope network; Ecumenical Ministries of Iowa;
Child and Family Programs (Kansas); Minnesota Association of
Community Mental Health Programs, Inc.; Nebraska Office of Rural
Health; Carrington Health Center (North Dakota); Easter Seals South
Dakota; and Wisconsin Farm Center.
AREAS SERVED
Underserved rural agricultural population in the seven states (Iowa,
Kansas, Minnesota, Nebraska, North Dakota, South Dakota, and
Wisconsin.
AGRIW ELLNESS , I NC.
H ARLAN, IA 51537
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T o services include the undersupply of adequately trained health care providers in rural areas, the high
cost of health insurance and unreimbursed health care expenditures and the lack of integration of
behavioral health services into settings, such as primary care clinics, to reduce the negative stigma about
behavioral health services.
PROJECT SUMMARY
T he Regional Outreach Network will create shared access to outreach methods, tools, program models,
strategies, and resources targeted to the behavioral health needs of the at-risk underserved rural
agricultural population in the seven states (Iowa, Kansas, Minnesota, Nebraska, North Dakota, South
Dakota, and Wisconsin) that participate in Sowing the Seeds of Hope network. T he primary purpose of
the project is to link all core services of the seven state projects and their affiliates in a regional network
with a central location and clearinghouse of information, technical assistance, training, electronic media,
coordination of services, and evaluation.
T he target population for services is 91.6 percent Caucasian, 3.6 percent Hispanic, 3 percent American
Indian, 1.5 percent African American, and less than 1 percent Asian/Pacific Islander/Alaska Native.
Access barriers to services include the undersupply of adequately trained health care providers in rural
areas, the high cost of health insurance and unreimbursed health care expenditures and the lack of
integration of behavioral health services into settings, such as primary care clinics, to reduce the negative
stigma about behavioral health services. The services area is designated as a Health Professional
Shortage Area.
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AgriWellness, Inc.
T he network partners are AgriWellness, Inc., the lead applicant and nonprofit corporation that provides
administrative support for the Sowing the Seeds of Hope network; Ecumenical Ministries of Iowa; Child
and Family Programs (Kansas); Minnesota Association of Community Mental Health Programs, Inc.;
Nebraska Office of Rural Health; Carrington Health Center (North Dakota); Easter Seals South Dakota;
and Wisconsin Farm Center.
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Crisis Intervention Services
Program Director
TOPIC AREAS
Domestic violence, Sexual abuse, Provider education
PROJECT PERIOD
May 1, 2004 – April 30, 2006
D AWN STEPHENS
C RISIS I NTERVENTION SERVICES
500 H IGH AVENUE
OSKALOOSA, I OWA 52577
PHONE : (641) 673-0336, EXT. 11
F AX : (641) 673-0336
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Year 1 - 195,076.00
Year 2 - 187,061.00
Year 3 - 151,486.00
Crisis Intervention Services formed a consortium of local health
agencies including the Keokuk County Health Center, Keokuk
County Public Health, and the Mahaska Health Partnership
(Community Health, Mahaska Hospital, and New Directions).
AREAS SERVED
Mahaska and Keokuk counties.
Health care needs of survivors of domestic abuse and sexual assault.
C RISIS I NTERVENTION SERVICES
OSKALOOSA, IA 52577
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Health professionals frequently treat survivors of domestic abuse and sexual assault, but physicians often
treat injuries only symptomatically. As a result, important opportunities for intervention are missed, and
survivors continue to suffer adverse health consequences of physical and emotional abuse. Of the
estimated 6.9 million intimate partner rapes and physical assaults committed annually, 2.6 million will
result in an injury to the survivor, and more than 695,400 will result in medical treatment. In addition to
the climbing medical expenses resulting from domestic abuse, estimated between $3 billion and $5 billion
annually, businesses are forfeiting nearly an additional $100 million annually in lost wages, sick leave,
and non-productivity. Survivors of domestic abuse are more likely to experience numerous chronic
health problems including depression, post-traumatic stress disorder, chronic pain syndrome,
gynecological problems, irritable bowel syndrome, eating disorders, and complications during pregnancy
than others.
T o address these and other unmet health care needs of survivors of domestic abuse and sexual assault in
Mahaska and Keokuk counties, Crisis Intervention Services formed a consortium of local health agencies
including the Keokuk County Health Center, Keokuk County Public Health, and the Mahaska Health
Partnership (Community Health, Mahaska Hospital, and New Directions). Through a coordinated
community response, with leadership and guidance from the Domestic Abuse/Sexual Assault T askforce,
the consortium seeks to provide intensive education for medical and mental health care providers of
domestic abuse and sexual assault victimization issues, develop and implement effective screening
protocols for medical and mental health providers, develop and implement a Sexual Assault Nurse
Examiner (SANE) program, provide extensive education for teenagers and their parents, and develop and
implement an extensive public awareness campaign on sexual assault prevention.
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Crisis Intervention Services
T he target population is 90 percent Caucasian, 4 percent Hispanic, and a smaller mix of American
Indians, African Americans, and Asians and Pacific Islanders.
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Northwest Iowa Mental Health Center
Program Director
TOPIC AREAS
Mental health, Substance abuse, and Education
PROJECT PERIOD
May 1, 2004 – April 30, 2006
JUDITH MCD ONOUGH
N ORTHWEST I OWA MENTAL H EALTH
C ENTER
201 EAST 11TH STREET
SPENCER, I OWA 51301
PHONE : (712) 262-2922
F AX : (712) 262-2741
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

Year 1 - 195,644.00
Year 2 - 199,937.00
Year 3 - 199,992.00
Northwest Iowa Mental Health Center; Seasons Center for
Community Mental Health; Northwest Iowa Alcohol and Drug
T reatment; and the sheriff departments and health departments.
AREAS SERVED
Northwest Iowa counties of Buena Vista, Osceola, Dickinson, Lyon,
Emmet, O’Brien, Clay, and Palo Alto
A great number of people living with co-occurring mental health and
substance abuse disorders.
N ORTHWEST I OWA MENTAL H EALTH
C ENTER
SPENCER, IA 51301
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Experts believe that 1.8 percent of the U.S. general population live with severe mental disorders.
According to the Substance Abuse and Mental Health Services Administration of the U.S. Department of
Health and Human Services, the rate of severe mental disorders among those entering jail is 6.4 percent
for male detainees and 12.2 percent for female detainees. Of these, 72 percent also suffer with alcohol or
drug abuse disorders. In 1999, there were 11.4 million admissions to jail, meaning that an estimated
802,000 detainees had severe mental disorders, and 577,440 of those also met the criteria for alcohol or
drug abuse. Minorities are disproportionately represented in our criminal justice system, and also
experience a higher rate of co-occurring disorders, with Hispanics being the fastest growing group in jail
populations, (approximately 8 percent Hispanic versus more 90 percent Caucasian/Non-Hispanic). A
great number of people living with co-occurring mental health and substance abuse disorders in the target
area of the northwest Iowa counties of Buena Vista, Osceola, Dickinson, Lyon, Emmet, O’Brien, Clay,
and Palo Alto face inappropriate incarceration and re-incarceration because they are not diverted from the
judicial system into the mental health and substance abuse treatment systems, and cannot be effectively
and immediately connected with services following their jail stay to reintroduce them into the community
successfully.
T he Integrated Service Pathways Network—which includes Northwest Iowa Mental Health Center;
Seasons Center for Community Mental Health; Northwest Iowa Alcohol and Drug T reatment; and the
sheriff departments and health departments of Emmet, Dickinson, Lyon, and Osceola counties—seeks to
address these surprising statistics by diverting people with co-occurring disorders from the traditional
I OWA
Northwest Iowa Mental Health Center
criminal justice system/jail by implementing officer training and education of magistrates and other
judicial officers, providing in-jail mental health and substance abuse assessment and treatment to
detainees, utilizing translation and telehealth technologies as appropriate, and initiating non-traditional
case management services to offenders with co-occurring disorders to ease the transition into the
community’s support system and break the cycle of arrest, jail, release, and re-arrest.
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Marshalltown Medical and Surgical Center
Program Director
TOPIC AREAS
Prenatal care
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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JANA ENFIELD, PROJECT D IRECTOR
MARSHALLTOWN MEDICAL AND
SURGICAL C ENTER
ST
104 SOUTH 1 STREET
PHONE : (641) 752-1730
EMAIL:
CAPSJANA@ THEWEBUNWIRED. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
MARSHALLTOWN MEDICAL AND
SURGICAL C ENTER
ORHP Contact:
T he project is designed to meet the unique cultural, social, and
linguistic needs of pregnant Hispanic women living in Marshall
County.
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
Marshall County, population 39,311, is located in rural Central Iowa. T he 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. T his 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.
T he Building Healthy Families project is a culmination of 5 years of research, data collection, review, and
program planning. T he 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.
T he 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
I OWA
Marshalltown Medical and Surgical Center
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. T his project will address the severe lack of
services available to our target group due to cultural and language barriers.
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Wayne Community School District
Program Director
TOPIC AREAS
Mental health services
PROJECT PERIOD
May 1, 2006 – April 30, 2008
R OBERT B USCH
W AYNE C OMMUNITY SCHOOL D ISTRICT
102 N. D EKALB
C ORYDON, IA 50060
PHONE : (641) 872-1220
F AX : (641) 872-2091
E-MAIL: BUSCHR@AEA15. K12. IA. US
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
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
W AYNE C OMMUNITY SCHOOL D ISTRICT
C ORYDON, IA 50060
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he proposed Wayne County Multi-Generational Behavioral Health Project will serve one of the State’s
most poor, isolated, and distressed areas. T his 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.
T hese four strata of life will be integrated into this project.
T he 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. T he
target population consists of 1,500 Mercer County children and elderly persons.
T he 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 T eam (BLAST ) model
from the Rathbun Area Mental Health Center in Centerville, Iowa and the UCLA Center for Mental
Health in Schools.
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Wayne Community School District
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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.
T he 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.
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Early Smiles
Program Director
TOPIC AREAS
Oral Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010
JEAN D REY
U PPER D ES MOINES OPPORTUNITY
620 MICHIGAN
STORM L AKE , IA 50588
712-213-8478
F AX –712-213-8478
JDREY @ UDMO. COM
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Year 1 - 143,085.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T here 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
T he 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.
T he target population is families with young children ages 0-5,
residing in rural northwest Iowa.
U P P E R D E S M OI N E S
O P P OR TU N I TY , I N C ( U D MO )
G R A E TTI N GE R , I A 5 1 3 4 2 - 0 5 1 9
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he applicant and lead agency for the proposed project is Upper Des Moines Opportunity, Inc (UDMO).
T here are two other consortium partners, United Community Health Center (UCHC), a federally qualified
community health center, and Lakes Area Community Empowerment (Lakes CE). T he project title is
Early Smiles. T he target population is families with young children ages 0-5, residing in rural northwest
Iowa. T he purpose of the project is to “ create an oral health care system”. T he 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.
K ANS AS
PrairieStar Health Center
Program Director
TOPIC AREAS
Dental
PROJECT PERIOD
May 1, 2006 – April 30, 2008
SALLY TESLUK, EXECUTIVE D IRECTOR
PRAIRIE STAR H EALTH C ENTER
200 W EST 2ND AVENUE
H UTCHINSON, KS 67501
PHONE : (620) 663-8484
E-MAIL:
TESLUKS @ PRAIRIESTARHEALTH. ORG
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T his 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.
PRAIRIE STAR H EALTH C ENTER
H UTCHINSON, KS 67501
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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.
T he South Central Dental Project will establish a dental team that is shared by PrairieStar Health Center
and Health Ministries Clinic. T he cost of services will be offset by using a sliding fee schedule of
discounts based upon the patient's income. T his 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. T his 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. T he 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 group indicated that this unmet
K ANS AS
PrairieStar Health Center
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 FT E 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. T he 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.
T his 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.
K ANS AS
Senior Outreach Services Consortium
Program Director
TOPIC AREAS
Mental Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010
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STEVEN D ENNY
F OUR C OUNTY MENTAL H EALTH
C ENTER
P.O. B OX 688
3751 W EST MAIN STREET
I NDEPENDENCE , KS
620-331-1748
F AX –620-332-1940
SDENNY @ FOURCOUNTY . COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
T hrough the Senior Outreach Services Consortium outreach and
community-based services will be expanded in Montgomery County
and initiated in Wilson County, Kansas.
F OUR C OUNTY MENTAL H EALTH
C ENTER
I NDEPENDENCE , KS 67301
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
T he target population is older adults, age 60 or older with unmet
mental health and substance abuse treatment needs. T hese seniors are
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. T he 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
T he 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 inhome therapy will be provided by this project. T he consortium will consist of representatives from mental
health and substance abuse treatment services, public health, aging services, hospitals, and assisted living
facilities. T he Consortium will form a focus group to address the needs of seniors.
T he program will outreach to older adults, age 60 or older, with unmet mental health and substance abuse
treatment needs. T hese seniors are currently not being served by traditional methods due to financial,
K ANS AS
Senior Outreach Services Consortium
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.
T he Senior Outreach Services Consortium will:
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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.
K ANS AS
Promoting Healthy Lifestyles
Program Director
TOPIC AREAS
School (nutrition)
PROJECT PERIOD
May 1, 2007 – April 30, 2010
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PHILISHA STALLBAUMER
H EALTH EDUCATION ACTION
PARTNERSHIP
119 N. K ANSAS AVENUE
F RANKFORT, KS
785-292-4453
F AX –785-292-4455
P H I L I S H A @ S B E C ON L I N E . OR G
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
AREAS SERVED
Marshall and Nemahan Counties
H EALTH EDUCATION ACTION
PARTNERSHIP
F RANKFORT, KS 66427
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
T he communities and individuals specifically and directly targeted in
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. T his 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. T hese 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.
K ANS AS
Promoting Healthy Lifestyles
T he 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. T his 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. T he 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) T o increase the awareness and promote the development of healthy eating behaviors and engagement
in physical activity.
2) T o improve the health and quality of life for children ages 4- 19 by increasing levels of physical
activity.
3) T o improve the health and quality of life for children ages 4- 19 by providing opportunities for
nutritional education.
T hese 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. T his grant application will allow HEAP to take the action they need to help promote healthy
environments for children in these rural communities.
K ENTUC KY
Appalachian Regional Healthcare, Inc.
Program Director
TOPIC AREAS
Health promotion/disease prevention (general), Health screening
PROJECT PERIOD
May 1, 2003 – April 30, 2005



R OBERT D EEN
APPALACHIAN R EGIONAL
H EALTHCARE , I NC.
260 H OSPITAL D RIVE
SOUTH W ILLIAMSON, K ENTUCKY
41503
PHONE : (606) 237-1700
F AX : (606) 237-1701
Year 1 - 196,824.00
Year 2 - 197,072.00
Year 3 - 196,387.00
A.B.L.E. Families, Inc., T he Huntington, office of the Mid-Atlantic
Division of the American Cancer Society, and other network
members will offer after-school use of their facilities, educational
materials, community workshops on healthy eating and nutrition, and
a food distribution center.
AREAS SERVED
T ug Valley area of eastern Pike and Southern Martin counties of
Kentucky and Mingo County in West Virginia.
Will provide consumer health education, community outreach
workers, and screening and assessment services to residents.
APPALACHIAN R EGIONAL
H EALTHCARE , I NC.
SOUTH W ILLIAMSON, KY 41503
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he eight-partner Williamson Wellness Outreach Program will provide consumer health education,
community outreach workers, and screening and assessment services to residents of the Tug Valley area
of eastern Pike and Southern Martin counties of Kentucky and Mingo County in West Virginia. T hese
communities straddle a rugged mountainous area in the heart of Central Appalachian. In this medically
underserved area, poverty, unemployment, and preventable chronic diseases plague whole communities
tucked back in “ hollers” and along narrow riverbanks. Financial and geographic barriers to accessing
medical services—as well as strong individual self-reliance and limited local resources for health
education, prevention, and early detection—prevent the predominantly native Appalachian residents from
learning about lifestyle changes that could improve their health. More than half of all households fall
below 200 percent of the Federal poverty level, and almost 23 percent of Kentucky residents are
estimated as having no health insurance. According to the Centers for Disease Control and Prevention,
Kentucky ranks fourth highest overall in cancer mortality rates among the 50 states and the District of
Columbia, and the prevalence of diabetes has increased at an alarming rate statewide over the past decade.
In addition, Martin County and part of Mingo County are designated Health Professional Shortage Areas,
and Pike, Martin, and Mingo counties are designated Medically Underserved Areas.
T he Williamson Wellness Outreach Program will provide community-based services, including health
education, screening and early detection, and referral and preventive maintenance, to residents in the area
who are at risk for diabetes, cancer, and heart disease. Services will focus on the needs of special
populations, in particular, women, the elderly, and the poor. T elehealth technology will be used to
K ENTUC KY
Appalachian Regional Healthcare, Inc.
improve the quality, accessibility, and continuity of health care in the communities. For example,
radiology images can be transmitted digitally to medical specialists outside the area to expand the
capacity for diagnosis and management of patients. Among the network members, A.B.L.E. Families,
Inc., a nonprofit community service organization, will provide a teaching kitchen, a computer lab, and
event space for the project. T he Huntington, West Virginia, office of the Mid-Atlantic Division of the
American Cancer Society will commit staff time, printed materials, and monthly collaboration to the
development of the Wellness Outreach Program. Other network members will offer after-school use of
their facilities, educational materials, community workshops on healthy eating and nutrition, and a food
distribution center.
K ENTUC KY
Foothills Community Action Partnership
Program Director
TOPIC AREAS
Health promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2004 – April 30, 2006



VERONICA TAYLOR, M.P.A.
HCAP PROJECT D IRECTOR
F OOTHILLS C OMMUNITY ACTION
PARTNERSHIP
128 K ENTUCKY AVENUE
I RVINE , K ENTUCKY 40336
PHONE : (606) 723-6629
F AX : (606) 723-9726
Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he Kentucky River Health Network consists of Marcum and
Wallace Memorial Hospital (a Critical Access Hospital), the
Kentucky River District Public Health Department, Lee County
Constant Care (a long-term nursing and assisted-living facility), the
Lee County Emergency Medical Services, the Lee County Fiscal
Court, and the Lee County Area T echnology Center (a vocational
technology high school).
AREAS SERVED
T he seven rural counties that make up the proposed target area for
this project (Lee, Owsley, Jackson, Powell, Wolfe, Estill, and
Breathitt) are among the poorest counties in Kentucky.
F OOTHILLS C OMMUNITY ACTION
PARTNERSHIP
I RVINE , KY 40336
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
Improve access to preventive care services for the underinsured and
uninsured in the target area.
PROJECT SUMMARY
T he seven rural counties that make up the proposed target area for this project (Lee, Owsley, Jackson,
Powell, Wolfe, Estill, and Breathitt) are among the poorest counties in Kentucky. Besides being
economically disadvantaged, these counties have limited access to health care services. Only two of the
seven counties have local hospitals, and the other five counties have, at best, access to limited service
clinics that are managed from outside the local area. Within KRHN’s service area, five counties are
designated as Medically Underserved Areas. T he high illiteracy rate in these counties negatively impacts
the potential for these populations to gain access to health care services. T he socioeconomic stress on the
underinsured and uninsured is further exacerbated by the lack of access to local health care services.
KRHN is in phase 1 of a twofold mission to improve access to preventive care services for the
underinsured and uninsured in the target area. T he proposed services and activities for phase 1 include
mammography, prostate and prostate-specific antigen (PSA) screenings, development of a hepatitis
screening service, transportation services, educational programs to recruit students interested in the
medical field, continuing educational programs for participating health care providers, and public
awareness programs in Lee County. Phase 2 consists of KRHN’s long-term plan to implement the
proposed services and activities in the other 6 counties, while further developing the network system to
sustain this and other future collaborative projects. T he long-term plan focuses on community
K ENTUC KY
Foothills Community Action Partnership
development that places an emphasis on the education of children and students throughout the region and
continuing education for health care providers.
T he Kentucky River Health Network consists of Marcum and Wallace Memorial Hospital (a Critical
Access Hospital), the Kentucky River District Public Health Department, Lee County Constant Care (a
long-term nursing and assisted-living facility), the Lee County Emergency Medical Services, the Lee
County Fiscal Court, and the Lee County Area T echnology Center (a vocational technology high school).
T he target population is more than 98 percent Caucasian and nearly 2 percent African American. While
there is a growing number of Hispanics in the region, they are expected to represent less than 1 percent of
the total population served by this project.
K ENTUC KY
Murray State University
Program Director
TOPIC AREAS
Dental health, Preventive care
PROJECT PERIOD
May 1, 2004 – April 30, 2006
L ORETTA MALDANER
MURRAY STATE U NIVERSITY
PURCHASE AHEC
225 W ELLS H ALL
MURRAY , K ENTUCKY 42071
PHONE : (270) 762-4123
F AX : (270) 762-4125



Year 1 - 187,150.00
Year 2 - 187,150.00
Year 3 - 190,781.00
T he West Kentucky Dental Health Project (WKDHP) organizations
include the Purchase and Pennyrile District Health Department, the
Graves County Migrant Program, the Office of Family Resource and
Youth Services Center, Murray Head Start, the West Kentucky
T echnical College (WKT C) Dental Hygiene/Dental Assisting
Program, the Purchase Area Development District (PADD), and the
Purchase Area Health Education Center (AHEC).
AREAS SERVED
T he project that aims to build an infrastructure in 12 counties in rural
western Kentucky to address early childhood caries and dental caries.
MURRAY STATE U NIVERSITY
MURRAY , KY 42071
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
T he project will target children and families of the Women, Infants,
and Children (WIC) program, Head Start, and first and second
graders through educational programming, preventive projects, and
activities to increase access to treatment.
PROJECT SUMMARY
T he Surgeon General’s Report on Oral Health (2000) describes oral disease in America as a “ silent
epidemic.” Healthy People 2000 reports 18 percent of 2- to 4-year-olds have visible decay, and the
numbers are rising. More than half of elementary school children have dental decay, and by the time they
graduate from high school, it has increased to 84 percent. 99 percent of the population ranging from high
school graduation to mid life (age 45) has tooth decay. Children can avoid cavities entirely if provided
with early and proper dental care, but not all children receive appropriate oral health care. In children age
5 to 17, 80 percent of cavities are found in a particular subgroup. Specifically, this subgroup is within
25 percent of the lower end of the socioeconomic scale. T he problem lies with the success of preventive
measures not extending to those at the lower end of the socioeconomic scale. Previous studies conducted
indicate that poor children have about five times more unfilled, decayed teeth than children above
300 percent of the poverty line.
T he West Kentucky Dental Health Project (WKDHP) is a collaborative community-driven project that
aims to build an infrastructure in 12 counties in rural western Kentucky to address early childhood caries
and dental caries. T he project will target children and families (80 percent Caucasian, 10 percent African
American, and 10 percent Hispanic) of the Women, Infants, and Children (WIC) program, Head Start,
K ENTUC KY
Murray State University
and first and second graders through educational programming, preventive projects, and activities to
increase access to treatment. Similar to goals contained within the Healthy People 2010 Report,
WKDHP’s goals are to reduce the proportion of children and adolescents who have dental caries
experience in their primary or permanent teeth or untreated dental decay, increase the proportion of
children and adolescents under age 19 at or below 200 percent of the Federal poverty level who use the
oral health care system each year, and who receive any preventive dental service during the past year,
increase access by purchasing restorative services from community dentists for those children without
insurance or adequate resources, and to increase the proportion of children who have received dental
sealants on their molar teeth.
T he WKDHP organizations include the Purchase and Pennyrile District Health Department, the Graves
County Migrant Program, the Office of Family Resource and Youth Services Center, Murray Head Start,
the West Kentucky T echnical College (WKT C) Dental Hygiene/Dental Assisting Program, the Purchase
Area Development District (PADD), and the Purchase Area Health Education Center (AHEC).
K ENTUC KY
Kentucky United Methodist Home
Program Director
TOPIC AREAS
Health promotion/disease prevention (tobacco, overweight/obesity,
alcohol abuse)
PROJECT PERIOD
May 1, 2006 – April 30, 2008
D EWEY SANDERS , PH.D.
C HIEF EXECUTIVE OFFICER
K ENTUCKY U NITED METHODIST H OME
2050 L EXINGTON R OAD
VERSAILLES , KY 40383
PHONE : (859) 873-4481
E-MAIL: DRSANDERS @KYUMH. ORG



Year 1 - 149,974.00
Year 2 - 124,987.00
Year 3 - 99,986.00
T he Kentucky Cabinet for Health and Family Services, and the
Madison County Health Department.
AREAS SERVED
T wo rural counties of central Kentucky (Anderson and Madison).
T o provide health care and human services for low-income children,
youth, and families
K ENTUCKY U NITED METHODIST H OME
VERSAILLES , KY 40383
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he 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-T AP) a fundamental priority of our case management services, and we will
help enroll individuals and families as appropriate.
T he 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.
K ENTUC KY
Kentucky United Methodist Home
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 psychoeducational 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.
K ENTUC KY
Montgomery County Kentucky Health Department
Program Director
TOPIC AREAS
Dental care, Minority health
PROJECT PERIOD
May 1, 2006 – April 30, 2008



JAN C HAMNESS
PUBLIC H EALTH D IRECTOR
MONTGOMERY C OUNTY K ENTUCKY
H EALTH D EPARTMENT
117 C IVIC C ENTER
MT. STERLING, KY 40353
PHONE : (859) 498-3808
E-MAIL: JANM. CHAMNESS @KY . GOV
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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. T he 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 wellequipped to fulfill the consortium’s mission.
AREAS SERVED
T he 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.
MONTGOMERY C OUNTY K ENTUCKY
H EALTH D EPARTMENT
MT. STERLING, KY 40353
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
T he 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
T his project plans to establish an outreach program developed by the Western Appalachian Kentucky
Health Care Access Consortium. T he 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.
T he 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.
K ENTUC KY
Montgomery County Kentucky Health Department
T he 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. T he 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.
T he 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.
T hrough 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. T he University Kentucky College of Public Health will assist
with process and outcome evaluations, and with the dissemination of findings.
K ENTUC KY
Promoting Health among Diabetics (PHD)
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2007 – April 30, 2010



APRIL STONE
K ENTUCKY R IVER F OOTHILLS
D EVELOPMENT
TH
176 12 STREET
C LAY C ITY , KY
606-663-9011
F AX –606-663-1254
CFN1@ FOOTHILLSCAP . ORG
Year 1 - 149,357.00
Year 2 - 124,561.00
Year 3 - 99,519.00
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.
Provide medical and supportive services to low-income adults with
diabetes and related conditions residing in Powell and Estill counties,
Kentucky.
K ENTUCKY R IVER F OOTHILLS
D EVELOPMENT
C LAY C ITY , KY 40912
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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.
LOUIS IANA
Grambling State University
TOPIC AREAS
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
MARTIN AYIM
GRAMBLING STATE U NIVERSITY
SCHOOL OF N URSING
D EPARTMENT HPER, B OX 1193
GRAMBLING, L OUISIANA 71245
PHONE : (318) 274-2372
F AX : (318) 274-6053
Year 1 - 199,800.00
Year 2 - 199,800.00
Year 3 - 199,800.00
Grambling State University, the lead applicant, the Morehouse Parish
Health Department, Morehouse General Hospital, Morehouse Parish
School System, Morehouse/Bastrop Chamber of Commerce, the
Morehouse Parish Social Service Agency, and the Morehouse Ministers
Alliance.
AREAS SERVED
Morehouse Parish in the Mississippi Delta Region of Louisiana. T he
service area is designated as a Health Professional Shortage Area.
T he target populations for the project are school-age children (8-18) and
the adult population (18-75), especially those in the faith community.
GRAMBLING STATE U NIVERSITY
SCHOOL OF N URSING
GRAMBLING, LA 71245
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Morehouse Parish Community Health Outreach Project will
establish a formal network of preventive health service providers and agencies that will maximize
resources, increase the number of individuals and families receiving preventive care, and foster a sense of
positive behavior that reflects health and self-help. Services include an after school health education
program, health education sessions, group and individual counseling, role-playing, and nutritional
counseling and assessment.
T he target populations for the project are school-age children (8-18) and the adult population (18-75),
especially those in the faith community, in Morehouse Parish in the Mississippi Delta Region of
Louisiana. T he population in Morehouse Parish is 56 percent Caucasian and 44 percent African
American. More than 40 percent of the children under age 20 in Northeast Louisiana are in poverty.
Among female-headed households with children under age 5, the poverty rate is 80 percent. Access
barriers to services include a number of cultural and socioeconomic factors, including family-based
interventions rather than global-based interventions, a sense of devaluing health among African American
males, a psycho-spiritual emphasis on prayer rather than treatment for medical issues, and a persistently
high poverty rate. T he service area is designated as a Health Professional Shortage Area.
T he network partners are Grambling State University, the lead applicant, the Morehouse Parish Health
Department, Morehouse General Hospital, Morehouse Parish School System, Morehouse/Bastrop
Chamber of Commerce, the Morehouse Parish Social Service Agency, and the Morehouse Ministers
Alliance.
LOUIS IANA
Grambling State University
LOUIS IANA
Opelousas General Hospital
Program Director
TOPIC AREAS
Case management, referral
PROJECT PERIOD
May 1, 2003 – April 30, 2005
W ILLIAM B AROW
OPELOUSAS GENERAL H OSPITAL
539 EAST PRUDHOMME STREET
P.O. B OX 1208
OPELOUSAS , L OUISIANA 70570
PHONE : (337) 948-3011
F AX : (337) 943-5126



Year 1 - 162,700.00
Year 2 - 197,616.00
Year 3 - 193,323.00
Opelousas General Hospital, the lead applicant, Southwest Louisiana
Primary Health Care Center, United Community Health Center, and
Glenn’s Family Pharmacy.
AREAS SERVED
Rural St. Landry Parish in Louisiana.
Access to health services and improve the quality of essential health
care services to the underserved at-risk residents
OPELOUSAS GENERAL H OSPITAL
OPELOUSAS , LA 70570
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he St. Landry Rural Health Network will expand access to health services and improve the quality of
essential health care services to the underserved at-risk residents of rural St. Landry Parish in Louisiana.
T he program will provide case managers for one-on-one assistance to referred clients in removing barriers
to access health care by (1) educating clients in available services using the St. Landry Parish Medical
Directory, and (2) procuring assistance in obtaining prescribed pharmaceuticals through the
Pharmaceutical Access Program, which will recruit and train volunteers in applying for assistance through
the indigent patient programs of various pharmaceutical companies.
T he target population for the program is all residents of St. Landry Parish (57 percent Caucasian,
42 percent African American, and 1 percent Hispanic). Access barriers to services include a high poverty
rate in St. Landry Parish (60 percent of residents have incomes less than 200 percent of the poverty rate),
lack of insurance among 23 percent of the population, low educational levels, and lack of awareness of
available health services. T he service area is designated as a Health Professional Shortage Area.
T he network partners are the Opelousas General Hospital, the lead applicant, Southwest Louisiana
Primary Health Care Center, United Community Health Center, and Glenn’s Family Pharmacy.
LOUIS IANA
Union General Hospital
Program Director
TOPIC AREAS
PROJECT PERIOD
May 1, 2003 – April 30, 2005
EVALYN ORMOND
U NION GENERAL H OSPITAL
901 JAMES AVENUE
F ARMERVILLE , L OUISIANA 71241
PHONE : (318) 368-9751
F AX : (318) 368-8270
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Year 1 - 200,000.00
Year 2 - 165,258.00
Year 3 - 170,377.00
Critical Access Hospital and Union Parish
AREAS SERVED
Union Parish in north-central Louisiana
Providing health care preventive education.
U NION GENERAL H OSPITAL
F ARMERVILLE , LA 71241
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
PROJECT SUMMARY
HRSA/ORHP
L.I.F.E.: A Union of Forces to Rescue Our Communities Health is a
5600 F ISHERS L ANE
six-partner network dedicated to providing health care preventive
301-594-5105
education. L.I.F.E. stands for Linking the community with health
VHOOKER@ HRSA. GOV
care services, Improving key health indicators, Facilitating new
partnerships in health care delivery, and L.I.F.E.: A Union of Forces to Rescue Our Communities Health
is a six-partner network dedicated to providing health care preventive education. L.I.F.E. stands for
Linking the community with health care services, Improving key health indicators, Facilitating new
partnerships in health care delivery, and Equipping health care providers with training and resources.
L.I.F.E. will serve the residents of Union Parish in north-central Louisiana, which received the lowest
score of the 50 states for overall health in a national ranking. T he risk for heart disease in Union Parish is
16 percent above the national average. In fact, health statistics for Union Parish are well above the state
and national average in several key indicators, including poverty, infant mortality, teen pregnancy, cancer,
diabetes, and unemployment. For example, the infant mortality rate in Union Parish is 19.6 percent,
whereas the state average is 9.1 percent and the national average is 7.1 percent. In African Americans,
the infant mortality rate in Union Parish jumps to a staggering 41.2 percent. Union General Hospital,
which provides the health needs of the community, is a Critical Access Hospital, and Union Parish is a
Health Professional Shortage Area. The target population is approximately 70 percent Caucasian,
28 percent African American, and 2 percent Hispanic.
Under the L.I.F.E. program, a health care team consisting of a nurse education, a social worker, and a
referral coordinator will provide outreach services in Union Parish. T o increase equity and access to care
for the area’s most vulnerable populations, a referral coordinator will be hired to facilitate transportation
services for the parish’s elderly and disabled residents. T o eliminate health disparities among the target
population groups in Union Parish, a nurse and a social worker will travel to schools, workplaces, and
rural areas to present screenings, exercise classes, and preventive health programs. Assessment and
referral to health care services will be a primary function of the health care team, as will education on teen
LOUIS IANA
Union General Hospital
pregnancy risks, prenatal and infant care, and drug abuse, which will be offered in the schools. T o reduce
the incidence of deaths due to chronic disease, the health team will provide information about exercise,
nutrition, smoking, and diabetes. A social worker will educate the community on mental health issues,
such as depression, attention deficit hyperactivity disorder (ADHD), and domestic violence and rape. The
health team also will work closely with ConAgra’s nurses to conduct weight, cholesterol, diabetes, and
blood pressure screenings. School-based outreach will be achieved by creating a referral system called
the Student Assistance Program. Finally, the L.I.F.E. project will encourage training and continued
education for current and future health care providers at Union General Hospital.
LOUIS IANA
Louisiana Tech University
Program Director
TOPIC AREAS
Obesity, Chronic Diseases, Health Education
PROJECT PERIOD
May 1, 2005 – April 30, 2007
MARY W. MURIMI
L OUISIANA TECH U NIVERSITY
P.O. B OX 3168
R USTON, L OUISIANA 71272
PHONE : (318) 257-2607
F AX : (318) 257-4014
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Year 1 - 197,385.00
Year 2 - 178,963.00
Year 3 - 191,285.00
In addition to Louisiana T ech 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
T he project will serve the town of Dubach and surrounding rural
communities in northern Lincoln Parish, Louisiana,
T he 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.”
L OUISIANA TECH U NIVERSITY
R USTON, LA 71272
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he purpose of the Dubach Health Outreach Project is to provide access to a multidisciplinary
community-based intervention to combat obesity and related chronic diseases. T he 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.
T he 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.
T he project also will target adults, who will receive secondary and tertiary prevention services such as
screening, testing, health education, nutritional assessment, and counseling.
T he 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. T he 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.
LOUIS IANA
Louisiana Tech University
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.
In addition to Louisiana T ech University, the lead applicant, consortium members include Lincoln
General Hospital, T own of Dubach, Dubach High School, Dubach Revitalization Coalition, Dubach
Restoration and Beautification Organization (DRABO), and Lincoln Council on Aging.
LOUIS IANA
City of Grambling/Grambling Family Medical Clinic
Program Director
TOPIC AREAS
Obesity, Diabetes
PROJECT PERIOD
May 1, 2005 – April 30, 2007
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SHARON MURFF
C ITY OF GRAMBLING/GRAMBLING
F AMILY MEDICAL C LINIC
2045 MARTIN L UTHER K ING JR.
AVENUE
P.O. B OX 108
GRAMBLING, L OUISIANA 71245
PHONE : (318) 247-6120
F AX : (318) 247-0940
Year 1 - 195,140.00
Year 2 - 184,890.00
Year 3 - 184,890.00
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.
T he 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.
C ITY OF GRAMBLING/GRAMBLING
F AMILY MEDICAL C LINIC
GRAMBLING, LA 71245
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T he 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. T he 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
LOUIS IANA
City of Grambling/Grambling Family Medical Clinic
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). Obesityrelated 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.”
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.
LOUIS IANA
Bayou Teche Community Health Network (ByNet)
Program Director
TOPIC AREAS
Medication assistance, T elehealth, Chronic Disease
PROJECT PERIOD
May 1, 2006 – April 30, 2008

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R EV . C RAIG A. MATHEWS
B Y N ET EXECUTIVE D IRECTOR
B AYOU TECHE C OMMUNITY H EALTH
N ETWORK (B Y N ET)
P.O. B OX 278
F RANKLIN, LA 70538
PHONE : (337) 828-5638, EXT 104
E-MAIL: CMATHEWS @BYNET-LA. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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 T errebonne Parishes in south central Louisiana
along the Gulf Coast.
T he target population for the project is the underinsured and
uninsured residents.
B AYOU TECHE C OMMUNITY H EALTH
N ETWORK (B Y N ET)
F RANKLIN, LA 70538
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he CEI: Project Outreach will expand upon the Bayou T eche 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:
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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 T eams;
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.
LOUIS IANA
Bayou Teche Community Health Network (ByNet)
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. T he 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 T errebone Parishes have now
become home to thousands of survived families requiring these services.
T he target population for the project is the underinsured and uninsured residents of St. Mary, Iberia, and
T errebonne Parishes in south central Louisiana along the Gulf Coast. T his population has recently
experienced an enormous influx due to Hurricane Katrina survivors who have migrated into local
communities. T hose organizations comprising the consortium are the founding members of the Bayou
T eche Community Health Network (ByNet). T he 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.
LOUIS IANA
Louisiana Rural Health Association
Program Director
TOPIC AREAS
Infrastructure development, Elderly (education), Medication
assistance, Quality improvement
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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D ONNA N EWCHURCH
EXECUTIVE D IRECTOR
L OUISIANA R URAL H EALTH
ASSOCIATION
167 H IGHWAY 402
P.O. B OX 387
N APOLEONVILLE , LA 70390
PHONE : (985) 369-3813
E-MAIL: NEWCHURCH@LRHA. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T hrough 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.
Dedicated to increasing adult immunizations and adult vaccinations.
PROJECT SUMMARY
T he 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.
L OUISIANA R URAL H EALTH
ASSOCIATION
N APOLEONVILLE , LA 70390
ORHP Contact:
SHEILA W ARREN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0246
SWARREN@ HRSA. GOV
T hrough 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.
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. T he end results were major
quality improvements, transformational changes, and increased access to care in 30 rural Louisiana
parishes.
T he goals for this project are as follows: 1) T o engage partners in making transformational changes that
will enhance efficiency, increase access to care, improve service coordination, and improve quality of
care; 2) T o educate Medicare beneficiaries about their rights and benefits, increase the number of allied
LOUIS IANA
Louisiana Rural Health Association
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) T o identify strategies for sustaining PEAL after ORHP funding ceases.
LOUIS IANA
Franklin Parish Hospital Service District No. 1
Program Director
TOPIC AREAS
Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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PAULA W ALKER
F RANKLIN PARISH H OSPITAL SERVICE
D ISTRICT N O. 1
2106 L OOP R OAD
W INNSBORO, LA 71295
PHONE : (318) 435-9411
E-MAIL: PWALKER@FMC-CARES . COM
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.
T hese 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
T here is a lack of behavioral health care services in Louisiana’s
Franklin and T ensas parishes, both of which are located in the rural,
impoverished region of the Mississippi River Delta. T here are two
key services to be developed under the project—case management
and psychological evaluation and treatment services. T hese services
will be provided to individuals at three rural health clinics, long-term
care facilities, and home-bound patients. T he target population will be
primarily African American adults.
F RANKLIN PARISH H OSPITAL SERVICE
D ISTRICT N O. 1
W INNSBORO, LA 71295
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
T he overarching goal of this project is to establish a primary care-based behavioral health program. T he
eight related goals that support this are:
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T o identify and enroll individuals in the behavioral health care management program;
T o 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;
T o expand the behavioral health program to include patients residing in area long-term care facilities;
T o expand the program upon implementation to include patients who are home-bound and actively
enrolled as a home health patient;
T o reduce the incidence of serious mental illness, depression, schizophrenia, and generalized anxiety
disorders;
T o reduce the proportion of homeless adults who have serious mental illness;
T o ensure program sustainability; and
T o conduct a program evaluation.
LOUIS IANA
Richard Parish Hospital
Program Director
TOPIC AREAS
Cardiovascular disease
PROJECT PERIOD
May 1, 2006 – April 30, 2008
MICHAEL C ARROLL
R ICHARD PARISH H OSPITAL
407 C INCINNATI STREET
D ELHI, LA 71232
PHONE : (318) 878-5171
E-MAIL:
MICHAELWCARROLL@ YAHOO. COM
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Year 1 - 150,000.00
Year 2 - 124,760.00
Year 3 - 99,130.00
T he 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.
Designed to provide health assessments, health promotion, and health
education in settings such as the school, worksite, health care facility,
and community.
R ICHARD PARISH H OSPITAL
D ELHI, LA 71232
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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.
T here are significant access barriers to health care as reflected in the income and poverty demographics,
health status indicators, and health disparities.
T he primary needs to be addressed through this project are as follows:
 T o increase the quality, availability, and effectiveness of community-based programs designed to
prevent cardiovascular disease, improve health, and improve quality of life;
 T o expand the availability of health education resources to underserved, vulnerable, and special-needs
populations to reduce cardiovascular disease;
 T o decrease the risk factors and the resulting high incidence rate of cardiovascular disease and
correlating chronic diseases;
 T o 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.
LOUIS IANA
Richard Parish Hospital
T he 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.
M AINE
Healthy Community Coalition
Program Director
TOPIC AREAS
Obesity, Clinical Interventions
PROJECT PERIOD
May 1, 2005 – April 30, 2007
L EAH B INDER
H EALTHY C OMMUNITY C OALITION
20 C HURCH STREET
W ILTON, MAINE 04294-3803
PHONE : (207) 645-3136
F AX : (207) 645-4138
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Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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
T he target population comprises residents of Franklin County and
eight neighboring towns.
T he 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.
H EALTHY C OMMUNITY C OALITION
W ILTON, ME 04294-3803
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he 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.
T he 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.
T he 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. T he 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. T he 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. T he
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.
M AINE
Healthy Community Coalition
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. T he 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.
M AINE
Northeast Health
Program Director
TOPIC AREAS
Mental health, Substance abuse
PROJECT PERIOD
May 1, 2004 – April 30, 2006
PHIL MONACO
N ORTHEAST H EALTH
6 GLEN C OVE R OAD
R OCKPORT, MAINE 04856
PHONE : (207) 596-8392
F AX : (207) 596-5316
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Year 1 - 199,913.00
Year 2 - 199,913.00
Year 3 - 199,913.00
Mid-Coast Mental Health Center, the Penobscot Bay YMCA, and the
Maine Department of Behavioral and Developmental Services joined
forces to form the Mid-Coast Mental Health Integration Initiative.
AREAS SERVED
Knox, Lincoln, and Waldo counties, Maine
Increase access to adolescent mental health and substance abuse
services.
N ORTHEAST H EALTH
R OCKPORT, MAINE 04856
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Almost 21 percent of U.S. children age 9 to 17 (15 million persons)
have a mental or addictive disorder that causes some impairment.
However, studies show that pediatricians do not identify 80 percent of children living with behavioral and
emotional problems, and in any given year, it is estimated that less than one in five of these youth receive
treatment. T he Maine Medical Association recently passed a resolution identifying the lack of mental
health care for children as the biggest health issue for the state, an action well supported by Maine’s
health statistics.
Northeast Health in cooperation with three partner organizations, Mid-Coast Mental Health Center, the
Penobscot Bay YMCA, and the Maine Department of Behavioral and Developmental Services joined
forces to form the Mid-Coast Mental Health Integration Initiative in an effort to increase access to
adolescent mental health and substance abuse services in Knox, Lincoln, and Waldo counties, Maine.
T he goals of the Mid-Coast Mental Health Integration Initiative are to improve access to child and
adolescent mental health services, reduce the stigma associated with mental health, reduce the number of
crisis interventions, improve coordination and cooperation among local health providers, and disseminate
an innovative model. Nearly 97 percent of Maine’s population is Caucasian. T he ethnic mix of this
program is similar, targeting 95 percent Caucasian, 2 percent Hispanic, 1 percent Asian, and a mix of
African Americans and Native Americans totaling less than 1 percent of the target population. Children
between the ages of 0 to 12 make up 40 percent of the target population, while adolescents age 13 to 17,
at nearly 50 percent, represent the largest group to be served.
M AINE
Health Access Network, Inc.
Program Director
TOPIC AREAS
Aging/Elderly
PROJECT PERIOD
May 1, 2006 – April 30, 2008



D AWN C OOK
R URAL MAINE H EALTHY AGING
PROGRAM
H EALTH ACCESS N ETWORK, I NC.
51 MAIN STREET
L INCOLN, ME 04457
PHONE : (207) 794-6700
E-MAIL: DCOOK@HANFQHC. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 75,000.00
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.
T he 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.
H EALTH ACCESS N ETWORK, I NC.
L INCOLN, ME 04457
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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
M AINE
Health Access Network, Inc.
(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 workingage adult population will grow only 5 percent; and the elderly will jump 38 percent.
T he 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.
T hese 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.
T he project’s primary goals are: 1) T o improve access to high quality, locally coordinated, multi-specialty
and integrated health care; 2) T o 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) T o 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.
M ARYLAND
Worcester County Health Department
Program Director
TOPIC AREAS
Service Accessibility, In-home Care, Behavioral Health
PROJECT PERIOD
May 1, 2005 – April 30, 2007
R EBECCA SHOCKLEY
W ORCESTER C OUNTY H EALTH
D EPARTMENT
P.O. B OX 249
SNOW H ILL, MARYLAND 21863-0149
PHONE : (410) 632-1100
F AX : (410) 632-0906



Year 1 - 199,521.00
Year 2 - 199,521.00
Year 3 - 199,521.00
T he 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
T he target population—adults age 60 and older.
W ORCESTER C OUNTY H EALTH
D EPARTMENT
SNOW H ILL, MD 21863-0149
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he
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. T he current long-term care infrastructure cannot support the population
of older residents in need of personal care assistance. T he 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. T he 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. T he 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
M ARYLAND
Worcester County Health Department
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.
M ARYLAND
Eastern Shore Area Health Education Center
Program Director
TOPIC AREAS
Dental
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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 T hree Lower
Counties, Inc.; and a local hospital, Shore Health System, Inc. Funds.
AREAS SERVED
Six counties on the mid and lower Eastern Shore.
T o address disparities in access to, and use of, oral health care
services for children and low-income families.
JACOB F. F REGO
EXECUTIVE D IRECTOR
EASTERN SHORE AREA H EALTH
EDUCATION C ENTER
814 C HESAPEAKE D RIVE
P.O. B OX 795
C AMBRIDGE , MD 21613
PHONE : (410) 221-2600
F AX : (410) 221-2605
E-MAIL: JFREGO@ESAHEC. ORG
W EBSITE : WWW . ESAHEC. ORG
EASTERN SHORE AREA H EALTH
EDUCATION C ENTER
C AMBRIDGE , MD 21613
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T hrough this network planning process, a service delivery consortium was created to address
oral health access issues, particularly in Dorchester County, Maryland. T he 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 T hree 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.
M ARYLAND
Eastern Shore Area Health Education Center
CROC's work plan focuses on low-income children who are uninsured or enrolled in medical assistance.
T he target population for Cambridge Dental Center includes the 3,900 children residing in Dorchester
County who are eligible for medical assistance. T he target population for the hospital-based pediatric
dental program includes low-income children in the six counties on the mid and lower Eastern Shore.
T here are approximately 26,800 children in who are eligible for medical assistance MA in these six
counties.
T here 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.
M AS S ACHUS ETTS
Island Health Plan, Inc.
TOPIC AREAS
Rural Health Clinic, Referral services
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
C YNTHIA MITCHELL
I SLAND H EALTH PLAN, I NC.
560 OLD C OUNTY R OAD
P.O. B OX 1298
W EST TISBURY , MASSACHUSETTS
02575
PHONE : (508) 696-0020 EXT. 14
F AX : (508) 696-7352
Year 1 - 189,475.00
Year 2 - 140,400.00
Year 3 - 132,331.00
Partners in the project are the Vineyard Nursing Association, the
Visiting Nurse Service, the Vineyard Health Care Access Program,
and the Island Health Plan. Vineyarders also rely greatly on mainland
providers, especially for medical specialties, diagnostic testing, and
secondary and tertiary inpatient services.
AREAS SERVED
Uninsured residents with low income in Dukes County,
Massachusetts.
Will improve the health status of the underserved residents of Dukes
County, Massachusetts, by improving their access to a full continuum
of health services.
I SLAND H EALTH PLAN, I NC.
W EST TISBURY , MA 02575
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Martha’s Vineyard Rural Health Outreach Project will improve the health status of the underserved
residents of Dukes County, Massachusetts, by improving their access to a full continuum of health
services. Dukes County covers an entirely rural area consisting of Martha’s Vineyard and Elizabeth
Island. Located approximately 7 miles off the southern coast of Cape Cod, Martha’s Vineyard is the only
part of Dukes County with year-round inhabitants. Three of its six towns are among the poorest rural
towns in the state. On this high-cost-of-living island resort for the rich and famous, full-time residents
struggle to live on part-time employment and low wages. T he target population of the project includes
uninsured residents with low income and residents who have limited English-language ability.
Approximately 30 percent of the residents are immigrants from Brazil. With limited incomes, language
barriers, and no insurance, residents face significant challenges to accessing health services. In addition,
the island is a designated Health Professional Shortage Area.
Five principal strategies have been devised to improve residents’ access to a full continuum of health
services: (1) identify people who face access barriers and link them to a primary care health home,
(2) strengthen and expand the reduced fee program for uninsured residents, (3) establish a rural health
clinic, (4) formalize an interpreter program for the island, and (5) streamline and strengthen referral
relationships among partners and collaborators. Partners in the project are the Vineyard Nursing
Association, the Visiting Nurse Service, the Vineyard Health Care Access Program, and the Island Health
Plan. Vineyarders also rely greatly on mainland providers, especially for medical specialties, diagnostic
testing, and secondary and tertiary inpatient services.
M AS S ACHUS ETTS
Island Health Plan, Inc.
M ICHIGAN
Central Michigan District Health Department
TOPIC AREAS
Health education, T elehealth, Senior citizens
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
D AWN L UKOMSKI
C ENTRAL MICHIGAN D ISTRICT
H EALTH D EPARTMENT
2012 EAST PRESTON AVENUE
MOUNT PLEASANT, MICHIGAN 48858
PHONE : (989) 773-5921 EXT. 160
F AX : (989) 773-4319
Year 1 - 100,561.00
Year 2 - 88,756.00
Year 3 - 90,620.00
Women’s Cardiovascular Disease Program, the Senior Wellness
Outreach Project the Commission on Aging, and the Central
Michigan District Health Department.
AREAS SERVED
Isabella County
Combine group education, rural telehealth opportunities, and health
screenings for 400 senior citizens.
C ENTRAL MICHIGAN D ISTRICT H EALTH
D EPARTMENT
MOUNT PLEASANT, MI 48858
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Senior Wellness Outreach Project will combine group education,
rural telehealth opportunities, and health screenings for 400 senior
citizens in Isabella County, located in the heart of central lower
Michigan. Mount Pleasant, the county seat, is the home of Central
Michigan University (CMU) and the Saginaw-Chippewa Indian T ribe. T he target population for the
project is 85 percent Caucasian and 15 percent American Indian. Because access to transportation is a
service barrier for senior citizens, the program will be conducted at seven popular congregate meal sites
throughout the county. Many of the seniors who frequent these meal sites have risk factors for
cardiovascular disease, diabetes, osteoporosis, and stroke. In fact, heart disease and stroke account for
40 percent of all deaths in the county. T he seniors need education on heart disease risk factors and stroke
warning signs, as well as on diabetes, osteoporosis, and depression. T he county is a designated Health
Professional Shortage Area (HPSA) and a mental health HPSA. In addition, 15 percent of county
residents are uninsured.
T he goal of the Senior Wellness Outreach Project is to reduce the barriers associated with receiving health
information and resources for persons age 55 and older in the county. T he three network partners have a
history of providing services to seniors, community members, and students around the state. For
example, they worked successfully on the Women’s Cardiovascular Disease Program and the Michigan
Rural Health Initiative in the past. T he Senior Wellness Outreach Project will provide the seven meal
sites with computers and Internet access to link seniors to the CMU rural telehealth program Healthwise
knowledge base. T raining will enable the seniors to break through barriers in technology and access
information about health care. Another network partner, the Commission on Aging, will promote the
program through a newsletter, provide site space, and supply Internet access for the rural telehealth
network. Finally, the Central Michigan District Health Department will provide health education staff to
conduct health risk appraisals and will develop press releases about monthly health topics.
M ICHIGAN
Borgess Health Alliance
Program Director
TOPIC AREAS
T elehealth, Health promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
PAUL N OSEWORTHY
B ORGESS -L EE MEMORIAL H OSPITAL
B ORGESS H EALTH ALLIANCE
1521 GULL R OAD
K ALAMAZOO, MICHIGAN 49048
PHONE : (616) 226-6690
F AX : (616) 226-5966



Year 1 - 199,361.00
Year 2 - 199,957.00
Year 3 - 198,297.00
Borgess-Lee Memorial Hospital, the lead applicant, Van Buren-Cass
County District Health Department, Borgess Medical Center and
Health Alliance, Community Hospital of Watervliet, Hillsdale
Community Health Center, Community Health Center in Coldwater,
Berrien County Health Department, Borgess-Pipp Health Center, and
the T hree Rivers Area Hospital.
AREAS SERVED
Allegan, Branch, Cass, Hillsdale, St. Joseph, and Berrien) in
southwest Michigan.
Given the region’s remote location, limited primary care resources,
and higher than average incidence of health problems, health care
providers and their communities identified increased community
health education and prevention activities as a priority goal for the
telehealth network.
B ORGESS H EALTH ALLIANCE
K ALAMAZOO, MICHIGAN 49048
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Southwest Michigan Rural T elehealth Network project will serve the residents of six rural counties
(Allegan, Branch, Cass, Hillsdale, St. Joseph, and Berrien) in southwest Michigan. Given the region’s
remote location, limited primary care resources, and higher than average incidence of health problems,
health care providers and their communities identified increased community health education and
prevention activities as a priority goal for the telehealth network. T he target population for the T elehealth
Network services, which is all residents (247,940) in the six counties, is 91.2 percent Caucasian,
4.8 percent African American, 3.2 percent Hispanic, 1.2 percent Asian/Pacific Islander/Alaska Native,
and 0.5 percent American Indian.
Access barriers to services include the lack of a public transportation infrastructure between rural and
urban sites, the isolation of health care providers from specialized health services and consultation,
making it difficult to stay current on diagnostic and treatment protocols, and the lack of professional
growth opportunities for health care providers. Cass and Hillsdale counties are designated Health
Professional Shortage Areas for both medical and dental professionals.
M ICHIGAN
Borgess Health Alliance
T he network partners are Borgess-Lee Memorial Hospital, the lead applicant, Van Buren-Cass County
District Health Department, Borgess Medical Center and Health Alliance, Community Hospital of
Watervliet, Hillsdale Community Health Center, Community Health Center in Coldwater, Berrien County
Health Department, Borgess-Pipp Health Center, and the T hree Rivers Area Hospital.
M ICHIGAN
Harbor Beach Community Hospital
Program Director
TOPIC AREAS
Cardiovascular disease, Health Screening
PROJECT PERIOD
May 1, 2003 – April 30, 2005
STEVE B ARNETT
H ARBOR B EACH C OMMUNITY H OSPITAL
210 SOUTH F IRST STREET
H ARBOR B EACH, MICHIGAN 48441
PHONE : (989) 479-3201
F AX : (989) 479-9841



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Harbor Beach Community Hospital, Genesys Regional Medical
Center-Genesys Health Systems, and the Huron County Health
Department.
AREAS SERVED
All three counties in the service area have been designated as a partial
or full county Primary Care Provider Shortage Area, Mental Health
Care Provider Shortage Area, and Dental Provider Shortage Area.
T o provide preventive and/or further diagnostic procedures through
cardiac scoring; and increase by 60 percent the number of participants
with identified risk factors that take specific action steps to prevent
CVD.
H ARBOR B EACH C OMMUNITY H OSPITAL
H ARBOR B EACH, MI 48441
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he goals of the T humb Cardiac Outreach and Referral Network (TCORN) are to identify 900 people at
risk for cardiovascular disease (CVD) through screening and assessments; identify 200 patients for
preventive and/or further diagnostic procedures through cardiac scoring; and increase by 60 percent the
number of participants with identified risk factors that take specific action steps to prevent CVD.
T CORN also will help contain the costs of CVD treatment by detecting risk factors earlier and reducing
invasive testing and/or surgery. T CORN will serve rural residents in Huron, Sanilac, and T uscola
counties, commonly referred to as the “ Thumb” of Michigan. The population in the counties is
98 percent Caucasian and 2 percent Hispanic.
Access barriers include provider shortages, a high unemployment rate (more than 7 percent), low income
levels (more than 14 percent below the 100 percent poverty rate), limited transportation, limited healthrelated technology, costs of health services, and resistance to preventive health care. All three counties in
the service area have been designated as a partial or full county Primary Care Provider Shortage Area,
Mental Health Care Provider Shortage Area, and Dental Provider Shortage Area.
T he network partners are the Harbor Beach Community Hospital, the lead applicant, Genesys Regional
Medical Center-Genesys Health Systems, and the Huron County Health Department.
M ICHIGAN
Upper Peninsula Health Education Corp.
TOPIC AREAS
Provider education, heart/stroke disease prevention
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
D AVID L UOMA
U PPER PENINSULA H EALTH
EDUCATION C ORP .
418 W EST MAGNETIC STREET
MARQUETTE , MICHIGAN 49855
PHONE : (906) 228-7970
F AX : (906) 228-5734
Year 1 - 183,090.00
Year 2 - 190,178.00
Year 3 - 199,920.00
T he network partners are the Upper Peninsula Health Education
Corporation, the lead applicant, Marquette General Health System, and
Ferris State University College of Pharmacy.
AREAS SERVED
Marquette, Alger, and Delta counties, all rural counties within the
Upper Peninsula of Michigan
Will address problems in turnaround time for adjusting warfarin
dosages, and will improve the skills of rural health practitioners in
anticoagulation therapy.
U PPER PENINSULA H EALTH
EDUCATION C ORP .
MARQUETTE , MI 49855
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Gift of T ime project will establish six anticoagulation clinics over a
3-year period in Marquette, Alger, and Delta counties, anticoagulation
clinics over a 3-year period in Marquette, Alger, and Delta counties, all
rural counties within the Upper Peninsula of Michigan. T he six anticoagulation clinics, which will serve
a total of approximately 650 patients each year, will address problems in turnaround time for adjusting
warfarin dosages, and will improve the skills of rural health practitioners in anticoagulation therapy.
All three of the counties targeted by the Gift of T ime project have a population over age 65 that exceeds
the state average, a high rate of heart disease, and a significant number of elderly residents on warfarin
therapy. T he target population for the project is 95.1 percent Caucasian, 1.6 percent Hispanic, 1.5 percent
American Indian, 1.3 percent African American, and 0.5 percent Asian/Pacific Islander/Alaska Native.
Access barriers to services include limited access to medical laboratories, geographic isolation and
transportation difficulties, barriers at the practitioner’s office (long turnaround times for completing and
reporting lab results), communication and patient education barriers caused by communication by
telephone with elderly patients, the lack of access to dietary education and knowledge gaps on the part of
practicing physicians with regard to anticoagulation use. Of the 15 counties in the Upper Peninsula, 1 has
been fully designated as a Health Professional Shortage Area, 9 have received full designation for a
population group, and 4 have received partial designation. Of the 15 counties, 8 have received full
designation as a Medically Underserved Area, and 3 have received partial designation.
T he network partners are the Upper Peninsula Health Education Corporation, the lead applicant,
Marquette General Health System, and Ferris State University College of Pharmacy.
M ICHIGAN
Upper Peninsula Health Education Corp.
M ICHIGAN
Marquette General Health System
Program Director
TOPIC AREAS
Geriatric care, Mental health
PROJECT PERIOD
May 1, 2004 – April 30, 2006
L AURIE N ELDBERG-W EESEN
MARQUETTE GENERAL H EALTH SYSTEM
420 W EST MAGNETIC STREET
MARQUETTE , MICHIGAN 49855
PHONE : (906) 225-3251
F AX : (906) 225-3180



Year 1 - 199,910.00
Year 2 - 197,882.00
Year 3 - 199,314.00
Grand View Health System, Keweenaw Memorial Medical Center,
and the Portage Health System.
AREAS SERVED
T he 6 counties in Michigan’s Upper Peninsula targeted for this
project are Baraga, Gogebic, Houghton, Keweenaw, Marquette, and
Ontonagon counties.
T argeted populations include older adults experiencing memory loss
and their family members and caregivers.
MARQUETTE GENERAL H EALTH SYSTEM
MARQUETTE , MI 49855
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Alzheimer disease is the eighth leading cause of mortality among elderly persons in the United States,
accounting for more than 100,000 deaths annually. T he cost of irreversible dementia is presently
estimated at $100 billion per year, making the illness our Nation’s third most costly medical condition
behind heart disease and cancer. At present, most dementia disorders are costly, progressive, and without
a cure. T he effects are devastating to the caregivers and family as well as the affected individual. It is
projected that by 2050, more than 13 million Americans will have Alzheimer disease.
T he 6 counties in Michigan’s Upper Peninsula targeted for this project are Baraga, Gogebic, Houghton,
Keweenaw, Marquette, and Ontonagon counties. T his geographical area has an Alzheimer disease rate
nearly double that of the state of Michigan. It is conservatively estimated that 5,593 residents (4 percent
of the population) suffer from a dementia disorder. Some dementia disorders can be treated; others are
irreversible but can benefit from coordinated medical and social management. Unfortunately, many
people with memory disorders remain undiagnosed and under-managed. T he project recognizes five
issues that result in less than optimal care management for people suffering from memory loss: delayed
entry into medical services, variation in care coordination and clinical practice, family member difficulty
in recognition and intervention (particularly those geographically distant), caregiver risk for health and
psycho/social problems, and the compliance variation in care provided within the home setting.
T he applicant, Marquette General Health System, has joined with its network partners, Grand View
Health System, Keweenaw Memorial Medical Center, and the Portage Health System to develop
M ICHIGAN
Marquette General Health System
Softening the Sunset Journey, a community-based collaborative which seeks to maximize local
coordinated care resources toward the improvement of community awareness, early identification, access
to care, and caregiver screening for older adult memory loss. T argeted populations include older adults
experiencing memory loss and their family members and caregivers. T he majority of people experiencing
memory loss will be age 65 and older (95 percent), with the remainder of the target population age 18 to
64 (5 percent).
M ICHIGAN
Alcona Health Centers
Program Director
TOPIC AREAS
Behavioral Health, Psychiatric Services
PROJECT PERIOD
May 1, 2005 – April 30, 2007
TIMOTHY U HLMANN
ALCONA C ITIZENS FOR H EALTH, I NC.
ALCONA H EALTH C ENTERS
177 N ORTH B ARLOW R OAD
L INCOLN, MICHIGAN 48742
PHONE : (989) 736-3020
F AX : (989) 736-8380



Year 1 - 196,543.00
Year 2 - 183,124.00
Year 3 - 190,139.00
T he primary members of the consortium include Alcona Health
Centers, T hunder 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.
T he 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.
ALCONA H EALTH C ENTERS
L INCOLN, MI 48742
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
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 T hunder 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. T he 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 T hunder Bay Community Health Services. T he expansion of services is
holistic, cost-efficient, and very much needed. Eventually, telepsychiatry will be added to improve access
to care.
T he target area served by the consortium comprises four counties—Iosco, Alcona, Montmorency, and
Presque Isle—in the lower peninsula of Michigan. T he 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. T hese individuals
face multiple obstacles to services, including low income, lack of education, cultural barriers, rural
M ICHIGAN
Alcona Health Centers
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. T here are 0.25 psychiatrists as well as one psychologist and two behavioral health
consultants in the four-county service area. T he main providers of behavioral health are primary care
physicians. T he primary reason patients are generally unable to access behavioral health services is the
lack of qualified behavioral health specialists in primary health care settings. T he target area is
designated as a Health Professional Shortage Area and a Medically Underserved Area.
T he primary members of the consortium include Alcona Health Centers, Thunder Bay Community Health
Services, Alpena General Hospital, and Northern Collaborative Care.
M ICHIGAN
Sanilac Medical Services, Inc.
Program Director
TOPIC AREAS
EMS Providers, Capacity Building
PROJECT PERIOD
May 1, 2005 – April 30, 2007
K ATHY E. B ALCER
SANILAC MEDICAL SERVICES , I NC.
119 EAST SANILAC R OAD, SUITE 1
SANDUSKY , MICHIGAN 48471-1184
PHONE : (810) 648-3092
F AX : (810) 648-2513



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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
T he primary target audience is residents living in Huron and Sanilac
counties located in the “ Thumb” of the mitten-shaped state of
Michigan.
T he primary target audience is residents living in Huron and Sanilac
counties located in the “ Thumb” of the mitten-shaped state of
Michigan.
SANILAC MEDICAL SERVICES , I NC.
SANDUSKY , MI 48471-1184
ORHP Contact:
JACOB R UEDA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0835
JRUEDA@ HRSA. GOV
PROJECT SUMMARY
T he 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. T his will enable Huron
and Sanilac counties to replace outgoing EMS volunteers and build their volunteer rosters. A twopronged 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.
T he primary target audience is residents living in Huron and Sanilac counties located in the “ Thumb” of
the mitten-shaped state of Michigan. T he 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.
M ICHIGAN
Sanilac Medical Services, Inc.
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.
M ICHIGAN
Tuscola County Health Department
Program Director
TOPIC AREAS
Obesity/overweight
PROJECT PERIOD
May 1, 2006 – April 30, 2008



ANN H EPFER
TUSCOLA C OUNTY H EALTH
D EPARTMENT
1309 C LEAVER R OAD, SUITE B
C ARO, MI 48723
PHONE : (989) 673-8114, EXT. 115
F AX : (989) 673-6191
E-MAIL: AHEPFER@TCHD. US
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he T uscola 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.
AREAS SERVED
Huron and Sanilac Counties
T he T ask Force has emphasized the need to address childhood obesity
and reach youth who have a greater propensity for change than adults.
TUSCOLA C OUNTY H EALTH
D EPARTMENT
C ARO, MI 48723
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he T humb Area Nutrition and Physical Activity Campaign is a result
of a community health assessment conducted by the T humb Rural
Health Network. Results indicated that the overarching issue related
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. T he proposed project is the result of 15 months of research and
planning by the task force.
T he T uscola 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) T o 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) T o reduce the proportion of adults who are obese from 28.8 percent to 26.8 percent by 2015; 3)
T o reduce the proportion of children and adolescents that are overweight or obese from 40 percent to 30
percent by 2015; and 4) T o 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.
T he T humb Steps Up T ask Force has developed a community-wide campaign that goes beyond health
education. T he campaign is based on State models and Centers for Disease Control and Preventionrecommended 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
M ICHIGAN
Tuscola County Health Department
Eating"; and providing technical assistance to grocers, restaurants, human service providers,
governmental bodies, schools, and worksites. T he T ask 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. T herefore,
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: T he percentage of youth exhibiting healthy eating behaviors will increase significantly.
 Outcome 8: T he percentage of youth exhibiting physical activity behaviors will increase significantly.
M ICHIGAN
Helen Newberry Joy Hospital
Program Director
TOPIC AREAS
Obesity/overweight
PROJECT PERIOD
May 1, 2006 – April 30, 2008
L AURA F RISCH, F.N.P.
H ELEN N EWBERRY JOY H OSPITAL
502 W. H ARRIE STREET
N EWBERRY , MI 49868-1209
PHONE : (906) 477-6066
E-MAIL: FRISCHLA@PORTUP . COM



Year 1 - 149,988.00
Year 2 - 124,999.00
Year 3 - 100,000.00
T he consortium partners are Mackinac Straits Hospital, a critical
access hospital, and Marquette General Health System, a 364-bed
regional referral center.
AREAS SERVED
T he project targets families in three counties in Michigan’s Upper
Peninsula—Luce Mackinac, and Marquette.
T hese 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.
H ELEN N EWBERRY JOY H OSPITAL
N EWBERRY , MI 49868-1209
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T wo critical access hospitals have joined with their regional referral center to reduce the proportion of
children and adolescents who are overweight or obese. T he project targets families in three counties in
Michigan’s Upper Peninsula—Luce Mackinac, and Marquette. T hese 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.
T his 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.
M ICHIGAN
Helen Newberry Joy Hospital
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.
T he 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.
M ICHIGAN
Road to Good Health
Program Director
TOPIC AREAS
School-based
PROJECT PERIOD
May 1, 2007 – April 30, 2010



MARY K AYE R UEGG
EASTERN U PPER PENINSULA
I NTERMEDIATE SCHOOL D ISTRICT
P.O. B OX 883
315 ARMORY PLACE
SAULT STE MARIE , MI 49783
906-632-3373, EXT. 143
F AX –906-632-1125
MRUEGG@ EUP . KL2. MI. US
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T he consortium will target the 4 - 18 age population, with
approximately 40% Native American and 60% Caucasian ethnicities.
T he school based health clinics will result in 4,500 health service
encounters during the first year for 400 children.
EASTERN U PPER PENINSULA
I NTERMEDIATE SCHOOL D ISTRICT
SAULT STE MARIE , MI 49783
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he 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 T ownships. Goals of the Road to Good Health are:
1) T o work together to strengthen the collaborative relationships within the consortium and expand to
include additional health care providers and, 2) T o 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
M ICHIGAN
Road to Good Health
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. T hese 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. T he 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. T he 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.
M ICHIGAN
Dental Access Program
Program Director
TOPIC AREAS
Medical, dental, vision and mental health services
PROJECT PERIOD
May 1, 2007 – April 30, 2010



ARLENE B RENNAN
THE GRAND TRAVERSE R EGIONAL H EALTH
C ARE C OALITION
3155 L OGAN VALLEY R OAD
TRAVERSE C ITY MI 49686
231-935-0799
F AX –231-935-0795
BRENNANGTRHCC@ CHARTERINTERNET. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Dental Clinics North, T he T raverse Bay Area Intermediate School
District, Community Health Clinic, Inc., and T he Grand T raverse
Regional Health Care Coalition.
AREAS SERVED
Northwest Michigan
T he 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
T he Grand T raverse Regional Health Care Coalition (GT RHCC) is
a community-based network with a mission to improve access to
THE GRAND TRAVERSE R EGIONAL H EALTH
C ARE C OALITION
TRAVERSE C ITY MI 49686
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T his represents 37% of the total population in the 5
county area. T he evidence is clear, from our interviews and focus group of members of the target group,
that they have no access to dental care. T his group does not visit the dentist, 27% has active decay, and
18% look forward to having no natural teeth by age 65. T he incidence of sealant protection and fluoride
protection is 18%. Even with Medicaid for children only 25% of all children are receiving preventive
care. T his is a dental profession underserved area.
O ur 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. T raverse Bay Intermediate School District is working with us to launch the
school based programming.
O ur Goals—Our clients indicate that they need access to dental care and a “ Dental Home”. T hese goals
are important for Health People 2010. This Collaborative will attack dental access by integrating existing
M ICHIGAN
Dental Access Program
resources of our community as well as adding resources to meet the needs. T o 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 T echnology (paperless dental record).
Our program is multi-fold:




School Age Programs
 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)
 School Referrals - in cooperation with the health department and T BAISD, 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.
Be nefits—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. T his effort is sustainable because of the broad collaborative of support and by the program
design. T he difficult part is getting the processes in place. T he Coalition will supplement HRSA grant
funds with the help of our community-based collaborative.
M ICHIGAN
Healthy Families Applicant
Program Director
TOPIC AREAS
School (nutrition)
PROJECT PERIOD
May 1, 2007 – April 30, 2010



TERESA F RANKOVICH, M.D., M.P.H.,
FAAP
BHK C HILD D EVELOPMENT B OARD
700 PARK AVENUE
I-I OUGHTON, MI 49931
906-482-3663
F AX –906-482-7329
TLFRANKO@ BHKFIRST. ORG,
BHK@, BHKFIRST. ORG
Year 1 - 149,918.00
Year 2 - 124,998.00
Year 3 - 100,000.00
T he 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.
AREAS SERVED
Baraga, Houghton and Keweenaw counties in Michigan’s Upper
Peninsula are rural, rugged and remote.
T he 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.
B ARAGA-H OUGHTON-K EEWEENAW
I-I OUGHTON, MI 49931
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
Baraga, Houghton and Keweenaw counties in Michigan’s Upper Peninsula are rural, rugged and remote.
T he region, known as the Copper Country for its copper-mining past, is home to approximately 1,500
children aged 3 to 5. T he 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.
T he 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. T he project seeks to improve the health and wellness of rural families with young
children. T he project has three cornerstone goals, each of which has specific, measurable objectives. T he
goals, which align with Healthy People 2010 goals, are to: 1) To improve the health and wellness of 400
preschool children; 2) T o increase the health and wellness of 400 families with preschoolers; 3) T o further
expand collaboration between agencies/institutions promoting wellness and disease prevention and to
M ICHIGAN
Healthy Families Applicant
increase utilization of their services by community members. Key activities include inclusion of researchbased and validity tested physical activity and nutrition curricula in preschool classrooms; parentinvolvement 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 T eresa 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.
T he 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.
M INNES OTA
Le Sueur County Department of Human Services
Program Director
TOPIC AREAS
Primary care, Dental care, Promotoras
PROJECT PERIOD
May 1, 2003 – April 30, 2005
SUSAN R YNDA
L E SUEUR C OUNTY D EPARTMENT OF
H UMAN SERVICES
88 SOUTH PARK AVENUE
L E C ENTER, MINNESOTA 56057
PHONE : (507) 357-8288 EXT. 310
F AX : (507) 357-6122



Year 1 - 171,479.00
Year 2 - 166,264.00
Year 3 - 177,456.00
LeSueur County Department of Human Services, LeSueur County
Family Services Collaborative, Minnesota State University-Mankato
Dental Hygiene, Saludando Salud, and the New Ulm Medical CenterAllina Health System.
AREAS SERVED
LeSueur and Brown counties in south central Minnesota.
T o improve the overall health and dental status of the uninsured and
underserved rural Latino population.
SUEUR C OUNTY D EPARTMENT
H UMAN SERVICES
L E C ENTER, MN 56057
OF
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he goal of the Reaching Out with Saludando Salud project is to
improve the overall health and dental status of the uninsured and
underserved rural Latino population residing in LeSueur and Brown
counties in south central Minnesota. The project is modeled on Saludando Salud, a program established
with Rural Health Outreach funds that has provided services to the Latino population in two other rural
counties in Minnesota. T he Reaching Out with Saludando Salud project will make extensive use of
bilingual Outreach Workers/Community Health Advisors (CHAs) in each county to work directly with
the target population and with health care providers. T he target population served by the Reaching Out
project is the Latino population residing in LeSueur County (3.9 percent of the total population, or 997
Latinos) and the Latino population in Brown County (2 percent of the total population, or 545 Latinos).
Access barriers to services for the target population include very limited access to dental clinics by the
Medical Assistance population, lack of health/dental insurance, the lack of culturally specific health
education for Latinos in the target counties, high incidence rates of certain diseases, such as type 2
diabetes, low educational levels, and low income levels (approximately 83 percent of respondents to the
1999 Latino Health Survey reported annual household income levels under $20,000). The service area
for the project is a designated Health Professional Shortage Area.
T he network partners are LeSueur County Department of Human Services, the lead applicant, LeSueur
County Family Services Collaborative, Minnesota State University-Mankato Dental Hygiene, Saludando
Salud, and the New Ulm Medical Center-Allina Health System.
M INNES OTA
Northwestern Mental Health Center
Program Director
TOPIC AREAS
Mental Health Services
PROJECT PERIOD
May 1, 2005 – April 30, 2007
B RENDA ANDERSON
N ORTHWESTERN MENTAL H EALTH
C ENTER
603 B RUCE STREET
C ROOKSTON, MINNESOTA 56716
PHONE : (218) 281-3940
F AX : (218) 281-6261



Year 1 - 180,835.00
Year 2 - 185,993.00
Year 3 - 191,300.00
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.
T he 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.
N ORTHWESTERN MENTAL H EALTH
C ENTER
C ROOKSTON, MN 56716
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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. T he consortium will provide professional homebased 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. T he 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.
T he 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
M INNES OTA
Northwestern Mental Health Center
boundaries of the White Earth Indian reservation. T he 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. T he 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.
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.
M INNES OTA
Cass County Health, Human and Veterans Services
Program Director
TOPIC AREAS
Women’s Health
PROJECT PERIOD
May 1, 2005 – April 30, 2007



ANE C. R ODGERS
C ASS C OUNTY H EALTH, H UMAN AND
VETERANS SERVICES
400 MICHIGAN AVENUE , W EST
P.O. B OX 40
W ALKER, MINNESOTA 56484-0040
PHONE : (218) 547-1340, EXT. 210
F AX : (218) 547-7232
Year 1 - 180,019.00
Year 2 - 194,670.00
Year 3 - 200,000.00
Consortium members include Cass County Health, Human, and
Veterans Services; T odd 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, T odd, and Wadena counties, the low-income, primarily rural
area the project will serve.
T he target population is women of reproductive age, with an
emphasis on low-income or uninsured/underinsured women.
C ASS C OUNTY H EALTH, H UMAN AND
VETERANS SERVICES
W ALKER, MINNESOTA 56484-0040
ORHP Contact:
JULIE B RYAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0736
JCHANG@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he 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. T he 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, T odd, and Wadena counties, the
low-income, primarily rural area the project will serve. T he target population is women of reproductive
age, with an emphasis on low-income or uninsured/underinsured women. T he majority of the population
M INNES OTA
Cass County Health, Human and Veterans Services
in all three counties is white. T he American Indian population (10.8 percent in Cass County, 0.5 percent
in T odd 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. T odd 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. T hirty 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. T he project
population is a Medically Underserved Population.
Consortium members include Cass County Health, Human, and Veterans Services; T odd 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.
M INNES OTA
Rice Memorial Hospital
Program Director
TOPIC AREAS
Dental
PROJECT PERIOD
May 1, 2006 – April 30, 2008
L AWRENCE MASSA
R ICE MEMORIAL H OSPITAL
301 B ECKER AVENUE SW
W ILLMAR, MN 56201
PHONE : (320) 231-4227
E-MAIL: LORRY @RICE . WILLMAR. MN. US



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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
T he 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.
T he 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.
R ICE MEMORIAL H OSPITAL
W ILLMAR, MN 56201
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T he 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 interprofessional education; and 6) strengthening the dental clinic infrastructure.
T he 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
M INNES OTA
Rice Memorial Hospital
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.
T he Rice Regional Dental Clinic will be constructed on the campus of Rice Memorial Hospital in
Willmar, Minnesota. T he 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.
M INNES OTA
Early Intervention Mental and Behavioral Health Outreach Services
Program Director
TOPIC AREAS
Maternal/Child Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010



GARY R USSELL
EVERGREEN H OUSE , I NC.
622 MISSISSIPPI AVENUE
P.O. B OX 662
B EMIDJI, MN
218-751-4332
F AX –218-751-8070
GARY @ EVERGREENHOUSE . ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T o 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
E V E R GR E E N H OU S E , I N C .
B E MI D J I , MN 5 6 6 1 9
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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). T his 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.
T he 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 T ribe’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.
T he 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
M INNES OTA
Early Intervention Mental and Behavioral Health Outreach Services
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. T he two reservations are also designated
Health Professional Shortage Areas.
T he 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.
M IS S IS S IPPI
Claiborne County Family Health Center
Program Director
TOPIC AREAS
Primary Health Care, Prevention Services, Health Education
PROJECT PERIOD
May 1, 2005 – April 30, 2007



C ONEY L. JOHNSON
C LAIBORNE C OUNTY F AMILY H EALTH
C ENTER
P.O. B OX 741
PORT GIBSON, MISSISSIPPI 391500741
PHONE : (601) 437-3052
F AX : (601) 437-3051
Year 1 - 196,236.00
Year 2 - 185,750.00
Year 3 - 178,123.00
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.
T he target population is students in the Claiborne County Public
School District.
C LAIBORNE C OUNTY F AMILY H EALTH
C ENTER
PORT GIBSON, MS 39150-0741
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he 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. T he 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.
T he service area, Claiborne County, is located in the mid-Mississippi Delta region—the poorest region of
the United States. T he target population is students in the Claiborne County Public School District.
Currently, there is limited access to health care in the schools. T he majority (approximately 99.8 percent)
M IS S IS S IPPI
Claiborne County Family Health Center
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. T he 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-topatient 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.
M IS S OURI
Randolph County Health Department
Program Director
TOPIC AREAS
Dental care
PROJECT PERIOD
May 1, 2003 – April 30, 2005



C ARLA PRICE
R ANDOLPH C OUNTY H EALTH
D EPARTMENT
423 EAST L OGAN
P.O. B OX 488
MOBERLY , MISSOURI 65270
PHONE : (660) 263-6643 EXT. 3022
F AX : (660) 263-0333
Year 1 - 93,095.00
Year 2 - 93,025.00
Year 3 - 81,349.00
Randolph County Health Department, the lead applicant; Byland and
Johnson, D.D.S., Inc.; ProDental; and the Mid Missouri Dental
Center.
AREAS SERVED
Randolph County, Missouri
T o decrease dental disease and poor oral health in low-income
families in Randolph County, Missouri
R ANDOLPH C OUNTY H EALTH
D EPARTMENT
MOBERLY , MO 65270
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he goal of the Filling the Gaps program is to decrease dental disease
and poor oral health in low-income families in Randolph County,
Missouri. T he Filling the Gaps program will accomplish the goal
through two strategies: increasing access to dental care via an expansion of the outreach clinic and
voucher system and promoting dental hygiene in the schools, in the Women, Infants, and Children’ (WIC)
Nutrition program, and in the health department’s primary care clinic.
T he direct care component of the Filling in the Gaps program will target low-income residents of
Randolph County. T he educational component of the program will target all children and youth (4,250)
in the public schools in Randolph County and children and adults receiving services through the WIC
program and the health department’s primary care clinic (1,500 individuals). T he population in Randolph
County is 91 percent Caucasian, 7 percent African American, and 2 percent Hispanic. Approximately
17 percent of all residents live in poverty, and 44 percent of children residing in the county receive
Medicaid. Access barriers to services include a severe shortage of dentists, a waiting period of 6-7
months for a dental appointment, and limitations on emergency dental care for low-income individuals.
T he service area is designated as a Health Professional Shortage Area.
T he network partners are the Randolph County Health Department, the lead applicant; Byland and
Johnson, D.D.S., Inc.; ProDental; and the Mid Missouri Dental Center.
M IS S OURI
Princeton R-V School District
Program Director
TOPIC AREAS
Behavioral Health Care
PROJECT PERIOD
May 1, 2005 – April 30, 2007
C HERYL SNAPP
PRINCETON R-V SCHOOL D ISTRICT
1008 EAST C OLEMAN STREET
PRINCETON, MISSOURI 64673-1210
PHONE : (660) 748-3211
F AX : (660) 748-3212



Year 1 - 192,941.00
Year 2 - 192,292.00
Year 3 - 199,910.00
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.
PRINCETON R-V SCHOOL D ISTRICT
PRINCETON, MO 64673-1210
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
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.
PROJECT SUMMARY
T he 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. T he 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.
T he 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. T he target
population is 921 Mercer County students and 124 farm families in the context of family, school, and
community. T he county is 98.7 percent Caucasian. In 2002, there were 3,669 residents with a median
M IS S OURI
Princeton R-V School District
age of 42.4. Depression is a major health issue, and the county has the state’s highest suicide rate. T he
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.
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.
M IS S OURI
District III Area Agency on Aging
TOPIC AREAS
Primary Health Care, Health Education, Social Support Services
PROJECT PERIOD
May 1, 2005 – April 30, 2007
Program Director
K ATHLEEN ANNE H OWARD
D ISTRICT III AREA AGENCY ON AGING
106 W EST YOUNG STREET
W ARRENSBURG, MISSOURI 640931124
PHONE : (660) 747-3107



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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
T he target population is medically underserved and uninsured residents
of Lafayette County, Missouri.
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.
D ISTRICT III AREA AGENCY ON AGING
W ARRENSBURG, MISSOURI 640931124
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he goal of the Lafayette County 4 Health Project, a 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. T he 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. T he 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.
T he target population is medically underserved and uninsured residents of Lafayette County, Missouri.
T here 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. T he 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. T here 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-topopulation 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.
M IS S OURI
Southeast Health On Wheels (S.H.O.W.) Mobile Project
Program Director
TOPIC AREAS
Mobile (Oral, HL)
PROJECT PERIOD
May 1, 2007 – April 30, 2010



SANDY ORTIZ
SOUTHEAST MISSOURI STATE
U NIVERSITY
ONE U NIVERSITY PLAZA, MS 1900
C APE GIRARDEAU, MO
573-651-5980
F AX –673-651-5981
SJORTIZ@ SEMO. EDU
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Southeast Missouri State University, Campbell Housing Authority,
Delta Area Economic Opportunity Corporation (DAEOC), Oasis
Center, and T rinity Community Church
AREAS SERVED
T he 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.
Dunklin, Mississippi, New Madrid and Pemiscot counties) have been
well documented.
SOUTHEAST MISSOURI STATE
U NIVERSITY
C APE GIRARDEAU, MO 63701
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he Southeast Health On Wheels (S.H.O.W.) Mobile Project is a
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. T he program is
administered by the College of Health and Human Services of Southeast Missouri State University. T he
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.
T he needs of the target population (Dunklin, Mississippi, New Madrid and Pemiscot counties) have been
well documented. T he 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
M IS S OURI
Southeast Health On Wheels (S.H.O.W.) Mobile Project
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. T he 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.
T he 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).
T he amount of funding being requested for this project is $150,000 in Year One
($375,000 over three years).
M ONTANA
St. Luke’s Community Hospital
Program Director
TOPIC AREAS
Primary care
PROJECT PERIOD
May 1, 2003 – April 30, 2005
SHANE R OBERTS
ST. L UKE ’ S C OMMUNITY H OSPITAL
107 6TH AVENUE SOUTH W EST
R ONAN, MONTANA 59864
PHONE : (406) 676-4441
F AX : (406) 676-0835



Year 1 - 199,580.00
Year 2 - 199,721.00
Year 3 - 189,465.00
St. Luke Community Hospital, Barrett Memorial Hospital, Clark Fork
Valley Hospital, Marcus Daly Memorial Hospital, Mineral
Community Hospital, Powell County Memorial Hospital, Granite
County Hospital, Steel Memorial Hospital, Ruby Valley Hospital, and
Monida Healthcare Network.
AREAS SERVED
Western Montana and Eastern Idaho region. T he service area is a
designated Health Professional Shortage Area.
T he Western Montana/Eastern Idaho Specialty Outreach Network
will improve the quality of life and health status in the western
Montana and eastern Idaho region by establishing a sphere model of a
sustainable, integrated system that links rural primary care physicians
and their local hospitals with consulting/visiting specialists and with a
regional referral center.
ST. L UKE ’ S C OMMUNITY H OSPITAL
R ONAN, MT 59864
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Western Montana/Eastern Idaho Specialty Outreach Network will improve the quality of life and
health status in the western Montana and eastern Idaho region by establishing a sphere model of a
sustainable, integrated system that links rural primary care physicians and their local hospitals with
consulting/visiting specialists and with a regional referral center. T he project plans on establishing 192
new rural specialty clinics offered on a visiting basis in Year 1 and increasing the number of clinics to
312 by Year 2.
T he target population—which is 91 percent Caucasian, 6 percent American Indian, 2 percent Hispanic,
and less than 1 percent African American—includes residents of a nine-county region that covers almost
26,000 square miles. T he demographic characteristics of the service area underline the need for local
specialists. Approximately 16 percent of the total population are seniors over the age of 65, 6 percent of
the population is Native American, and the area’s average household income is 25 percent lower than the
national average. Access barriers to services include long travel distances resulting from geographic
isolation, the lack of local physician specialists, and physician opportunity costs (lost revenue from time
away from a primary clinic). The service area is a designated Health Professional Shortage Area.
M ONTANA
St. Luke’s Community Hospital
T he network partners are St. Luke Community Hospital, the lead applicant, Barrett Memorial Hospital,
Clark Fork Valley Hospital, Marcus Daly Memorial Hospital, Mineral Community Hospital, Powell
County Memorial Hospital, Granite County Hospital, Steel Memorial Hospital, Ruby Valley Hospital,
and Monida Healthcare Network.
M ONTANA
Lincoln County, State of Montana
Program Director
TOPIC AREAS
Case management, Health promotion/disease prevention (specific:
asbestos related diseases)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
K AROL SPAS
L INCOLN C OUNTY , STATE OF MONTANA
418 MAIN STREET
L IBBY , MONTANA 59923
PHONE : (406) 293-2660
F AX : (406) 293-9282



Year 1 - 133,744.00
Year 2 - 162,267.00
Year 3 - 190,477.00
Lincoln County, St. John’s Lutheran Hospital and its Center for
Asbestos-Related Disease (CARD) Clinic, the Asbestos-Related
Health Care Project (ARHCP), Libby Clinic, and the Lincoln County
Community Health Center.
AREAS SERVED
Lincoln County
T he target population is individuals who have been directly or
indirectly exposed to tremolite asbestos through the mining and
processing of vermiculite.
L INCOLN C OUNTY , STATE OF MONTANA
L IBBY , MT 59923
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Asbestos-Related Disease Care Network will create an integrated system of care for victims of
asbestos exposure, including their families and caregivers. T he Network will provide patients with case
management, health education, referrals, and some direct services. T he Network also will provide health
care providers with better medical information about asbestos patients and their needs and will create a
hierarchy of payors to reduce the incidence of unpaid medical care that can threaten access for all. T he
target population for the program is individuals residing in Lincoln County who have been directly or
indirectly exposed to tremolite asbestos through the mining and processing of vermiculite. In 2000,
testing from the Agency for T oxic Substances and Disease Registry (AT SDR) indicated that
approximately 1,000 persons in the Libby, Montana area had pleural abnormalities associated with
asbestos exposure. An estimated 80 percent of the individuals diagnosed with asbestos-related disease
from the Libby exposure still reside within a 25-mile radius of the screening clinic, an area that includes
Libby and the neighboring city of T roy.
T he target population for the project is 96 percent Caucasian, 2.3 percent Hispanic, 1.2 percent American
Indian, 0.4 percent Asian/Pacific Islander/Alaska Native, and 0.01 percent African American. Access
barriers to services include long travel distances resulting from rural isolation, the lack of public
transportation, a culture of poverty resulting from low educational levels, a high unemployment rate that
is more than two times the state average, a high percentage of uninsured (21 percent) residents, and the
lack of specialty care for individuals with asbestos-related disease in Lincoln County. T he service area is
a designated Health Professional Shortage Area.
M ONTANA
Lincoln County, State of Montana
T he network partners are Lincoln County, the lead applicant, St. John’s Lutheran Hospital and its Center
for Asbestos-Related Disease (CARD) Clinic, the Asbestos-Related Health Care Project (ARHCP), Libby
Clinic, and the Lincoln County Community Health Center.
M ONTANA
Critical Illness and Trauma Foundation, Inc.
Program Director
TOPIC AREAS
Provider training, Continuing medical education (CME)
PROJECT PERIOD
May 1, 2004 – April 30, 2006



TERI L. SANDDAL
ASSOCIATE D IRECTOR
R ESEARCH/I NJURY PREVENTION
C RITICAL I LLNESS AND TRAUMA
F OUNDATION, I NC.
300 N ORTH W ILLSON AVENUE , #3002
B OZEMAN, MT 59715
PHONE : (406) 585-2659
F AX : (406) 585-2741
Year 1 - 199,974.00
Year 2 - 199,974.00
Year 3 - 199,974.00
T he Critical Illness and T rauma Foundation, the Burns
T elecommunications Center at Montana State University, the Billings
Area Indian Health Service, the National Association of Emergency
Medical Service Physicians, the National Association of State
Emergency Medical Service Directors, and other collaborators seek to
modify the delivery format of a training program titled: Guide for
Preparing Medical Directors, currently distributed by the National
Highway T raffic Safety Administration.
C RITICAL I LLNESS AND TRAUMA
F OUNDATION, I NC.
B OZEMAN, MT 59715
ORHP Contact:
AREAS SERVED
T argeting the states of Alaska, Kansas, and Montana, 40 percent of
the secondary and tertiary population served will be Alaskan Natives
or American Indians.
T he goal of the project is to develop the Guide for Preparing Medical
Directors into an electronically delivered, mentor-supported, selfstudy program to train medical oversight physicians in rural, frontier,
and wilderness locations.
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
One of the most pressing needs for rural emergency medical services (EMS) systems is ongoing medical
oversight. T his is true regardless of whether the emergency medical response is provided by a volunteer,
government, fire department, hospital-based, or other organization. Rural physicians are required to
provide this oversight, often without training or understanding of the task. T hey are frequently
constrained by their ability to travel to medical oversight training offered within or outside their
geopolitical jurisdiction. T he lack of medical oversight within rural EMS systems impacts patient care,
utilization of health resources, and the preparation for large-scale disaster responses.
T he Critical Illness and T rauma Foundation, the Burns T elecommunications Center at Montana State
University, the Billings Area Indian Health Service, the National Association of Emergency Medical
Service Physicians, the National Association of State Emergency Medical Service Directors, and other
collaborators seek to modify the delivery format of a training program titled: Guide for Preparing
Medical Directors, currently distributed by the National Highway T raffic Safety Administration. T he
goal of the project is to develop the Guide for Preparing Medical Directors into an electronically
M ONTANA
Critical Illness and Trauma Foundation, Inc.
delivered, mentor-supported, self-study program to train medical oversight physicians in rural, frontier,
and wilderness locations. By making these materials available online, it is anticipated that medical
oversight training will become more widely available resulting in benefits to the emergency medical
services and disaster response systems in rural areas. T he demographic and ethnographic characteristics
of the target population will mirror the rural and frontier populations that the EMS agencies serve.
T argeting the states of Alaska, Kansas, and Montana, 40 percent of the secondary and tertiary population
served will be Alaskan Natives or American Indians. T he remaining ethnic mix will be predominately
Caucasian with a substantial mix of Hispanic/Latino individuals.
M ONTANA
Butte Silver Bow Primary Health Care Clinic, Inc.
(AKA Butte Community Health Center)
Program Director
TOPIC AREAS
Child Sexual Abuse, Education/Prevention
PROJECT PERIOD
May 1, 2005 – April 30, 2007



C INDY STERGAR
B UTTE SILVER B OW PRIMARY H EALTH
C ARE C LINIC, I NC.
(AKA B UTTE C OMMUNITY H EALTH
C ENTER)
445 C ENTENNIAL AVENUE
B UTTE , MONTANA 59701-2870
PHONE : (406) 496-6003
F AX : (406) 723-3059
Year 1 - 191,318.00
Year 2 - 165,475.00
Year 3 - 155,267.00
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.
T he target population is children at risk for sexual abuse or who have
been sexually abused within Butte and the surrounding area.
B UTTE SILVER B OW PRIMARY H EALTH
C ARE C LINIC, I NC.
(AKA B UTTE C OMMUNITY H EALTH
C ENTER)
B UTTE , MT 59701-2870
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he consortium will employ three strategies:
(1) prevention education for preschool and young children (grades K–3) using the T alking About
T ouching 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. T his 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. T here 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
M ONTANA
Butte Silver Bow Primary Health Care Clinic, Inc.
(AKA Butte Community Health Center)
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.
T he 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.
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.
M ONTANA
Wheatland Memorial Hospital & Nursing Home
Program Director
TOPIC AREAS
Chronic disease, Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008



D IANE JONES , R.N. D.O.N.
W HEATLAND MEMORIAL H OSPITAL &
N URSING H OME
530 3RD STREET, N.W.
H ARLOWTON, MT 59036-0307
PHONE : (406) 632-4351
E-MAIL:
DIANE . JONES @ WHEATLANDMEMORIAL. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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 T elemedicine 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.
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.
W HEATLAND MEMORIAL H OSPITAL &
N URSING H OME
H ARLOWTON, MT 59036-0307
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he 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 T elemedicine Network); and the South Central Montana Community Mental Health
Center (regional mental health services). All of the urban partners are located in Billings Montana.
T he 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.
M ONTANA
Wheatland Memorial Hospital & Nursing Home
T he 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. T he 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. T he 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.
M ONTANA
Fort Peck Assiniboine Sioux Tribes
Program Director
TOPIC AREAS
Mental health, Substance abuse, T elemedicine
PROJECT PERIOD
May 1, 2006 – April 30, 2008
K ENNETH SMOKER
F ORT PECK ASSINIBOINE SIOUX TRIBES
P.O. B OX 1027
POPLAR, MT 59255
PHONE : (406) 768-3469



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
the T ribal 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
T he Rural Access: Mental Health Care Project will increase
behavioral and mental health care services to low-income American
Indian children and youth living.
F ORT PECK ASSINIBOINE SIOUX TRIBES
POPLAR, MT 59255
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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. T his 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. T he
project also establishes a Harvard Medical School Psychiatric Internship Program that will station a postdoctoral fellow on the Fort Peck Indian Reservation for 6 months per year. T he project consortium
estimates that psychiatric care services will be increased by 420 new patient visits in both Year 2 and
Year 3.
M ONTANA
Cooperative Health Center, Inc.
Program Director
TOPIC AREAS
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
K ATHERINE W ILSON
EXECUTIVE D IRECTOR
C OOPERATIVE H EALTH C ENTER, I NC.
1930 N INTH AVENUE
H ELENA, MT 59601
PHONE : (406) 457-8956
F AX : (406) 457-8990
E-MAIL: KWILSON@CO. LEWIS -CLARK. MT. US
W EB SITE : WWW . CO. LEWIS CLARK. MT. US / HEALTH/ COOPERATIVE / INDEX . PHP
T he CHC will collaborate with two other federally supported
mental health/substance abuse service providers in the county,
Golden T riangle Community Mental Health Center and Boyd
Andrew Community Services.
AREAS SERVED
Lewis & Clark Counties
Low-income Lewis & Clark County residents have high rates of
mental illness, yet access to affordable mental health care
services is almost non-existent.
C OOPERATIVE H EALTH C ENTER, I NC.
H ELENA, MT 59601
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
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. T he three-agency consortium formed for this project will provide access to
mental health and substance abuse services, regardless of patients' ability to pay.
T he CHC will collaborate with two other federally supported mental health/substance abuse service
providers in the county, Golden T riangle Community Mental Health Center and Boyd Andrew
Community Services. Golden T riangle 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, solutionfocused therapy, mastery of panic and anxiety, brief alcohol intervention, and psychotherapy, when
M ONTANA
Cooperative Health Center, Inc.
judged appropriate. MH/SA services will be delivered during patients' primary care visits and during oneon-one visits with MH/SA providers, who will include a CHC mental,health specialist and a Golden
T riangle 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. T his 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.
T he 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.
T he CHC will track MH/SA patients with an expanded registry modeled on the Depression Collaborative
registry. T he case manager will use the registry to follow patients' progress and manage their treatments,
medications, and connections with necessary community services.
T he 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.
N EB RAS KA
DBA Great Plains Regional Medical Center
Program Director
TOPIC AREAS
Patient tracking
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Year 1 - 198,821.00
Year 2 - 198,821.00
Year 3 - 150,532.00
Great Plains Regional Medical Center (the lead applicant and a notfor-profit community-owned hospital in North Platte, Nebraska) and
13 other hospitals—Box Butte General Hospital, Cambridge
Memorial Hospital, Chase County Hospital, Cherry County Hospital,
Community Hospital, Decatur County Hospital, Dundy County
Hospital, Gothenburg Memorial Hospital, Jennie Melham Memorial
Medical Center, Ogallala Community Hospital, Perkins County
Hospital, T ri-County Hospital, and Valley County Hospital.
AREAS SERVED
Rural west-central Nebraska and Kansas.
Will create a master database of diagnostic images (x-rays, CT scans,
and MRIs) by patients using 14 hospitals in a 22-county region of
rural west-central Nebraska and Kansas.
L ANNA W EBSTER
N ORTH PLATTE N EBRASKA H OSPITAL
C ORPORATION
DBA GREAT PLAINS R EGIONAL
MEDICAL C ENTER
601 W EST L EOTA
P.O. B OX 1167
N ORTH PLATTE , N EBRASKA 69103
PHONE : (308) 535-7495
F AX : (308) 534-5422
DBA GREAT PLAINS R EGIONAL
MEDICAL C ENTER
N ORTH PLATTE , NE 69103
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Common Master Patient Index (CMPI) project will create a master database of diagnostic images (xrays, CT scans, and MRIs) by patients using 14 hospitals in a 22-county region of rural west-central
Nebraska and Kansas. T he CMPI project will make the entire database of images available to all 14
hospitals, decreasing or eliminating the need for repeat procedures and delays in treatment. The CMPI
project will require each of the partner hospitals to commit to storing their diagnostic images digitally in a
central archive; commit to using the capabilities of the CMPI as part of their standard care procedures;
and commit to contributing toward the cost of the CMPI.
T he target population of patients served by the 14 hospitals is 90.81 percent Caucasian, 7.24 percent
Hispanic, 0.79 percent American Indian, 0.38 percent Asian/Pacific Islander/Alaska Native, and
0.27 percent African American. Access barriers to services include lack of access to hospital care
because of geographic isolation, the lack of sufficient medical personnel, and a highly mobile rural
population, which results in treatment at different hospitals in the region. Of the 22 counties served by
the CMPI project, 17 are designated in whole or in part as either a Medically Underserved Area and/or a
Health Professional Shortage Area. Six of the hospitals participating in the project are Critical Access
Hospitals, and two more are in the process of applying for the designation.
N EB RAS KA
DBA Great Plains Regional Medical Center
T he network partners are the Great Plains Regional Medical Center (the lead applicant and a not-forprofit community-owned hospital in North Platte, Nebraska) and 13 other hospitals—Box Butte General
Hospital, Cambridge Memorial Hospital, Chase County Hospital, Cherry County Hospital, Community
Hospital, Decatur County Hospital, Dundy County Hospital, Gothenburg Memorial Hospital, Jennie
Melham Memorial Medical Center, Ogallala Community Hospital, Perkins County Hospital, T ri-County
Hospital, and Valley County Hospital.
N EB RAS KA
Panhandle Partnership for Health and Human Services
Program Director
TOPIC AREAS
Child health, Health education, Patient tracking
PROJECT PERIOD
May 1, 2003 – April 30, 2005



JEAN JENSEN
PANHANDLE PARTNERSHIP FOR
H EALTH AND H UMAN SERVICES
P.O. B OX 669
821 MOREHEAD STREET
C HADRON, N EBRASKA 69337
PHONE : (308) 432-2747
F AX : (308) 432-2737
Year 1 - 193,500.00
Year 2 - 177,250.00
Year 3 - 180,184.00
Panhandle Partnership for Health and Human Services; Chadron
Community Hospital; Garden County Health Services; Gordon
Memorial Hospital; Morrill County Community Hospital; Panhandle
Health Services; Western Community Health Resources; Bridgeport
Public Schools; Dawes County Schools; Garden County Schools;
Gordon Public Schools; and Mitchell Public Schools.
AREAS SERVED
Dawes, Garden, Morrill, Sheridan, and Scotts Bluff Counties in the
Panhandle region of Nebraska.
T argeting 3,200 school-age children (age 5-18) in child health
screenings, access to health care, integration of health and education,
childcare health consultants, and health promotion education.
PANHANDLE PARTNERSHIP FOR H EALTH
AND H UMAN SERVICES
C HADRON, NE 69337
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Child Health First project is a model program for delivering enhanced child health screenings, access
to health care, integration of health and education, childcare health consultants, and health promotion
education. Services include enhanced education-based child health clinics using local primary care
providers; the provision of nurses for case management, health education, and childcare health
consultants; creation of a secure, Internet-based Child Health Record; and the utilization of public health
surveillance data from the Child Health Records to create a database for planning the provision of
additional health education and service components.
T he Child Health First project is targeting 3,200 school-age children (age 5-18) in five counties (Dawes,
Garden, Morrill, Sheridan, and Scotts Bluff) in the Panhandle region of Nebraska. According to the 2000
Census, approximately 17 percent of the children in the Panhandle region live below 100 percent poverty,
compared to the state average of 11 percent, a high percentage of the regional population do not have
health insurance (12 percent) or are underinsured (21 percent). The target population of school children is
80 percent Caucasian, 12 percent Hispanic, and 7 percent American Indian. Access barriers to services
include rural isolation, a shortage of health professionals, reduced school budgets, the reluctance among
many residents to seek health care services, the economic downturn, and the lack of integration of
services. Garden, Morrill, and Sheridan counties are designated as full Health Professional Shortage
Areas, and Dawes County has a partial designation.
N EB RAS KA
Panhandle Partnership for Health and Human Services
T he network partners are the Panhandle Partnership for Health and Human Services, the lead applicant
and a community-based non-profit entity; Chadron Community Hospital; Garden County Health Services;
Gordon Memorial Hospital; Morrill County Community Hospital; Panhandle Health Services; Western
Community Health Resources; Bridgeport Public Schools; Dawes County Schools; Garden County
Schools; Gordon Public Schools; and Mitchell Public Schools.
N EB RAS KA
Goldenrod Hills Community Action, Inc.
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2003 – April 30, 2005



D USTI B ARGMANN
GOLDENROD H ILLS C OMMUNITY
ACTION, I NC.
1119 AVENUE EAST
P.O. B OX 280
W ISNER, N EBRASKA 68791
PHONE : (402) 529-3513
F AX : (402) 529-3209
Year 1 - 198,025.00
Year 2 - 198,025.00
Year 3 - 198,025.00
Goldenrod Hills Community Action, Franciscan Care Services, and
Northeast Health Care Partnership.
AREAS SERVED
Burt, Cuming, Madison, and Stanton in northeast Nebraska.
Provide diabetes screening, treatment, education, and prevention
services in the rural counties of Burt, Cuming, Madison, and Stanton
in northeast Nebraska. The service area is designated as a Health
GOLDENROD H ILLS C OMMUNITY
ACTION, I NC.
W ISNER, NE 68791
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he T argeting Lifestyle Changes (T LC) project will provide diabetes screening, treatment, education, and
prevention services in the rural counties of Burt, Cuming, Madison, and Stanton in northeast Nebraska.
T he T LC project will offer diabetes screening and education at a monthly clinic in each of the four
counties, combining Women’s, Infants, and Children (WIC) nutrition, immunization, and Well Child
Checks; individual case management and diabetes education; and dissemination of wellness information
in innovative ways.
T he target population for the T LC project is all underinsured or uninsured residents of the four-county
area. T he target population is approximately 88 percent Caucasian, 6 percent Hispanic, 3.5 percent other,
1 percent American Indian, 1 percent African American, and 0.20 Asian/Pacific Islander/Alaska Native.
Access barriers to services include a lack of insurance, limited access to physicians as a result of severe
drought and cultural barriers faced by the minority populations in the four-county area. T he service area
is designated as a Health Professional Shortage Area.
T he network partners are Goldenrod Hills Community Action, the lead applicant and a community action
agency that provides health and human services to 14 counties; Franciscan Care Services, a non-profit
hospital and rural health services program; Northeast Health Care Partnership, a collaboration of
individuals and agencies serving northeast Nebraska; and Elkhorn Logan Valley Health Department, a
newly formed health department serving four counties in northeast Nebraska.
N EB RAS KA
DBA Heartland Health Alliance
Program Director
TOPIC AREAS
T elehealth, Heart disease
PROJECT PERIOD
May 1, 2003 – April 30, 2005
C OLLEEN C HAPP
R URAL H EALTH PARTNERS , I NC.
DBA H EARTLAND H EALTH ALLIANCE
P.O. B OX 9
H OLBROOK, N EBRASKA 68948
PHONE : (402) 481-5192
F AX : (402) 481-4025



Year 1 - 198,208.00
Year 2 - 199,376.00
Year 3 - 199,640.00
Heartland Health Alliance (HHA) and 24 rural hospitals.
AREAS SERVED
HHA hospitals serve 34 of the 42 counties in Nebraska designated as
a Health Professional Shortage Area.
Will provide patients living in rural Nebraska with levels of cardiac
monitoring and cardiac consultation that meet current standards of
care for optimal outcomes.
DBA H EARTLAND H EALTH ALLIANCE
H OLBROOK, NE 68948
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Remote Electrocardiogram (ECG) Monitoring T elemedicine Project will provide patients living in
rural Nebraska with levels of cardiac monitoring and cardiac consultation that meet current standards of
care for optimal outcomes. T he Heartland Health Alliance (HHA), the lead applicant, is a 33-member
hospital network with hospitals in 29 of Nebraska’s 93 counties. As part of its Chest Pain and Cardiac
Program Initiative, the HHA will develop, implement, evaluate, and sustain the project. Remote
monitoring units will be located at 24 rural HHA hospitals, and a central monitoring unit will be located
at the BryanLCH Medical Center in Lincoln, Nebraska.
In Nebraska, a high proportion of the population in rural areas is affected by heart disease, requiring
excellence of care by local health providers and community hospitals for this high-risk population. T he
target population in the 24-county region is 88.3 percent Caucasian, 5.5 percent Hispanic, 4 percent
African American, 1.3 percent Asian/Pacific Islander/Alaska Native, and 0.9 percent American Indian.
Access barriers to services include the inability of rural community hospitals to provide levels of cardiac
care that have become the national standards, including the latest ECG technology to provide augmented
“ ST segment” ECG monitoring; continuous ECG monitoring; and a sufficient nursing workforce. HHA
hospitals serve 34 of the 42 counties in Nebraska designated as a Health Professional Shortage Area.
T he network partners are the HHA and 24 rural hospitals.
N EB RAS KA
Good Neighbor Community Health Center
Program Director
TOPIC AREAS
Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
JOLENE L ORDEMANN
GOOD N EIGHBOR C OMMUNITY H EALTH
C ENTER
ND
2282 EAST 32 AVENUE
C OLUMBUS , NE 60681
PHONE : (402) 563-9224
F AX : (402) 563-0554



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
AREAS SERVED
Rural medically underserved population of east central Nebraska.
T he specific needs of the underserved population of Hispanic
individuals and families
GOOD N EIGHBOR C OMMUNITY H EALTH
C ENTER
C OLUMBUS , NE 60681
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
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. T he overall goals of
the project are:
N EB RAS KA
Good Neighbor Community Health Center



T o 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
T o 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
T o 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.
T he 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.
N EB RAS KA
Staying Well at Home
Program Director
TOPIC AREAS
Elder Care
PROJECT PERIOD
May 1, 2007 – April 30, 2010



MARJORIE JONES
SAINT F RANCIS MEDICAL C ENTER
2126 W EST F AIDLEY AVENUE
P.O. B OX 9804
GRAND I SLAND, NE
308-398-2601
F AX –308-398-5823
MJ ON E S @ S F MC - GI . OR G
Year 1 - 149,976.00
Year 2 - 242,955.00
Year 3 - 392,931.00
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.
SAINT F RANCIS MEDICAL C ENTER
GRAND I SLAND, NE 68802
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
T he Central Nebraska Home Services T elecare Project proposes to serve the 15,466 elderly residents (age
65 and older) in nine counties. T he Staying Well at Home Coalition works with about 750 patients a year
through home healthcare services.
PROJECT SUMMARY
T he 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. T he 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. T hese 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.
N EB RAS KA
Staying Well at Home
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. T he 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)
T he 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.
T he Central Nebraska Home Services T elecare 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. T he Staying Well at Home Coalition works with about 750 patients a year through home
healthcare services.
T he use of telehealth monitors will allow more frail elderly residents to: 1) live at home, 2) improve selfmanagement 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.
N EB RAS KA
West Central District Health Department
Program Director
TOPIC AREAS
Dental services
PROJECT PERIOD
May 1, 2006 – April 30, 2008
SHIRLEEN SMITH
W EST C ENTRAL D ISTRICT H EALTH
D EPARTMENT
111 N ORTH D EWEY
PHONE : (308) 696-1201
E-MAIL: SHIRLEENSMITH@ALLLTEL. NET



Year 1 - 150,000.00
Year 2 - 90,000.00
Year 3 - 26,625.00
North Platte, Nebraska
Have formed a very limited dental clinic for youth up to age 18 whose
families meet the income requirements for Medicaid.
W EST C ENTRAL D ISTRICT H EALTH
D EPARTMENT
ORHP Contact:
PROJECT SUMMARY
L ILLY SMETANA
West Central District Health Department (WCDHD) has recognized a
PROJECT OFFICER
need for access to dental care among residents of its service area who
HRSA/ORHP
5600 F ISHERS L ANE
either rely on Medicaid or who self-pay for dental care. A survey of
residents in the eight counties served by WCDHD confirmed that
301-443-6884
Medicaid and self-pay residents forego dental care at much higher
LSMETANA@ HRSA. GOV
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,
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. T he experience with that clinic has convinced
WCDHD and its partners that a permanent clinic that serves both adults and youth is needed.
T herefore, 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.
N EVADA
Great Basin Primary Care Association
TOPIC AREAS
Dental care
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
R OGER VOLKER
GREAT B ASIN PRIMARY C ARE
ASSOCIATION
515 W EST 4TH STREET
C ARSON C ITY , N EVADA 89703
PHONE : (775) 887-0417
F AX : (775) 887-3562
Year 1 - 199,800.00
Year 2 - 199,800.00
Year 3 - 199,800.00
Great Basin Primary Care Association, the Nevada Office of Rural
Health; the State Health Division; and the Covering Kids Coalition.
AREAS SERVED
Fallon, Silver Springs, Yerington, Elko, Carson City, and
Winnemucca
Will provide the rural communities with licensed dental health
professionals at new and existing community-based dental sites.
GREAT B ASIN PRIMARY C ARE
ASSOCIATION
C ARSON C ITY , NV 89703
PROJECT SUMMARY
T he Nevada Rural Access Dental Project will provide the rural
communities of Fallon , Silver Springs, Yerington, Elko, Carson City,
ORHP Contact:
and Winnemucca with licensed dental health professionals at new and
VANESSA H OOKER
PROJECT OFFICER
existing community-based dental sites. T he project also will assist
HRSA/ORHP
the Covering Kids Coalition in increasing enrollment in Medicaid and
5600 F ISHERS L ANE
Nevada Check Up and will establish a pilot project to provide health
information to providers and consumers using WorldDoc. As the
301-594-5105
result of the passage of recent legislation (SB 133) in Nevada, there
VHOOKER@ HRSA. GOV
are now three new categories of licensure for dental providers that are
encouraging out-of-state providers to practice in rural areas of the state. With the Nevada Rural Access
Dental Project, dental professionals will provide services in the communities to the underserved
populations, including Medicaid and Nevada Check Up clients, the uninsured, working poor, children, the
elderly, and individuals with disabilities. T he target populations in the communities are 62 percent
Caucasian, 26 percent Hispanic, 10 percent American Indian, and 2 percent Asian/Pacific Islander/Alaska
Native.
T he state of Nevada ranks next to last in the United States for access to dental care. Underserved
populations in rural Nevada must travel up to 100 miles each way to seek dental services in Reno and Las
Vegas, and often must wait more than 6 months for an appointment. Children enrolled in the Head Start
program in Elko, Nevada must be taken to Salt Lake City, Utah for dental care, a round trip of 400 miles.
In 1999, five counties in Nevada had no dentist who accepted Medicaid. All or part of 17 out of 17
counties in Nevada are designated as Dental Health Care Professional Shortage Areas.
T he network partners are the Great Basin Primary Care Association, the lead applicant; the Nevada Office
of Rural Health; the State Health Division; and the Covering Kids Coalition, a project funded by the
N EVADA
Great Basin Primary Care Association
Robert Woods Johnson Foundation.
N EVADA
Great Basin College
Program Director
TOPIC AREAS
Human service training
PROJECT PERIOD
May 1, 2006 – April 30, 2008



D R. MICHAEL MCF ARLANE
VICE PRESIDENT FOR ACADEMIC
AFFAIRS
GREAT B ASIN C OLLEGE
1500 C OLLEGE PKWY
ELKO, NV 89801
PHONE : (775) 753-2187
E-MAIL: MIKEM@GWMAIL. GBCNV . EDU
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
T o 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.
GREAT B ASIN C OLLEGE
ELKO, NV 89801
ORHP Contact:
JULIE B RYAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0736
JCHANG@ HRSA. GOV
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
Nevada, GBC's service area covers over 45,000 square miles and includes the counties of Elko, Eureka,
Humboldt, Lander, and White Pine. T he 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. T he 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.
N EVADA
Great Basin College
T he 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).
T he project will seek to accomplish the following goals:
 T o 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.
N EVADA
BrightPath Adult Day Services, Inc.
Program Director
TOPIC AREAS
Health care
PROJECT PERIOD
May 1, 2006 – April 30, 2008



SYLVIA ELEXPURU
PROJECT D IRECTOR
B RIGHTPATH ADULT D AY
SERVICES , I NC.
P.O. B OX 279
ELKO, N EVADA 89803
PHONE : (775) 778-0547
E-MAIL: SELEX @FRONTIERNET. NET
Year 1 - 149,994.00
Year 2 - 149,994.00
Year 3 - 99,998.00
Center for Cognitive Aging’s (CCA) Alzheimer Disease Diagnostic
and T reatment Center (ADDTC).
AREAS SERVED
Geographically remote areas of Nevada and other western states.
T his project primarily serves the elderly, 65 year of age and over,
including American Indian and Hispanic populations.
B RIGHTPATH ADULT D AY
PROJECT SUMMARY
SERVICES , I NC.
T he goal of the Rural Dementia T elemedicine Initiative (RDTI)
ELKO, N EVADA 89803
project is to establish a long-term, sustainable method of service
delivery to Alzheimer's (dementia) patients, caregivers, and health
ORHP Contact:
care professionals involved in the delivery of diagnosis, disease
EILEEN H OLLORAN
PROJECT OFFICER
management, and treatment in rural and underserved communities of
HRSA/ORHP
Nevada and other western states through the Center for Cognitive
5600 F ISHERS L ANE
Aging’s (CCA) Alzheimer Disease Diagnostic and T reatment Center
(ADDT C) via telemedicine. T hrough the capabilities that
301-443-7529
telemedicine offers the RDT I program can bring urban medical
[email protected]
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. T he 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 RDT I program over the next 3
years. T his 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. T he RDT I 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.
N EW H AMPS HIR E
Home Healthcare, Hospice and Community Services, Inc.
Program Director
TOPIC AREAS
Chronic Disease Management, Diabetes, Congestive Heart Failure,
T elehealth
PROJECT PERIOD
May 1, 2005 – April 30, 2007
JUDITH P. H ARRIS
H OME H EALTHCARE , H OSPICE AND
C OMMUNITY SERVICES , I NC.
312 MARLBORO STREET
K EENE , N EW HAMPSHIRE 03431-4163
PHONE : (603) 352-2253 OR (800)
541-4145
F AX : (603) 358-3904



Year 1 - 182,000.00
Year 2 - 183,031.00
Year 3 - 189,643.00
T he 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
T wo towns (Acworth and Charlestown in Sullivan County) in the
service area are designated as Medically Underserved Populations.
Implementation of a chronic disease management program for
individuals with diabetes and congestive heart failure in rural
southwestern New Hampshire.
H OME H EALTHCARE , H OSPICE AND
C OMMUNITY SERVICES , I NC.
K EENE , NH 03431-4163
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he 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
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. T he 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.
T he service area is rural and isolated with no divided highways. T he general population in the area is
97.3 percent white. T he chance of experiencing chronic illness increases significantly with age, and the
poor and less educated have an increased likelihood of chronic illness. T he 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
N EW H AMPS HIR E
Home Healthcare, Hospice and Community Services, Inc.
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. T wo towns
(Acworth and Charlestown in Sullivan County) in the service area are designated as Medically
Underserved Populations.
T he 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).
N EW H AMPS HIR E
The Caring Community Network of the Twin Rivers
Program Director
TOPIC AREAS
Chronic disease, T elehealth
PROJECT PERIOD
May 1, 2006 – April 30, 2008
R ICHARD D. SILVERBERG
THE C ARING C OMMUNITY N ETWORK OF
THE TWIN R IVERS
841 C ENTRAL STREET
F RANKLIN, NH 03235
PHONE : (603) 934-0177, EXT. 107
E-MAIL: RSILVERBERG@CCNTR. ORG



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
AREAS SERVED
State of New Hampshire
T he 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
T he Caring Community Network of the T win Rivers (CCNT R) is a
recognized nonprofit organization in the State of New Hampshire
formed in 1996. CCNT R has been working as a collective to create a
coordinated, accessible system of care across the region. T his 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.
THE C ARING C OMMUNITY N ETWORK OF
THE TWIN R IVERS
F RANKLIN, NH 03235
ORHP Contact:
H EATHER D IMERIS
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-4657
HDIMERIS @ HRSA. GOV
Individuals in the T win Rivers face higher rates of many health risk indicators than the rest of the state.
T here 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. T hese barriers reduce use and
inhibit the continuity of care, decreasing the overall effectiveness of the service delivery system.
T here 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. T hese staff positions include:

175 days of contracted outreach care coordination each year will be arranged with existing network
N EW H AMPS HIR E
The Caring Community Network of the Twin Rivers



staff to work with residents that need to be connected to primary care and other supports;
One FT E 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 FT E project manager to integrate care coordination and disease management with the system of
uncompensated care, and overall project management.
A CCNT R staff evaluator will be contracted. A small amount of consulting time will be used to
develop modifications to telehealth tools.
T he 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.
N EW H AMPS HIR E
Northern Human Services
Program Director
TOPIC AREAS
Mental health, Telehealth
PROJECT PERIOD
May 1, 2006 – April 30, 2008
MICHAEL K ASSON
N ORTHERN H UMAN SERVICES
87 W ASHINGTON STREET
C ON WAY , NH 03818
PHONE : (603) 447-3347
F AX : (603) 447-8893
E-MAIL: MKASSON@NORTHERNHS . ORG



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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.
T o improve the mental health of children and teens.
PROJECT SUMMARY
T he Northern Tele-psychiatry Initiative will provide access to child
psychiatry through telemedicine in northern New Hampshire. T he
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
N ORTHERN H UMAN SERVICES
C ON WAY , NH 03818
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
prescribing of psychotropic medications by primary care practitioners to children and adolescents.
T he 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. T he 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 T elepsychiatry Initiative will also promote the use of child tele-psychiatry through education of community
leaders and family members. Finally, the Northern T ele-psychiatry Initiative will evaluate the project on
an ongoing basis to ensure the satisfaction of the child tele-psychiatry treatments.
T he 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. T he 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
N EW H AMPS HIR E
Northern Human 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.
T he 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.
N EW H AMPS HIR E
Adult Oral Health Outreach Program
Program Director
TOPIC AREAS
Oral Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010
MARTHA MCL EOD
N ORTH C OUNTRY H EALTH C ONSORTIUM
646 U NION STREET
L ITTLETON, NH
603-444-4461
F AX –603-444-4460
MMCLEOD@ NCHCNH. ORG



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T he North Country Health Consortium proposes to expand its public
health mobile dental service, T he Molar Express, to serve a target
population of unserved and underserved adults residing in the service
area. T he Molar Express has been providing preventive, diagnostic
and restorative dental care to Medicaid eligible children in Northern
New Hampshire since July of 2005.
N ORTH C OUNTRY H EALTH C ONSORTIUM
L ITTLETON, NH 03561
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he North Country Health Consortium proposes to expand its public health mobile dental service, T he
Molar Express, to serve a target population of unserved and underserved adults residing in the service
area. T he Molar Express has been providing preventive, diagnostic and restorative dental care to
Medicaid eligible children in Northern New Hampshire since July of 2005.
T he 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.
N EW H AMPS HIR E
Adult Oral Health Outreach Program
T o 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.
T he 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.
N EW M EXICO
Mora/Colfax Head Start
Program Director
TOPIC AREAS
Pre/peri/post-natal care, Preventive health
PROJECT PERIOD
May 1, 2004 – April 30, 2006
JOSEPH GRIEGO
MORA/C OLFAX H EAD START
P.O. B OX 180
H OLMAN, N EW MEXICO 87723
PHONE : (505) 387-3139
F AX : (505) 387-6656



Year 1 - 192,003.00
Year 2 - 181,365.00
Year 3 - 184,594.00
AREAS SERVED
Mora and San Miguel counties are located in rural Northeastern New
Mexico.
Promote healthier pregnancies with reduced rates of low birth weight
and infant mortality, lower the incidence of child abuse and neglect,
and to promote healthy child development through an emphasis on
early intervention in developmental delays, immunizations and other
preventive health care.
MORA/C OLFAX H EAD START
H OLMAN, NM 87723
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
PROJECT SUMMARY
HRSA/ORHP
Mora and San Miguel counties are located in rural Northeastern New
5600 F ISHERS L ANE
Mexico. For most of its history, Northern New Mexico has enjoyed a
301-594-5105
tradition of close-knit, extended families living in convenient
VHOOKER@ HRSA. GOV
proximity for generations. This allowed young people to benefit from
the instruction and support of their elders and neighbors. T hrough
poverty and general displacement and isolation, the modern economic
structure has extended into local culture in a way that has left people cut off from customary support
systems without providing an alternative. One of the results of this shift has been that young; first-time
mothers can no longer count on learning how to be parents and care for their children through the
traditional extended family process of learning, nor are social service agency’s available to rural
homebound first-time specific parents. Currently, the children of the largely rural San Miguel and Mora
counties are at higher risk for illness, abuse, and even mortality than those in other areas of New Mexico
and, in fact, the United States.
T he Mora & San Miguel Primeros Pasos/First Steps Program proposes to serve up to 60 first-time parents
and their children through the implementation of the research-based Healthy Families America Program.
T he target population is 88 percent Hispanic, 8 percent Caucasian, and a 4-percent mix of African
American and Native American descent. T he program will be staffed by family assessment workers and
three promotoras who will provide intensive home visiting services for the first 3 years of the baby’s life.
T he goals of the Mora & San Miguel Primeros Pasos/First Steps Program are to promote healthier
pregnancies with reduced rates of low birth weight and infant mortality, lower the incidence of child
abuse and neglect, and to promote healthy child development through an emphasis on early intervention
in developmental delays, immunizations and other preventive health care.
N EW M EXICO
Mora/Colfax Head Start
N EW M EXICO
Frontier Education Center, Inc.
Program Director
TOPIC AREAS
PROJECT PERIOD
May 1, 2004 – April 30, 2006
C AROL MILLER
F RONTIER EDUCATION C ENTER, I NC.
HCR 65, B OX 126
OJO SARCO, N EW MEXICO 87521
PHONE : (505) 820-6732
F AX : (505) 820-6783



Year 1 - 198,651.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he network partners of the project include the Frontier Education
Center, HCH Rural Health of Penasco, the Health Centers of
Northern New Mexico – Penasco Clinic, the T aos Public Health
Office of the New Mexico Department of Health, the Penasco
Independent School District, Picuris Pueblo, and the Health Science
Center of the University of New Mexico.
AREAS SERVED
T he target area consists of the communities in the Penasco
Independent School District, and includes all of southern T aos
County, the entire Picuris Pueblo reservation, and the southeastern
section of Rio Arriba County in north central New Mexico.
to address mental health and substance abuse and to build resiliency
among the youth.
F RONTIER EDUCATION C ENTER, I NC.
OJO SARCO, NM 87521
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Project R&R offers a solution to the critical need for mental health and substance abuse services in a
high-risk, multi-cultural frontier community. The target area consists of the communities in the Penasco
Independent School District, and includes all of southern T aos County, the entire Picuris Pueblo
reservation, and the southeastern section of Rio Arriba County in north central New Mexico. T he target
community of 3817 people is spread across an area of 900 square miles. However, there are no
incorporated villages or towns within this area and only minimal health services of any type. The actual
medical service area, which includes the closest towns of Espanola in Rio Arriba County and T aos in
T aos County, each with a hospital, extends the health care service area to 1600 square mile. T he racial
and ethnic mix of populations to be served reflects the community: 73 percent Hispanic, 14 percent
Native American, and 13 percent Caucasian. T he two foci of Project R&R are to address mental health
and substance abuse and to build resiliency among the youth.
Picuris Pueblo, a federally recognized Indian tribe, and the small traditional Hispanic agricultural villages
that make up the target community have long and proud histories. Still existing among the elders is a
tremendous amount of knowledge. T heir wisdom is not only about the natural world—the wild plants
and herbs (remedios) that sustained the communities before any health care was available locally—but
also about the very concept of neighborliness and community. T hrough recent discussions with the
N EW M EXICO
Frontier Education Center, Inc.
coordinator of the Rural Psychiatry Outreach Program at the University of New Mexico, Project R&R
discovered that any “ diagnosis” of its communities would have to include mention of Historical T rauma.
Historical T rauma is a clinical diagnosis of an ongoing psychiatric disorder related to loss of land,
relocation, economic disarray, and dislocation, which presents with symptomology and negative
behaviors including alcoholism, substance abuse, and difficult, often violent, interpersonal relationships.
Although the economic and health status data paint a picture of a very troubled community, that is only a
part of the picture.
T he network partners of the project include the Frontier Education Center, HCH Rural Health of Penasco,
the Health Centers of Northern New Mexico – Penasco Clinic, the Taos Public Health Office of the New
Mexico Department of Health, the Penasco Independent School District, Picuris Pueblo, and the Health
Science Center of the University of New Mexico.
N EW M EXICO
Border Area Mental Health Services, Inc.
Program Director
TOPIC AREAS
Substance Abuse, Mental Health Disorders
PROJECT PERIOD
May 1, 2005 – April 30, 2007



SILVIA MADRID
B ORDER AREA MENTAL H EALTH
SERVICES , I NC.
P.O. B OX 1349
SILVER C ITY , N EW MEXICO 880621349
PHONE : (505) 388-4497
F AX : (505) 534-1150
Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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.
T he 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.
B ORDER AREA MENTAL H EALTH
SERVICES , I NC.
SILVER C ITY , N EW MEXICO 880621349
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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. 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.
T he 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. T he percentage of the population below two times the Federal poverty level and not on Medicaid
is estimated at 27.9 percent. T he project will target children, adolescents, and adults who have mental
N EW M EXICO
Border Area Mental Health Services, Inc.
health or substance abuse disorders as well as their family members. T he 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. T he 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. T he target area for the
project is a designated Medically Underserved Area and a Health Professional Shortage Area for mental
health professionals.
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.
N EW M EXICO
Las Cumbres Learning Services, Inc.
Program Director
TOPIC AREAS
Early childhood mental health services
PROJECT PERIOD
May 1, 2005 – April 30, 2007
D EBORAH H ARRIS -U SNER
L AS C UMBRES L EARNING
SERVICES , I NC.
P.O. B OX 1362
ESPANOLA, NM 87532-1362
PHONE : (505) 753-4123
F AX : (505) 753-6947

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Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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. T hese
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
T he project will serve the residents of Rio Arriba County, a largely
rural and mountainous region between Santa Fe and the Colorado
state line.
Provide access to mental health services for high-risk families with
young children, from birth to age 5.
L AS C UMBRES L EARNING
SERVICES , I NC.
ESPANOLA, NM 87532-1362
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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. T he project will serve the
residents of Rio Arriba County, a largely rural and mountainous region between Santa Fe and the
Colorado state line. T he project will use a three-pronged approach: (1) provide comprehensive,
expanded infant mental health services at three sites; (2) provide training, consultation, and capacitybuilding 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.
T he 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. T he 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
N EW M EXICO
Las Cumbres Learning Services, Inc.
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. T he county qualifies as a
Medically Underserved Area and includes 13 divisions designated as Health Professional Shortage Areas.
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. T hese 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.
N EW M EXICO
Taos Health Systems
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008

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B ARBARA H AU
PROGRAM D IRECTOR
TAOS H EALTH SYSTEMS
H OLY C ROSS H OSPITAL
P.O. B OX DD
TAOS , NM 87571
PHONE : (505) 758-8818
E-MAIL: BHAU@TAOSNET. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 – 98,702.00
Collaborative Action for T aos County Health (CAT CH)
AREAS SERVED
T aos County
T o deliver Prescription Assistance to a target population defied as
residents of T aos 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.
H OLY C ROSS H OSPITAL
TAOS , NM 87571
ORHP Contact:
JACOB R UEDA
PROJECT SUMMARY
PROJECT OFFICER
HRSA/ORHP
T he word T aos means 'red willow' in the T ewa language. T wo
5600 F ISHERS L ANE
features dominate this sparsely populated region—the high desert
mesa, split in two by the 650-foot-deep chasm of the Rio Grande; and
301-443-0835
the Sangre de Cristo range, which tops out at 13,161-foot Wheeler
JRUEDA@ HRSA. GOV
Peak, New Mexico's highest mountain. The County is situated where
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 T aos County. One in four Hispanics are
uninsured. In addition to being more prevalent, diabetes in Hispanics tends to be more severe than nonHispanic 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 T aos County Needs
Assessment process, 144 low income County residents were interviewed in 2001 and over half the
N EW M EXICO
Taos Health Systems
families in this interview process did without needed medical care in order to make ends meet, or gave
priority to their children's care.
T his 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 T aos 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 T aos community and
surrounding areas. Collaborative Action for T aos County Health (CAT CH), 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.
N EW YORK
Citizen Advocates, Inc.
Program Director
TOPIC AREAS
Child and adolescent mental health, Provider recruitment
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JAMES B ROOKS
C ITIZEN ADVOCATES , I NC.
24 4TH STREET
MALONE , N EW YORK 12953
PHONE : (518) 483-3261
F AX : (518) 483-3383



Year 1 - 199,848.00
Year 2 - 199,048.00
Year 3 - 199,283.00
North Star Behavioral Health Services, St. Regis Mohawk T ribe
Health Services, the Essex County Mental Health Clinic, Mental
Health Association of Franklin County, Salmon River Central School
District, and Families First in Essex County.
AREAS SERVED
Essex and Franklin counties, New York
T he target population for the Children’s Mental Health Initiative is
children age 5 to 21 who are uninsured, underinsured or Medicaid
insured.
C ITIZEN ADVOCATES , I NC.
MALONE , NY 12953
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Essex and Franklin Children’s Mental Health Initiative will
improve access to board-certified child and adolescent psychiatric services in Essex and Franklin
counties, New York. T he proposed services will include the recruitment and hiring of a board-certified
child/adolescent psychiatrist and the recruitment and hiring of an intensive case manager to provide
access services to the Native American students attending the Salmon River Central School District in
Akwesasne, New York.
T he target population for the Children’s Mental Health Initiative is children age 5 to 21 who are
uninsured, underinsured or Medicaid insured. Of the 19,308 children represented within this age group in
the geographic area to be served, approximately 22.5 percent are living in poverty. The target population
is 70 percent Caucasian, 24 percent American Indian, 4 percent African American and 1 percent Hispanic.
Access barriers to services include an overly long travel time to access services, especially for single
parent families with multiple children, the lack of dedicated transportation that can be used for mental
health clinic appointments by many low-income families, difficulty recruiting to rural communities, a
very high rate of poverty in Essex and Franklin counties, and a lack of insurance for children. The service
area is designated as a Health Professional Shortage Area.
T he network partners are North Star Behavioral Health Services, the lead applicant, St. Regis Mohawk
T ribe Health Services, the Essex County Mental Health Clinic, Mental Health Association of Franklin
County, Salmon River Central School District, and Families First in Essex County.
N EW YORK
Chenango Memorial Hospital
Program Director
TOPIC AREAS
Primary care, Health promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2004 – April 30, 2006
SHIRLEY C AEZZA
C HENANGO MEMORIAL H OSPITAL
179 N ORTH B ROAD STREET
N ORWICH, N EW YORK 13815
PHONE : (607) 337-4033
F AX : (607) 337-4284



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Consortium members include the Chenango County Catholic
Charities, the Chenango Health Network, the Norwich School
District, and the Chenango Memorial Hospital.
AREAS SERVED
Students that live in Norwich, with some coming from the towns of
North Norwich, McDonough, East Pharsalia, Plymouth, South
Plymouth, or Oxford.
T he target population to be served by the project is 97 percent
Caucasian, 2 percent African American, and less than 1 percent of
Hispanic, Native American, and Asian school-age students age 4 to
18.
C HENANGO MEMORIAL H OSPITAL
N ORWICH, N EW YORK 13815
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Students in the Norwich School District have been identified with unmet health needs including
immunizations, physical exams, acute episodic care for ear infections, upper respiratory illness,
pharyngitis, strep infections, dermatitis, injuries including sprains and fractures, and the lack of regular
primary health care which would typically result in healthier children. Conditions including lack of
dental care, asthma, diabetes, obesity, and mental health issues have been identified as well. When school
nurses in the Norwich School District were asked to describe the problems experienced by school-age
children, such as cultural, social, geographical, and financial barriers; they cited lack of insurance or
being underinsured, high copayments, and the inability of the parent to leave work to access medical care,
as relevant conditions. In addition, many students do not have an established “ medical home” with
regular health care or primary care providers, so their care lacks continuity. Families have low literacy
rates, which affects their capacity to use information they receive from school, such as eligibility for
certain benefits or good health practices. Navigating the Medicaid system has proven problematic for
local families. T hey often do not understand that they must renew their eligibility periodically and are
confused as to how to receive the benefits to which they are entitled.
T he target population to be served by the project is 97 percent Caucasian, 2 percent African American,
and less than 1 percent of Hispanic, Native American, and Asian school-age students age 4 to 18. Most
students live in Norwich, with some coming from the towns of North Norwich, McDonough, East
Pharsalia, Plymouth, South Plymouth, or Oxford. The area served is large in geography and short on
N EW YORK
Chenango Memorial Hospital
major highways and public transportation. The lack of public transportation creates incredible barriers to
accessing any type of service. Chenango County has suffered severe economic changes due to business
closures. Many of the jobs that remain are low paying, with no health or dental insurance.
Along with the other members of the consortium (the Chenango County Catholic Charities, the Chenango
Health Network, and the Norwich School District), the Chenango Memorial Hospital plans to improve the
health status of its school-age populations by enrolling 90 percent of the target population into schoolbased health centers by the end of the school year; increasing access to primary care, mental health, and
dental care services for students; and increasing enrollment in Medicaid, Child Health Plus, and Family
Health Plus.
N EW YORK
Livingston County Department of Health
Program Director
TOPIC AREAS
EMS Provider Education, Older Adults, Case Management
PROJECT PERIOD
May 1, 2005 – April 30, 2007



MANISH SHAH
L IVINGSTON C OUNTY D EPARTMENT
OF H EALTH
2 L IVINGSTON C OUNTY C AMPUS
MOUNT MORRIS , N EW YORK 145101122
PHONE : (585) 243-7270
F AX : (585) 243-7287
Year 1 - 190,762.00
Year 2 - 195,520.00
Year 3 - 199,977.00
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 T ri-County Family Medicine.
AREAS SERVED
Livingston County, New York is designated as a Medically
Underserved Population.
L IVINGSTON C OUNTY D EPARTMENT
OF H EALTH
MOUNT MORRIS , NY 14510-1122
ORHP Contact:
T he target population adults age 60 and older in rural areas of
Livingston County, New York.
JACOB R UEDA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0835
JRUEDA@ HRSA. GOV
PROJECT SUMMARY
In this injury and illness prevention project, the Livingston County Department of Health and its partners
seek to maximize the health 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. T he 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. T he 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.
T he target population adults age 60 and older in rural areas of Livingston County, New York.
T he percentage of older adults in the county is rapidly increasing, resulting in increased demands for
community-based and in-home services. T he 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
N EW YORK
Livingston County Department of Health
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. T here 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. T his project will affect all service providers and provide older adults with increased ease of access
to services. T he county is designated as a Medically Underserved Population.
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 T ri-County Family Medicine.
N EW YORK
The Mary Imogene Bassett Hospital
Program Director
TOPIC AREAS
School-based services, Dental, Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
JANE H AMILTON, R.N.
SCHOOL-B ASED H EALTH C ENTER
PROGRAM C LINICAL C OORDINATOR
THE MARY I MOGENE B ASSETT
H OSPITAL
ONE ATWELL R OAD
C OOPERSTOWN, NY 13326-1394
PHONE : (607) 746-9332
E-MAIL:
JANE . HAMILTON@ BASSETT. ORG
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.
T argeted school-age children (5-18 years of age) for services.
THE MARY I MOGENE B ASSETT
H OSPITAL
C OOPERSTOWN, NY 13326-1394
PROJECT SUMMARY
ORHP Contact:
Bassett Healthcare and six school districts have formed a Consortium
SONJA TAYLOR
that seeks to expand and enhance their School-Based Health Centers
PROJECT OFFICER
HRSA/ORHP
(SBHC) to include dental and mental health care programs and
5600 F ISHERS L ANE
community outreach services. Bassett Healthcare and the school
districts of Delhi, Edmeston, Laurens, Morris, Sherbure-Earlville, and
301-443-1902
South Kortright are located in Chenango, Delaware, and Otsego
STAYLOR@ HRSA. GOV
counties—all of which have been designated as Mental Health
Professional Shortage Areas. Delaware County has been designated a Dental Health Professional
Shortage Area.
T he Consortium has specifically targeted school-age children (5-18 years of age) for services. T he 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.
T hese 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.
N EW YORK
The Mary Imogene Bassett Hospital
T his 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. T he Consortium anticipates caring for approximately 2,800
clients.
T he 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.
N EW YORK
Champlain Valley Physicians Hospital Medical Center
Program Director
TOPIC AREAS
Diabetes, T elehealth
PROJECT PERIOD
May 1, 2006 – April 30, 2008



SUSANNAH L E VON
ASSISTANT D IRECTOR OF N UTRITION
SERVICES
C HAMPLAIN VALLEY PHYSICIANS
H OSPITAL MEDICAL C ENTER
75 B EEKMAN STREET
PLATTSBURGH, NY 12901
PHONE : (518) 562-7550
E-MAIL: SLEVON@CVPH. ORG
Year 1 - 149,806.00
Year 2 - 124,308.00
Year 3 - 98,673.00
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.
T argeting Clinton, Essex and Franklin County residents over the age
of 45 who have diabetes or are at risk for developing diabetes.
C HAMPLAIN VALLEY PHYSICIANS
H OSPITAL MEDICAL C ENTER
PLATTSBURGH, NY 12901
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
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
leader;, and the Joint Council of Economic Opportunity of Clinton and Franklin Counties (JCEO), a
social service agency that conducts community outreach programs. T he 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.
T he 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.
T his region is medically underserved with shortages of primary care providers. It is also
socioeconomically disadvantaged. T he median household income is significantly below State and national
levels. Education levels are low adversely affecting health behavior and outcomes. T his 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. T his 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.
N EW YORK
Champlain Valley Physicians Hospital Medical Center
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.
T he 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, T he Senior Citizens' Council, and the United Way will publicize the project's services.
T his 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.
N ORTH CAROLINA
Migrant Benevolent Association Inc.
Program Director
TOPIC AREAS
Primary care
PROJECT PERIOD
May 1, 2003 – April 30, 2005



D. B ARON
MIGRANT B ENEVOLENT
ASSOCIATION I NC.
P.O. B OX 185
N EWTON GROVE , N ORTH C AROLINA
28366
PHONE : (910) 567-6194, EXT. 5018
F AX : (910) 567-5678
Year 1 - 197,300.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Migrant Benevolent Association, Inc., the Coharie, Meherrin, HaliwaSaponi, and Waccamaw Siouan T ribes, Cumberland County
Association for Indian People, Tribal Council of the Lumbee T ribe,
T win County Rural Health Center, Robeson Health Care Corporation,
Greene County Health Care, Stedman-Wade Health Services, T riCounty Community Health Center, Goshen Medical Center, North
Carolina Commission of Indian Affairs, the North Carolina
Department of Health and Human Services, the National Cancer
Institute’s Cancer Information Center of the Southeast, Wake Forest
University School of Medicine, Native American Interfaith
Ministries/Healing Lodge, Duke University Medical Center, and the
University of North Carolina at Pembroke.
MIGRANT B ENEVOLENT
ASSOCIATION I NC.
N EWTON GROVE , NC 28366
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
AREAS SERVED
Robeson County
T he overall goal of the project is to improve the health status of 68,770 American Indians in eastern North
Carolina.
PROJECT SUMMARY
T he purpose of the Eastern Regional North Carolina American Indian Rural Health Outreach Project is to
build the foundation for a regional American Indian health outreach network that reduces disparities and
increases access to health care for the target population. The overall goal of the project is to improve the
health status of American Indians in eastern North Carolina. T hrough its developmental success, it is
hoped that the project will serve as a model that can be replicated in other American Indian regions not
served by Indian Health Service (IHS). T he target population for the project is 68,770 American Indians
residing in a rural 21-county eastern region of North Carolina. T he highest concentration of American
Indians is in Robeson County, which is home to 46,896 Lumbee. In North Carolina, the Eastern Band of
Cherokee is the only tribe residing on a Federal reservation and the only tribe served by IHS. All of the
remaining tribes access care through their community providers.
Access barriers to services include a high rate of poverty, the lack of insurance or underinsurance among
the target population, the reluctance of care providers to treat patients on Medicaid, especially for
dentistry, a lack of awareness of American Indian health issues in public health programs, the lack of
N ORTH CAROLINA
Migrant Benevolent Association Inc.
cultural sensitivity among many health care providers and transportation issues. T he entire service area
for the project is designated as a Health Professional Shortage Area for medical, dental, and mental
health.
T he network partners are the Migrant Benevolent Association, Inc., the lead applicant, the Coharie,
Meherrin, Haliwa-Saponi, and Waccamaw Siouan T ribes, Cumberland County Association for Indian
People, T ribal Council of the Lumbee T ribe, T win County Rural Health Center, Robeson Health Care
Corporation, Greene County Health Care, Stedman-Wade Health Services, T ri-County Community
Health Center, Goshen Medical Center, North Carolina Commission of Indian Affairs, the North Carolina
Department of Health and Human Services, the National Cancer Institute’s Cancer Information Center of
the Southeast, Wake Forest University School of Medicine, Native American Interfaith
Ministries/Healing Lodge, Duke University Medical Center, and the University of North Carolina at
Pembroke.
N ORTH CAROLINA
Ashe Memorial Hospital, Inc.
Program Director
TOPIC AREAS
Urgent care, T elehealth
PROJECT PERIOD
May 1, 2003 – April 30, 2005
C. B. JONES
ASHE MEMORIAL H OSPITAL, I NC.
200 H OSPITAL AVENUE
JEFFERSON, N ORTH C AROLINA 28640
PHONE : (336) 246-0723
F AX : (336) 246-0746



Year 1 - 185,616.00
Year 2 - 188,690.00
Year 3 - 170,382.00
Ashe Memorial Hospital, the Appalachian District Health
Department, and the Ashe County School System.
AREAS SERVED
Ashe County is designated as a Health Professional Shortage Area.
T he Ashe Urgent Care/School Based Health Center Program has been
serving the health needs of students in Ashe County since 1998 at the
Ashe County Middle School, the only middle school in the county.
ASHE MEMORIAL H OSPITAL, I NC.
JEFFERSON, NC 28640
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Ashe Urgent Care/School Based Health Center Program has been serving the health needs of students
in Ashe County since 1998 at the Ashe County Middle School, the only middle school in the county.
Using the School Based Health Center’s free standing, fully equipped facility, this project will establish
an after hours urgent care facility that will be connected electronically to Ashe Memorial Hospital’s
Emergency Department. T he facility will offer access to the only medical after hours, non-emergency
program in Ashe County.
Ashe County is a rural and economically depressed county located in the northwest corner of North
Carolina. Of the total population of 24,384 (2000 Census), 15.5 percent live below the poverty level, and
25.5 percent of households have an income of less than $14,999 per year. In the public schools,
65 percent of families report an income that is less than 185 percent of the Federal poverty level. Access
barriers to services for the target population, which is 97.2 percent Caucasian, 2.4 percent Hispanic,
0.7 percent African American, 0.3 percent American Indian, and 0.2 percent Asian/Pacific
Islander/Alaska Native, include the lack of after hours non-emergency services in the county, a high
unemployment rate primarily due to the loss the manufacturing jobs, the lack of priority given to even
basic preventive health care by county residents, and geographic barriers to services (distance and poor
roads). T he service area is designated as a Health Professional Shortage Area.
T he network partners are the Ashe Memorial Hospital, the lead applicant, the Appalachian District Health
Department, and the Ashe County School System.
N ORTH CAROLINA
Albemarle Hospital Foundation, Inc.
Program Director
TOPIC AREAS
Chronic disease, Minority health, HIV/AIDS, Mental health,
Substance abuse
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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
T he service area is now seeing HIV/AIDS cases growing
exponentially among African Americans and Hispanics ages 20 to 49.
PHIL D ONAHUE
EXECUTIVE D IRECTOR
ALBEMARLE H OSPITAL
F OUNDATION, I NC.
1144 N. R OAD STREET
ELIZABETH C ITY , N ORTH C AROLINA
27909
PHONE : (252) 384-4072
F AX : (252) 384-4677
E-MAIL:
PDONAHUE @ ALBEMARLEHOSP . ORG
ALBEMARLE H OSPITAL
F OUNDATION, I NC.
ELIZABETH C ITY , NC 27909
ORHP Contact:
H EATHER D IMERIS
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-4657
PROJECT SUMMARY
T he 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. T he 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.
T hey continue to show that the area is plagued with chronic cardiovascular disease, cancer, respiratory
disorders, a growing problem with T ype 2 diabetes and obesity. T he 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
N ORTH CAROLINA
Albemarle Hospital Foundation, Inc.




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.
T he 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.
N ORTH CAROLINA
Community Health Access Network
Program Director
TOPIC AREAS
Health Literacy
PROJECT PERIOD
May 1, 2007 – April 30, 2010
L ORNA B ARNETT
C OMMUNITY H EALTH L INK
538 SCOTTS C REEK R OAD, SUITE 100
SYLVA, NC
828-587-8224
F AX –828-63 1-2634
LORNABARNETT@ JACKSONNC. ORG



Year 1 - 149,906.00
Year 2 - 125,000.00
Year 3 - 100,000.00
CHAN Network members include Community Health Link (applicant
and lead agency); 91% of Jackson County Physicians; the Jackson
County Department of Public Health, the Jackson County Department
of Social Services; the Good Samaritan Clinic; WestCare Health
System; the North Carolina Cooperative Extension Service, and the
Medication Assistance Program of Jackson County. Literally, the
entire medical community is committed to making this program a
success.
AREAS SERVED
Jackson County, North Carolina
C OMMUNITY H EALTH L INK
SYLVA, NC 28779
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
T he target population for Community Health Access Network is
uninsured adults, 18-64, in Jackson County, North Carolina who have
incomes at or below 150% of the Federal Poverty guidelines and do not qualify for any insurance
programs.
PROJECT SUMMARY
Community Health Link, Inc. (CHL) is requesting $149,906.00 for the first year of a three year grant to
expand and improve Community Health Access Network (CHAN). T he request for three years is
$374,906.00. CHAN is expanding and enhancing a program that provides comprehensive health care to
residents of Jackson County, North Carolina who are between the ages of 18 and 64, at or below 150% of
the federal guidelines for poverty, and have no health insurance. The program provides a medical home to
enrolled participants, purchases medications, and makes arrangements for further treatment, lab work,
diagnostic tests, physical and respiratory therapy, cardiac services, surgical services, and emergency
services.
T his grant will provide for expanded services which will include patient assistance with securing free or
low-cost medication from pharmaceutical companies, a medication safety component, a wellness
partnership with the NC Cooperative Extension, basic health literacy instruction, increase the number of
patients served by CHAN by 15% per year to 455 patients over three years and a volunteer component to
provide opportunity to patients to give back to the community and to assist CHAN staff with medication
assistance.
N ORTH CAROLINA
Community Health Access Network
CHAN will serve 345 patients in year one, 395 in year 2 and 455 in year 3. CHAN will provide basic
health literacy instruction and materials to all patients at Lunch and Learn monthly sessions and when
individuals enroll and reenroll every six months. Basic health literacy will provide patients with a sense of
control and the knowledge that they can make a difference in their own health.
CHAN will partner with new consortium member, NC cooperative extension to encourage patients to
develop healthier lifestyles at Lunch and Learn monthly sessions. As an incentive to attend CHAN will
offer to pay the medication co-pays for patients who make use of this training. Partnership with the
Jackson County Department of Public Health will continue to provide free complete physicals to CHAN
patients referred by CHAN physicians.
By following the highly successful Buncombe County model, having extraordinary participation of the
entire medical community, and having tremendous community support for Community Health Access
Network, we are confident that we will be able to fulfill our goals and objectives for this project. Thank
you for giving careful consideration to this worthy and much needed project.
N ORTH CAROLINA
Johnston County Outreach Initiative (JOI)
Program Director
TOPIC AREAS
Safety net-Migrant
PROJECT PERIOD
May 1, 2007 – April 30, 2010



J. MICHAEL B AKER
TRI-C OUNTY C OMMUNITY H EALTH
C OUNCIL, I NC.
3331 EASY STREET
D UNN, NC
910-567-7004
F AX –910-567-5342
NCMIGRANT@ AOL. COM
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
T own of Clayton, Town of Smithfield - Site of Johnston Memorial
Hospital and Johnston, County Health Department, and T ri-County
Community Health Council - Main Site, Newton Grove
T arget $2,100 uninsured, migrant/seasonal farmworkers and the
elderly for outreach and new access to primary medical care.
TRI-C OUNTY C OMMUNITY H EALTH
C OUNCIL, I NC.
D UNN, NC 28334
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T ri-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, T CCHC has
provided culturally competent, linguistically appropriate primary medical, dental and behavioral
healthcare to vulnerable populations and the community. In response to HRSA-07-005, T ri-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.
T he 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. T he
program plan identifies specific sociodemographic, economic, cultural and geographic barriers
characteristic of the area and expands T CCHC’s safety net into a region without access to healthcare
services. T he JOI T eam, 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
T CCHC’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
N ORTH CAROLINA
Johnston County Outreach Initiative (JOI)
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.
N ORTH D AKOTA
West River Regional Medical Center
Program Director
TOPIC AREAS
Chronic disease management, Health Promotion/disease prevention
(general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
MELANA H OWE
W EST R IVER R EGIONAL MEDICAL
C ENTER
1000 H IGHWAY 12
H ETTINGER, N ORTH D AKOTA 58639
PHONE : (701) 567-6013
F AX : (701) 567-6363



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
West River Health Systems, Southwest District Health Unit, and
University of North Dakota School of Medicine.
AREAS SERVED
Frontier areas in southwestern North Dakota and southwestern South
Dakota.
A collaborative healthy lifestyle and disease management program for
residents.
W EST R IVER R EGIONAL
MEDICAL C ENTER
H ETTINGER, ND 58639
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Life Initiatives for Everyone (LIFE) is a collaborative healthy lifestyle and disease management
program for residents of the frontier areas in southwestern North Dakota and southwestern South Dakota.
T he LIFE program, which will be implemented at the Wellness and Healthy Lifestyle Center in Hettinger,
North Dakota, will target approximately 13,000 residents, of whom 99.6 percent are Caucasian,
0.3 percent are American Indian, and 0.1 percent are African American.
Some significant opportunities for health improvement identified in a 2002 community health needs
assessment were chronic disabling diseases; cardiovascular risk behavior; chronic pain; mental health and
mental disorders; substance abuse; and access to health care. T o address these opportunities, the LIFE
program will increase the awareness of five simple lifestyle changes through wellness and healthy
lifestyle education to the public and health care professionals (Year 1). In Year 2, collaborations will
include promoting community initiatives and developing a Community Health Information Network to
promote wellness and manage chronic diseases. In Year 3, the work initiated in previous years will
continue, and the LIFE program will develop a self-managed healthy lifestyle and wellness program for
corporate and individual participation.
Access barriers to services include the lack of public transportation and the resistance of some residents to
receiving medical care. T he service area is designated as a Health Professional Shortage Area.
T he network partners are West River Health Systems, the lead applicant; Southwest District Health Unit;
and University of North Dakota School of Medicine.
N ORTH D AKOTA
Cavalier County Job Development Authority
Program Director
TOPIC AREAS
Wellness Programs
PROJECT PERIOD
May 1, 2005 – April 30, 2007



JOYCE R. R ICE
C AVALIER C OUNTY JOB D EVELOPMENT
AUTHORITY
901 3RD STREET, SUITE 5
L ANGDON, N ORTH D AKOTA 582492457
PHONE : (701) 256-3475
F AX : (701) 256-3536
Year 1 - 199,781.00
Year 2 - 143,399.00
Year 3 - 122,047.00
T he 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
T he project will promote wellness programs to residents of every age,
gender, and activity level.
C AVALIER C OUNTY JOB D EVELOPMENT
AUTHORITY
L ANGDON, ND 58249-2457
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he 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. T he WILL project will be implemented with classes and lectures, screenings, and
fitness and nutrition programs to manage chronic disease and their modifiable risk factors. T he 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. T he 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. T he 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
N ORTH D AKOTA
Cavalier County Job Development Authority
this problem. In addition, the mindset and attitudes of rural residents can be a barrier to needed health
care services in this area. T hey 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.
T he 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.
N ORTH D AKOTA
Southwestern District Health Unit
Program Director
TOPIC AREAS
Cancer
PROJECT PERIOD
May 1, 2006 – April 30, 2008
C ARLOTTA EHLIS
SOUTHWESTERN D ISTRICT
H EALTH U NIT
2869 3RD AVENUE W
D ICKINSON, ND 58601
PHONE : (701) 483-0171
E-MAIL: CEHLIS @STATE . ND. US



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T he 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
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.
SOUTHWESTERN D ISTRICT
H EALTH U NIT
D ICKINSON, ND 58601
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
T he health care needs of the area were identified through a community health assessment initiated by the
Healthy 8 Communities Network. T his 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 T ask 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. T he 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,
N ORTH D AKOTA
Southwestern District Health Unit
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.
T he 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.
T he 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.
T he 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. T he 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.
N ORTH D AKOTA
Standing Rock Reservation
Program Director
TOPIC AREAS
Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
EMMETT W HITE TEMPLE , JR.
STANDING R OCK SIOUX TRIBE
STANDING R OCK R ESERVATION
P.O. B OX D
F ORT YATES , N ORTH D AKOTA
PHONE : (701) 854-7206
E-MAIL: THLTHDIR@WESTRIV . COM



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.
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.
STANDING R OCK R ESERVATION
F ORT YATES , ND
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
T he 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
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 T he Australian National University, to improve mental health knowledge, skills, and
attitudes.
T he 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.
T here 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. T hese 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
N ORTH D AKOTA
Standing Rock Reservation
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 T ribal communities
would be completed during this phase.
O HIO
Community Health Services
Program Director
TOPIC AREAS
Dental, Women’s health, Prenatal care, Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008
JOSEPH L ISZAK
EXECUTIVE D IRECTOR
C OMMUNITY H EALTH SERVICES
410 B IRCHARD AVENUE
F REMONT, OH 43420
PHONE : (419) 334-8943
E-MAIL: JLISZAK@FREMONTCHS . COM



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
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.
C OMMUNITY H EALTH SERVICES
F REMONT, OH 43420
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T his 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.
O HIO
Community Health Services
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. T he 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. T hese 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. T he 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.
O HIO
Twin City Hospital
Program Director
TOPIC AREAS
Overweight/obesity
PROJECT PERIOD
May 1, 2006 – April 30, 2008



MARJORIE JENTES
TWIN C ITY H OSPITAL
819 N. F IRST STREET
D ENNISON, OH 44621
PHONE : (740) 922-2800
E-MAIL:
MJENTES @ TWINCITYHOSPITAL. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he Goal of the T win City Hospital (TCH) Healthy Community/
Happy Children Outreach Program (HC/HCOP)
AREAS SERVED
Village of Dennison, T uscarawas County, and the surrounding
counties of Carroll, Harrison, and Guernsey.
T o provide an innovative, multi-agency means to reduce the number
of overweight and obese men, women, and children of all ages.
TWIN C ITY H OSPITAL
D ENNISON, OH 44621
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he Goal of the T win City Hospital (TCH) Healthy
Community/Happy Children Outreach Program (HC/HCOP) is to
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, T uscarawas County, and the surrounding counties of
Carroll, Harrison, and Guernsey. T he 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.
T win 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. T he project also plans to make information available via the T win City Hospital's web page at
www.twincityhospital.org.
T he 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 T uscarawas County.
O HIO
Twin City Hospital
T he T win 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 T win 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
T uscarawas County.
T o address transportation needs, T win 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.
O HIO
Zanesville-Muskingum County Health Department
Program Director
TOPIC AREAS
Medication assistance
PROJECT PERIOD
May 1, 2006 – April 30, 2008
C OREY H AMILTON
Z ANESVILLE -MUSKINGUM C OUNTY
H EALTH D EPARTMENT
TH
205 N ORTH 7 STREET
Z ANESVILLE , OH 43701
PHONE : (740) 454-9741
E-MAIL: COREYH@ZMCHD. ORG
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

Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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 T B and Respiratory Clinic,
Alfred Carr, Mental Health and Recovery Services Board, Six
County, Inc., and Muskingum County Job and Family Services.
AREAS SERVED
Southeastern Appalachia Ohio
T he program will assist any resident with a prescription medication
need who is not able to fill the prescription on his/her own. T hese
individuals include uninsured, low-income/fixed income, and those
residents experiencing hardships that would legitimately preclude
them from fill physician-prescribed medications.
Z ANESVILLE -MUSKINGUM C OUNTY
H EALTH D EPARTMENT
Z ANESVILLE , OH 43701
ORHP Contact:
JACOB R UEDA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0835
JRUEDA@ HRSA. GOV
PROJECT SUMMARY
T he RxCUE program is a community-based prescription medication assistance program. T his 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. T hese individuals include
uninsured, low-income/fixed income, and those residents experiencing hardships that would legitimately
preclude them from fill physician-prescribed medications.
T he 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 T B and Respiratory Clinic, Alfred Carr, Mental Health and Recovery Services
Board, Six County, Inc., and Muskingum County Job and Family Services. T hese 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:


T ier I will link individuals with free pharmaceutical-sponsored programs.
T ier II will fill prescriptions from the State pharmacy repository. The State of Ohio passed House Bill
O HIO
Zanesville-Muskingum County Health Department

221 provides for the development of a State Pharmacy repository for collection and redistribution of
surplus medications from individuals and agencies.
T ier 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.
T his 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.
O KLAHOMA
Northeastern Oklahoma Community Health Centers
Program Director
TOPIC AREAS
Alzheimer’s disease; Caregivers
PROJECT PERIOD
May 1, 2006 – April 30, 2008



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
L ORI TIMMONS
N ORTHEASTERN OKLAHOMA C OMMUNITY
H EALTH C ENTERS
119 W. MAIN STREET
H ULBERT, OK 74441
PHONE : (918) 772-3471
F AX : (918) 772-3102
E-MAIL: LORI. TIMMONS @NEOCHC. ORG
W EB SITE : HTTP :// NEOCHC. ORG
AREAS SERVED
T he target population is the service area of Northeastern Oklahoma
Community Health Centers, namely Cherokee County, and its four
surrounding counties
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
N ORTHEASTERN OKLAHOMA C OMMUNITY
H EALTH C ENTERS H ULBERT, OK 74441
ORHP Contact:
JACOB R UEDA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T he health center operates five sites, employs eight
full-time providers, and offers the full range of preventive and primary care services.
T he 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. T opics 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.
T he target population is the service area of Northeastern Oklahoma Community Health Centers, namely
Cherokee County, and its four surrounding counties. T he goals of this project are:
O KLAHOMA
Northeastern Oklahoma Community Health Centers






T o improve the ability of area organizations to better meet the mental and physical needs of
caregivers;
T o improve the ability of caregiving families to use health care and support services in their
communities;
T o support the mental and physical health caregivers;
T o educate area residents about maintaining brain health and decreasing the impact of Alzheimer’s;
T o use advanced communication tools, including the Internet, to achieve goals more efficiently; and
T o develop a plan for sustainability.
O REGON
Three Rivers Community Hospital
Program Director
TOPIC AREAS
Cardiovascular disease, Stroke, Elderly
PROJECT PERIOD
May 1, 2006 – April 30, 2008



SANDRA OLSON
D IRECTOR OF R ESEARCH &
D EVELOPMENT
THREE R IVERS C OMMUNITY H OSPITAL
2600 SISKIYOU B OULEVARD, SUITE 100
MEDFORD, OREGON 97504
PHONE : (541) 789-5298
E-MAIL: SOLSON@ASANTE . ORG
Year 1 - 149,982.00
Year 2 - 124,836.00
Year 3 - 99,980.00
T hree 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.
T his 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.
THREE R IVERS C OMMUNITY H OSPITAL
MEDFORD, OR 97504
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
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
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.
T he 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 T reatment 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) T o
improve the capacity of Josephine County stakeholders to identify and intervene in men and women's
cardiovascular disease specific risk factors; 2) T o 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) T o 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) T o improve the capacity for rapid transport and treatment of
Josephine County ST segment elevation myocardial infarction (ST EMI) patients.
O REGON
Three Rivers Community Hospital
T hese 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. T he 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. T his 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.
O REGON
ADAPT, Inc.
Program Director
TOPIC AREAS
Substance abuse, Mental health, Migrant health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
B RUCE PIPER, C HIEF EXECUTIVE
OFFICER
ADAPT, I NC.
P.O. B OX 1121
R OSEBURG, OR 97540
PHONE : (541) 672-2691



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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.
T he 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
ADAPT, I NC.
R OSEBURG, OR 97540
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
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 T ANF 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. T he 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 onequarter 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
O REGON
ADAPT, Inc.
providers. T o 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.
T he 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.
O REGON
La Clínica de Cariño Family Health Center
Program Director
TOPIC AREAS
Diabetes, Overweight/Obesity, Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
MARGERY D OGOTCH
L A C LÍNICA DE C ARIÑO F AMILY
H EALTH C ENTER
849 PACIFIC AVENUE
H OOD R IVER, OR 97031
PHONE : (541) 308-8340
F AX : (541) 386-1078



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he Next Door, Inc. and Providence Hood River Memorial Hospital.
AREAS SERVED
Hood River, Wasco, Klickitat, and Skamania counties.
T he 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.
L A C LÍNICA DE C ARIÑO F AMILY
H EALTH C ENTER
H OOD R IVER, OR 97031
ORHP Contact:
PROJECT SUMMARY
N ISHA PATEL
PROJECT OFFICER
La Clínica del Cariño, a community and migrant health center in
HRSA/ORHP
Hood River, Oregon—in partnership with T he Next Door, Inc., a
5600 F ISHERS L ANE
community social service agency, and Providence Hood River
301-443-6894
Memorial Hospital—is supporting a community project entitled
NPATEL@ HRSA. GOV
Steps to Wellness/Pasos a Salud. T his project is intended to
improve the 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) T o address mental health issues that
impact patient self-management of diabetes and/or obesity; 2) T o improve patients' ability to manage their
diabetes and/or obesity; 3) T o improve recognition of the importance of physical activity to the mental
and physical health of people with diabetes and/or obesity; and 4) T o increase community awareness of
diabetes, obesity, and the concurrent emotional issues.
O REGON
La Clínica de Cariño Family Health Center
T o 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, oneon-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. T he 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.
PENNS YLVA N IA
Wayne Memorial Hospital Contact
Program Director
TOPIC AREAS
Medication assistance
PROJECT PERIOD
May 1, 2006 – April 30, 2008



JOHN D ENNIS
MANAGER OF GRANTS
AND D EVELOPMENT
W AYNE MEMORIAL H OSPITAL C ONTACT
601 PARK STREET
H ONESDALE , PA 18431
PHONE : (570) 251-6533
E-MAIL: DENNIS @WMH. ORG
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Wayne Memorial Hospital, Lackawanna County, Pennsylvania, and
Sullivan County, New York.
AREAS SERVED
T he consortium also represents portions of Lackawanna County,
Pennsylvania, and Sullivan County, New York.
T he project will implement an integrated medication safety program
called the IMAPS Project, or Improving Medication and Patient
Safety.
W AYNE MEMORIAL H OSPITAL C ONTACT
H ONESDALE , PA 18431
ORHP Contact:
H EATHER D IMERIS
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-4657
PROJECT SUMMARY
T his 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. T he project will implement an integrated medication
safety program called the IMAPS Project, or Improving Medication and Patient Safety.
T hrough 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. T he 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. T he project
will include enhanced automation and information systems in the following Hospital areas: inpatient
units, operating rooms, and emergency services.
T he 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
PENNS YLVA N IA
Wayne Memorial Hospital Contact
information will be compared to baseline (historical data) before the new system was implemented. T he
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.
T he number of Hospital inpatients that will be affected by this project will be 4,000-4,500 per year. T he
number of emergency room encounters with potential for interaction with this project is 19,000-20,000
per year. T he number of provider orders impacted by this system will be 435-450 per day, or 158,000 to
164,000 per year.
S OUTH CAROLINA
South Carolina State University
TOPIC AREAS
Health Promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
D ONNIS Z IMMERMAN
SOUTH C AROLINA STATE U NIVERSITY
300 C OLLEGE STREET, N ORTH EAST
ORANGEBURG, SOUTH C AROLINA
29117
PHONE : (803) 536-7070
F AX : (803) 533-3686
Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
South Carolina State University, the Edisto Health District, the Center
of Excellence for Rural and Minority Health, and the Orangeburg,
Calhoun, Allendale, Bamberg Community Action Agency.
AREAS SERVED
Orangeburg, Bamberg, and Calhoun counties in South Carolina.
Reduce the incidence of diabetes, cancer, hypertension, and heart
disease in the target population of African American residents.
SOUTH C AROLINA STATE U NIVERSITY
ORANGEBURG, SC 29117
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he purpose of the Rural Health Education and Intervention
Development System (RHEIDS) project is to reduce the incidence of diabetes, cancer, hypertension, and
heart disease in the target population of African American residents in Orangeburg, Bamberg, and
Calhoun counties in South Carolina. Project activities include health education and prevention services,
including diet, nutrition, and exercise, and increasing the use of existing health care facilities through case
management and referrals. T he project also will address the loss of eyesight among members of the target
population resulting from diabetes through the application of tele-ophthalmology screening for diabetic
retinopathy.
Local health statistics indicate that the African American population in the target counties is severely
impacted by chronic diseases that are preventable through health education and access to health care
services on a routine basis. Access barriers to services include the lack of sufficient primary care
physicians in the target counties, the reluctance of health care providers to treat patients with Medicare or
Medicaid because of reimbursement rates (only one-third of the primary care providers in the Tri-County
service area will accept Medicaid patients), the lack of reliable transportation, the lack of telephone
service (between 12 percent to 20 percent of the population in the Tri-County service area is without
telephone service), and the level of mistrust and apprehension among older members of the target
population toward health providers. Orangeburg and Bamberg counties are designated partial Health
Professional Shortage Areas, and Calhoun County is designated as a full Health Professional Shortage
Area.
T he network partners are South Carolina State University, the lead applicant, the Edisto Health District,
the Center of Excellence for Rural and Minority Health, and the Orangeburg, Calhoun, Allendale,
Bamberg Community Action Agency.
S OUTH CAROLINA
South Carolina State University
S OUTH CAROLINA
Williamsburg Regional Hospital
Program Director
TOPIC AREAS
Mobile health, Health promotion/disease prevention (general)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JAMES R OGERS
W ILLIAMSBURG R EGIONAL H OSPITAL
500 N ELSON B OULEVARD
K INGSTREE , SOUTH C AROLINA 29556
PHONE : (843) 355-0151
F AX : (843) 355-9994



Year 1 - 199,700.00
Year 2 - 166,600.00
Year 3 - 159,100.00
Williamsburg Regional Hospital, Williamsburg T echnical College,
the Williamsburg Health Department, and Black River Health Care,
Inc., a federally designated indigent care clinic.
AREAS SERVED
Williamsburg County, a predominantly rural, minority region in the
coastal plain of South Carolina.
T he target population includes an effort to enhance access to health
education and preventative health care for the residents.
W ILLIAMSBURG R EGIONAL H OSPITAL
K INGSTREE , SC 29556
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Williamsburg Mobile Health Outreach Project is a collaborative effort to enhance access to health
education and preventative health care for the residents of Williamsburg County, a predominantly rural,
minority region in the coastal plain of South Carolina. T he project will use a mobile health clinic to reach
underserved, low-income, and minority residents in an effort to reduce chronic health problems that
impact the residents of Williamsburg County at disproportionately higher rates than those of South
Carolina and the rest of the United States. T he outreach effort will address preventable and manageable
health problems such as cancer, stroke, heart disease, chronic pulmonary disease, diabetes, and other
health conditions, as well as provide health assessment and education services to promote healthier
lifestyles among those most at-risk.
Williamsburg County has been identified as one of the top five most distressed counties in South
Carolina, with nearly one-third of all of its residents living below poverty (twice the statewide rate).
Williamsburg County consistently suffers from the highest unemployment in the state, which is nearly
three times state and national averages, and is at the heart of a region devastated by more than 32 plant
closings and more than 4,000 job losses over the last decade. T he target population for the proposed
project is 67 percent African American, 18 percent Caucasian, 4 percent Hispanic, and 1 percent
Asian/Pacific Islander/Alaska Native. Access barriers to health care for area residents include lack of
transportation, geographic isolation, low income levels, a high unemployment rate, a shortage of health
professionals, and low educational attainment. The Williamsburg community is designated as a
Medically Underserved Area and a Health Professional Shortage Area.
S OUTH CAROLINA
Williamsburg Regional Hospital
T he network partners are the Williamsburg Regional Hospital, the lead applicant, Williamsburg T echnical
College, the Williamsburg Health Department, and Black River Health Care, Inc., a federally designated
indigent care clinic.
S OUTH CAROLINA
Oconee Memorial Hospital, Inc.
Program Director
TOPIC AREAS
Chronic disease, Home health services, Self-management
PROJECT PERIOD
May 1, 2006 – April 30, 2008
AMY B ETH EDWARDS
OCONEE MEMORIAL H OSPITAL, I NC.
298 MEMORIAL D RIVE
SENECA, SC 29672
PHONE : (864) 888-8411
F AX : (864) 886-9773



Year 1 - 149,767.00
Year 2 - 124,190.00
Year 3 - 99,615.00
AREAS SERVED
Oconee County, South Carolina
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.
OCONEE MEMORIAL H OSPITAL, I NC.
SENECA, SC 29672
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6894
NPATEL@ HRSA. GOV
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. T his county
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. T his project’s model is designed to improve chronic disease management among rural,
HHS patients through trained community volunteers called “ Health Coaches.” T hese 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.
T he 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
S OUTH CAROLINA
Oconee Memorial Hospital, Inc.
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.
T he 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. T he also will be trained to implement Clemson University Extension nutrition and
physical activity curricula. T he 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.
S OUTH CAROLINA
Salkehatchie NEEDS Diabetes Initiative
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2007 – April 30, 2010



C AMILLE N AIRN
SALKEHATCHIE H EALTHY C OMMUNITIES
C OLLABORATIVE
P.O. B OX 617
ALLENDALE , SC 29810
803-584-3446, EXT. 124
F AX –803-584-5038
NAIRNCS @ GWM. SC. EDU
Year 1 - 149,829.00
Year 2 - 124,989.00
Year 3 - 99,999.00
Salkehatchie Healthy Communities Collaborative, Allendale County
ALIVE, Inc., Low Country Regional T ransportation 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
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.
SALKEHATCHIE H EALTHY C OMMUNITIES
C OLLABORATIVE
ALLENDALE , SC 29810
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T his 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.
S OUTH CAROLINA
Salkehatchie NEEDS Diabetes Initiative
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. T hrough 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. T hese 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. T he campus currently has the only fitness center in the county, and has agreed to open that
facility to NEEDS participants. T he 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.
S OUTH CAROLINA
Chronic Disease Case Management for Middle School
Students to Reduce Absenteeism
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2007 – April 30, 2010
B EVERLYANN V. AUSTIN
F AIRFIELD MEMORIAL H OSPITAL
P.O. B OX 620
W INNSBORO, SC
803-712-0375
F AX –803-712-1683
BEVERLVANN. AUSTIN@ FAIRFIELDMEMORIAL. COM
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he network partners include a Critical Access Hospital, a forprofit 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
Middle school students, ages 11-15, with asthma and diabetes
are the primary target population for this grant.
F AIRFIELD MEMORIAL H OSPITAL
W INNSBORO, SC 29180
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T his 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. T he primary goals of this grant are 1) T o strengthen the Network
and its effectiveness in improving the system of health care in the Network region, 2) T o reduce
absenteeism of middle school students with the chronic conditions of asthma and diabetes, and 3) T o
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. T he 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
S OUTH CAROLINA
Chronic Disease Case Management for Middle School
Students to Reduce Absenteeism
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.
T he 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%. T he 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.
T he 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. T he network partners include a Critical Access Hospital, a forprofit 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.
T he 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.
T he 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.
S OUTH D AKOTA
Oglala Lakota College
TOPIC AREAS
Diabetes prevention, Health promotion
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
JOAN N ELSON
OGLALA L AKOTA C OLLEGE
N URSING D EPARTMENT
P.O. B OX 861
PINE R IDGE , SOUTH D AKOTA 57770
PHONE : (605) 867-5856
F AX : (605) 867-5724
Year 1 - 199,776.00
Year 2 - 199,816.00
Year 3 - 199,290.00
Oglala Lakota College Nursing Department, the Oglala Lakota Tribal
Health Education and Fitness Center, and the SuAnn Big Crow Boys
and Girls Club.
AREAS SERVED
T he American Indian population residing on the Pine Ridge
Reservation, which comprises of three counties in the southwest
corner of South Dakota.
T he target population is the Oglala Lakota T ribe, including children,
adults, and seniors, who are prediabetic.
OGLALA L AKOTA C OLLEGE
PINE R IDGE , SD 57770
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Oyate Wicozani Ocanku (Road to Wellness in the Community) project will develop and implement a
diabetes prevention program based on increasing fitness activity, improving diet, and improving selfesteem. T he target population is the Oglala Lakota T ribe, including children, adults, and seniors, residing
on the Pine Ridge Reservation who are prediabetic. T he goal of the project is to reduce the development
of diabetes in the non-diabetic population by 50 percent, with a focus on making a positive change by
targeting children. T he American Indian population residing on the Pine Ridge Reservation, which
comprises of three counties in the southwest corner of South Dakota, are devastated by the effects of
diabetes. American Indians die from diabetes complications at a rate 390 percent higher when compared
to other Americans. T he Pine Ridge Reservation has a staggering rate of unemployment (more than
70 percent) and poor and overcrowded housing. According to the U.S. Census 2000, Shannon County
(the only county completely within the Pine Ridge Reservation boundary) is the second poorest county in
the United States.
Access barriers to services include the total lack of private health care facilities, doctors, pediatricians,
obstetricians, gynecologists, dentists or other health care providers on the Pine Ridge Reservation; few
opportunities for private industry employment that would provide health care insurance; underinsurance
through the Indian Health Service (IHS); few roads and no public transportation; and cultural factors that
impact the way that services are provided to the Oglala Lakota people. T he service area is a designated
T he network partners are Oglala Lakota College Nursing Department, the lead applicant, the Oglala
Lakota T ribal Health Education and Fitness Center, and the SuAnn Big Crow Boys and Girls Club.
S OUTH D AKOTA
Oglala Lakota College
S OUTH D AKOTA
Custer School District 16-1
Program Director
TOPIC AREAS
Drug Prevention Services, Equine-assisted Learning
PROJECT PERIOD
May 1, 2005 – April 30, 2007
AMY STOKES
C USTER SCHOOL D ISTRICT 16-1
527 MONTGOMERY STREET
C USTER, SOUTH D AKOTA 57730-1124
PHONE : (605) 673-4540
F AX : (605) 673-4710
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
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Year 1 - 199,900.00
Year 2 - 199,446.00
Year 3 - 199,512.00
Lifeways, Inc., Walking In Grace, Native American prevention
specialists, and an evaluator from Black Hills State University.
AREAS SERVED
T he 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.
T he 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.
C USTER SCHOOL D ISTRICT 16-1
C USTER, SD 57730-1124
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T he initiative will provide alcohol, tobacco, and other drug prevention and early intervention services in
grades 5 through 12 in five rural schools. T here 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. T he 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.
T he 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. T he 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,
S OUTH D AKOTA
Custer School District 16-1
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. T he 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.
S OUTH D AKOTA
Easter Seals South Dakota
Program Director
TOPIC AREAS
Durable Medical Equipment
PROJECT PERIOD
May 1, 2005 – April 30, 2007
PATRICIA K. MILLER
EASTER SEALS SOUTH D AKOTA
1351 N ORTH H ARRISON AVENUE
PIERRE , SOUTH D AKOTA 57501-2373
PHONE : (605) 224-5879
F AX : (605) 224-1033



Year 1 - 199,386.00
Year 2 - 190,518.00
Year 3 - 192,084.00
Easter Seals South Dakota, the lead applicant; the South Dakota
Office of Adult Services and Aging; and Northland Rehab Supply.
AREAS SERVED
Underserved Areas. T welve counties in South Dakota are among
counties with the highest poverty rates in the United States.
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.
EASTER SEALS SOUTH D AKOTA
PIERRE , SD 57501-2373
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T he Recycle for Life Program—operated by Easter Seals South Dakota 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. T welve 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
S OUTH D AKOTA
Easter Seals South Dakota
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. Easter Seals South Dakota (ESSD) 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 Easter Seals South Dakota, the lead applicant; the South Dakota Office of Adult
Services and Aging; and Northland Rehab Supply.
S OUTH D AKOTA
South Dakota Urban Indian Health, Inc.
Program Director
TOPIC AREAS
Overweight/obesity; Diabetes
PROJECT PERIOD
May 1, 2006 – April 30, 2008
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

D ONNA K EELER
EXECUTIVE D IRECTOR
SOUTH D AKOTA U RBAN I NDIAN
H EALTH, I NC.
1714 ABBEY R OAD
PIERRE , SD 57501
PHONE : (605) 224-8841
F AX : (605) 224-6852
E-MAIL: DONNAK@SDUIH. ORG
Year 1 - 150,000.00
Year 2 - 124,999.00
Year 3 - 99,997.00
South Dakota Urban Indian Health, Inc., is a non-profit, Federally
Qualified Health Center. T hrough the Keya (Lakota for Turtle)
Program - Long Life for Good Health, the Keya Program
AREAS SERVED
Pierre, Fort Pierre, and Aberdeen, South Dakota
T he 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.
SOUTH D AKOTA U RBAN I NDIAN
H EALTH, I NC.
PIERRE , SD 57501
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
South Dakota Urban Indian Health, Inc., is a non-profit, Federally
Qualified Health Center. T hrough 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. T he 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 T ribal programs on the reservations. South
Dakota Urban Indian Health has been providing health services continuously since early 1978. T hese
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. T hey
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.
T he 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:
S OUTH D AKOTA
South Dakota Urban Indian Health, Inc.


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. T his will be accomplished through a variety of health promotion and
education activities targeting exercise and diet, and through continued input from targeted clients.
T his 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. T he 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.
S OUTH D AKOTA
Pine Ridge Reservation: Creating an Early Health Care Community
Program Director
TOPIC AREAS
Child Health
PROJECT PERIOD
May 1, 2007 – April 30, 20010



SHELLY GRINDE
C ENTER FOR D ISABILITIES
SANFORD SCHOOL OF MEDICINE OF THE
U NIVERSITY OF SOUTH D AKOTA
414 E C LARK STREET
VERMILLION, SD
800-658-3080
F AX –605-357-1438
SHELLY . GRINDE @ USD. EDU
Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he interagency network is comprised of the Center for Disabilities at
the Sanford School of Medicine of the University of South Dakota;
Oglala Sioux T ribe Health Administration; Oglala Sioux T ribe Office
of Special Education Services; Porcupine Clinic Health Board;
Shannon County Public School District; and 123..Hi Baby!, Inc.
AREAS SERVED
Pine Ridge Reservation
T o identify developmental concerns in children birth through five
years of age.
C ENTER FOR D ISABILITIES
SANFORD SCHOOL OF MEDICINE OF THE
U NIVERSITY OF SOUTH D AKOTA
VERMILLION, SD 57069
ORHP Contact:
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
(301) 443-1902
STAYLOR@ HRSA. GOV
PROJECT SUMMARY
T he Pine Ridge Reservation: Creating an Early Health Care
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. T he lead agency for this
project is the Center for Disabilities (CD), Sanford School of Medicine of T he University of South
Dakota. CD is part of a national network of University Centers of Excellence in Developmental
Disabilities Education, Research and Service. T he 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. T hrough 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
S OUTH D AKOTA
Pine Ridge Reservation: Creating an Early Health Care Community
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. T racking and monitoring of children not eligible for services, but considered at-risk will also be
created as part of this comprehensive system. T he interagency network is comprised of the Center for
Disabilities at the Sanford School of Medicine of the University of South Dakota; Oglala Sioux T ribe
Health Administration; Oglala Sioux T ribe 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.
TENNES S EE
Ridgeview Psychiatric Hospital and Center, Inc.
Program Director
TOPIC AREAS
Substance abuse, Mental health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
B RIAN B UUCK
C HIEF OPERATING OFFICER
R IDGEVIEW PSYCHIATRIC H OSPITAL AND
C ENTER, I NC.
240 W EST TYRONE R OAD
OAK R IDGE , TN 37830
E-MAIL: BBUUCK@RIDGEVW . COM
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Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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, T ennessee
R IDGEVIEW PSYCHIATRIC H OSPITAL AND
C ENTER, I NC.
OAK R IDGE , TN 37830
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
T he 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
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.
T he 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. T hese DEC/DEI are
placed in custodial care of the natural parents, a relative, or a foster parent, dependent of the individual
circumstances. T he 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 3year 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,
TENNES S EE
Ridgeview Psychiatric Hospital and Center, Inc.
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. T he 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.
T he 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.
TEXAS
The Burke Center
Program Director
TOPIC AREAS
Domestic violence, Mental health
PROJECT PERIOD
May 1, 2004 – April 30, 2006
SUSAN R USHING
THE B URKE C ENTER
4101 SOUTH MEDFORD D RIVE
L UFKIN, TEXAS 75901
PHONE : (936) 639-1141
F AX : (936) 639-1149
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Year 1 - 198,725.00
Year 2 - 198,725.00
Year 3 - 198,725.00
CareLink, a collaborative initiative consisting of the Burke Center, a
regional community mental health center, the Women’s Shelter of
East T exas (WSET ), and East T exas Community Health Services
AREAS SERVED
East T exas has a significant medically unserved and underserved
population and faces a severe shortage of mental health services. All
nine counties in the service area are designated as mental health
professional shortage areas, and 7 of the 9 counties are designated
with a full medically underserved area status.
Improve access to comprehensive health screening and treatment for
victims of interpersonal violence in a nine county area of east Texas.
T he initiative will blend systematic screening and assessment for
unmet health and mental health needs, health education, professional
consultation and training, and the direct delivery of mental health and
primary care to the target population of mostly women and children
served through the WSET .
THE B URKE C ENTER
L UFKIN, TX 75901
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Interpersonal violence within the family is a national concern, with estimates of at least 2 million to
4 million women each year being physically abused across the country. T he physical, emotional, and
economic impact of this abuse is enormous for women victims and their children. T he Texas Council on
Family Violence (T CFV) conducted a telephone survey in 2002 regarding domestic violence. They found
that 74 percent of all T exans experienced or know someone who has experienced some form of domestic
violence. Of the 59 percent that had personal experience, 26 percent had been physically abused, and
31 percent report having been either physically abused, sexually abused, or threatened by their partner at
some point in their lifetime. East Texas exemplifies these problems, as there is a high incidence of family
violence and widespread poverty, which increases the risk of mental and physical health problems for
women and children in this area. East T exas has a significant medically unserved and underserved
population and faces a severe shortage of mental health services. All nine counties in the service area are
designated as mental health professional shortage areas, and 7 of the 9 counties are designated with a full
medically underserved area status.
TEXAS
The Burke Center
CareLink, a collaborative initiative consisting of the Burke Center, a regional community mental health
center, the Women’s Shelter of East Texas (WSET), and East Texas Community Health Services, a
federally qualified health center, was formed to improve access to comprehensive health screening and
treatment for victims of interpersonal violence in a nine county area of east T exas. The initiative will
blend systematic screening and assessment for unmet health and mental health needs, health education,
professional consultation and training, and the direct delivery of mental health and primary care to the
target population of mostly women and children served through the WSET. The ethnic background of the
target population is 65 percent Caucasian, 22 percent African American, 12 percent Hispanic, and
1 percent Native American.
TEXAS
Lavaca Medical Center
Program Director
TOPIC AREAS
Elderly
PROJECT PERIOD
May 1, 2006 – April 30, 2008



JAMES E VANEK
L AVACA MEDICAL C ENTER
1400 N ORTH TEXANA
H ALLETTSVILLE , TX 77964
PHONE : (361) 798-3671, EXT. 235
E-MAIL:
LMCCEO@ LAVACAMEDCEN. COM
Year 1 - 149,981.00
Year 2 - 122,314.00
Year 3 - 99,111.00
T exas 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
T he project service area is located between San Antonio, Houston,
and Corpus Christi.
T IP 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 T exas’ Colorado, Lavaca, and
Jackson Counties.
L AVACA MEDICAL C ENTER
H ALLETTSVILLE , TX 77964
ORHP Contact:
H EATHER D IMERIS
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-4657
PROJECT SUMMARY
T he T exas 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
T exas’ Colorado, Lavaca, and Jackson Counties. T IP 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 midlevel practitioners, all of whom are members of the T IP consortium.
T IP 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.
T he 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 T exas 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 T exas and the United States, the region exhibits an increasingly
TEXAS
Lavaca Medical Center
elderly population distribution. Fully 19 percent of the population is 65 years or older (T exas = 9.9
percent, United States = 12.4 percent).
T IP 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. T IP is based on nationally recognized care models, including PACE (Program of Allinclusive Care for the Elderly) and SOURCE (Service Options Using Resources in Community
Environments).
T he T IP 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. T he consortium will position T IP 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 T exas for enhanced case management, and by replicating T IP in other Texas counties.
TEXAS
East Texas Border Health
Program Director
TOPIC AREAS
Health promotion/disease prevention (general); Chronic disease;
PROJECT PERIOD
May 1, 2006 – April 30, 2008
W ANDA K ENNEL
EXECUTIVE D IRECTOR
EAST TEXAS B ORDER H EALTH
401 N. GROVE
MARSHALL, TX 75670
PHONE : (903)938-1146
E-MAIL: WKENNEL@ETEX . NET



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Sabine Valley Center, East T exas Council on Alcohol and Drug
Abuse, Wiley College, and United Churches Care
AREAS SERVED
Harrison and Marion counties.
T o deliver integrated primary and mental health care to isolated,
chronically ill population groups. T he 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.
EAST TEXAS B ORDER H EALTH
MARSHALL, TX 75670
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-4438
PROJECT SUMMARY
East T exas Border Health is a 501(c)(3) primary care clinic in rural Harrison County, T exas. For this
project, East Texas Border Health has joined forces with Sabine Valley Center, East T exas 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.
T he goals of this project are threefold: 1) T o enhance access to care for 3,000 primarily low income
individuals with chronic physical and mental illness over the three year grant period; 2) T o 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) T o 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 T exas Border Health is the counties' only provider of health care without regard to
TEXAS
East Texas Border Health
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 T exas'; 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. T he resulting paranoia, confusion, and general distrust impede selfcare and primary care compliance, with dangerous effect for those who also have chronic physical health
conditions.
T he 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 T exas Council on Alcohol and Drug Abuse will support outreach
and will connect patients with substance abuse problems to available resources. East T exas Border Health
will provide continuity care for patients with chronic illness. (2) T he 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.
TEXAS
Migrant Health Promotion, Inc.
Program Director
TOPIC AREAS
Migrant health, Health promotion/disease prevention (general),
Behavioral health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
N OEMI GARCIA
D IRECTOR OF H EALTH EDUCATION
MIGRANT H EALTH PROMOTION, I NC.
P.O. B OX 337
PROGRESO, TX 78579
PHONE : (956)-565-0002
E-MAIL:
NGARCIA@ MIGRANTHEALTH. ORG
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

Year 1 - 149,998.00
Year 2 - 125,000.00
Year 3 - 100,000.00
Nuevas Avenidas is a formal collaboration between Migrant Health
Promotion, Community Hope Projects, AVANCE-Rio Grande
Valley, and T ropical T exas Center for Mental Health and Mental
Retardation Hidalgo County.
AREAS SERVED
Hidalgo County, T exas is medically underserved.
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
MIGRANT H EALTH PROMOTION, I NC.
PROGRESO, TX 78579
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he Nuevas Avenidas (New Avenues) Program will establish new routes of primary, preventative, and
behavioral health care for medically underserved community members in Hidalgo County, T exas. T he
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 T ropical Texas Center for Mental Health and Mental Retardation Hidalgo County,
located in the southern tip of T exas, 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
TEXAS
Migrant Health Promotion, Inc.
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.
T he 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. T he 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.
TEXAS
Matagorda Episcopal Health Outreach Program
Program Director
TOPIC AREAS
Dental care, Diabetes, Chronic Disease, T elehealth
PROJECT PERIOD
May 1, 2006 – April 30, 2008
B RENDA H ARRIS
MATAGORDA EPISCOPAL H EALTH
OUTREACH PROGRAM
101 AVENUE F N ORTH
B AY C ITY , TX 77414
PHONE : (979) 245-2008
E-MAIL: BHARRIS @MEHOP . ORG
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Year 1 - 147,108.00
Year 2 - 123,470.00
Year 3 - 98,935.00
T he 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.
AREAS SERVED
T he service area is Matagorda County, T exas, and the city of Wharton
in Wharton County. Both of these counties are rural and designated as
medically underserved areas.
T o meet an identified need for health care services for poor residents
of all ages. T o provide health and dental services to the uninsured,
low-income residents.
MATAGORDA EPISCOPAL H EALTH
OUTREACH PROGRAM
B AY C ITY , TX 77414
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
T he 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.
T he service area is Matagorda County, T exas, and the city of Wharton in Wharton County. Both of these
counties are rural and designated as medically underserved areas. T he target population is approximately
12,000 low-income, uninsured residents of the service area.
T he project has four goals: 1) T o improve oral hygiene among low-income residents in Matagorda and
Wharton Counties, and to expand a T ooth Fairy program in Wharton County; 2) To improve
understanding and treatment of diabetes and other chronic conditions, and the ability of patients to selfmanage care through the expansion of interactive telehealth services for consumers and their families and
continuing education for providers; 3) T o 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) T o advance public policy regarding dental care, patient education, and case management services
for low-income and uninsured rural residents in T exas by sharing outcomes of program activities with
selected State and professional agencies and with health professions educators.
TEXAS
Matagorda Episcopal Health Outreach Program
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.
T he 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.
TEXAS
Partners in Health for Cherokee County
Program Director
TOPIC AREAS
Health Literacy
PROJECT PERIOD
May 1, 2007 – April 30, 2010
F RAN D ANIEL
H.O.P.E., I NC.
595 R AGSDALE
JACKSONVILLE , TX
903-565-7781
F AX –903-586-2569
F R A N D A N I E L @ S U D D E N L I N K MA I L . C OM
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Year 1 - 160,000.00
Year 2 - 135,000.00
Year 3 - 110,000.00
East T exas 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, T rinity Counseling
Associates of East T exas, Inc., and T rinity Mother Frances Health
System
AREAS SERVED
Cherokee County
T o provide access to healthcare resources for the uninsured,
underinsured, or medically underserved citizens of Cherokee
County.
H.O.P.E., I NC.
JACKSONVILLE , TX 75766
ORHP Contact:
L ILLY SMETANA
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
(301) 443-6884
LSMETANA@ HRSA. GOV
PROJECT SUMMARY
Cherokee County, located in the piney woods of East T exas is a
rural
county with a population of 48,464. T he 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. T he 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. T here is no public
transportation in the county or in any of the towns.
T he 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 T exans as a whole.
T here 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
TEXAS
Partners in Health for Cherokee County
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. T he 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. T hese
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.
VERMONT
Rutland Mental Health Services
Program Director
TOPIC AREAS
Mental health
PROJECT PERIOD
May 1, 2003 – April 30, 2005
GERALD B ERNARD
R UTLAND MENTAL H EALTH SERVICES
78 MAIN STREET
P.O. B OX 222
R UTLAND, VERMONT 05701
PHONE : (802) 775-0828
F AX : (802) 747-7692
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

Year 1 - 180,650.00
Year 2 - 186,070.00
Year 3 - 191,650.00
Rutland Mental Health Services, Rutland Housing Authority, Rutland
Area Visiting Nurse Association and Hospice, Rutland Regional
Health Services, and Rutland Health Foundation.
AREAS SERVED
Rutland County, Vermont
T he target population demonstrates an urgent need for mental health
treatment, in particular for depression, but has virtually no access to
mental health care.
R UTLAND MENTAL H EALTH SERVICES
R UTLAND, VT 05701
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Health Coalition for Housing Initiative (HCHI) will serve 253
persons in five U.S. Department of Housing and Urban Development (HUD) congregate housing sites in
Rutland County, Vermont, the second largest county in the state. T he housing sites comprise a mix of
72 percent low-income elderly and 28 percent low-income younger persons with disabilities. T he target
population, which is 99 percent Caucasian and 1 percent African American, demonstrates an urgent need
for mental health treatment, in particular for depression, but has virtually no access to mental health care.
Many of the residents have interconnected problems, such as substance abuse problems. T he unmet need
for appropriate mental health care is leading to the eviction of some residents, which in turn results in
homelessness, criminal behavior, and/or inpatient psychiatric committal for tenants who need only a small
amount of assistance to be able to maintain a lease.
HCHI represents a coalition of four mental health, social service, housing, and medical providers that will
implement a project designed to fill critical gaps in mental health treatment, education, and prevention.
Key features of the program will include an interdisciplinary team to provide coordinated and
comprehensive case management; a psychiatric nurse practitioner to prescribe medications; increased
mental health clinician hours; psychiatric therapy groups; assessment and case management for related
medical problems; support groups for chronic diseases; education, screening, and prevention; and
involvement of residents in planning, screening, and feedback.
Access barriers to services include the inability of residents to access providers; the inability to afford
medication and treatment; the perceived stigma among the residents and practitioners associated with
VERMONT
Rutland Mental Health Services
mental health and substance abuse problems; and site-specific access barriers, such as disruptive episodes
at the housing sites resulting from intergenerational conflicts.
T he network partners are Rutland Mental Health Services, the lead applicant, Rutland Housing Authority,
Rutland Area Visiting Nurse Association and Hospice, Rutland Regional Health Services, and Rutland
Health Foundation.
VERMONT
Central Vermont Community Action Council
Program Director
TOPIC AREAS
Primary care, Mental health
PROJECT PERIOD
May 1, 2003 – April 30, 2005
PETER B UTTERFIELD
C ENTRAL VERMONT C OMMUNITY
ACTION C OUNCIL
195 US R OUTE 302 B ERLIN
B ARRE , VERMONT 05641
PHONE : (802) 728-9506
F AX : (802) 479-1053



Year 1 - 199,910.00
Year 2 - 196,796.00
Year 3 - 199,752.00
Central Vermont Community Action Council, the Central Vermont
Community Partnership, the Central Vermont Medical Center,
Vermont Department of Health, Kellogg-Hubbard Library,
Prevention, Assistance, Transition and Health Access, People’s
Health and Wellness Clinic, the Area Health Education Center, and
the Wheels Public T ransportation Services.
AREAS SERVED
Central Vermont region. More than one-third of the region is
designated as either a Health Professional Shortage Area or a
Medically Underserved Area.
T he target population includes all Vermonters in the region who are
in need of health services, including physical, mental, and dental, but
are unable to access services because of transportation, finances, lack
of knowledge of availability of services or other related causes. T he
target population includes families with infants and young children,
senior citizens, and those who are underinsured or uninsured.
C ENTRAL VERMONT C OMMUNITY
ACTION C OUNCIL
B ARRE , VT 05641
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Central Vermont Community Partnership Outreach Project (CVCPOP) will provide health and health
education services to residents of 24 towns in Washington and Orange counties using “ VanGo,” a mobile
unit operated in collaboration with the Kellogg-Hubbard Library. T he target population includes all
Vermonters in the region who are in need of health services, including physical, mental, and dental, but
are unable to access services because of transportation, finances, lack of knowledge of availability of
services or other related causes. T he target population includes families with infants and young children,
senior citizens, and those who are underinsured or uninsured. T he target population is 97 percent
Caucasian, 1.3 percent Hispanic, 0.6 percent Asian/Pacific Islander/Alaska Native, 0.5 percent African
American, 0.3 percent American Indian, and 0.2 percent other.
T he Central Vermont region has a population of more than 63,000 and only two designated rural health
clinics. Although most of Vermont has significant health and access needs, the Central Vermont region
compares poorly with other regions in the state in the areas of primary care, screening for colorectal and
prostate cancer, infant mortality, lung cancer deaths, and suicide deaths. Access barriers to services
VERMONT
Central Vermont Community Action Council
include the lack of public transportation (trains, buses, and taxicabs), the lack of a one-stop process for
community members to access the range of services available through multiple service organizations, and
the large number of uninsured and underinsured Vermonters (estimated at 17 percent). More than onethird of the region is designated as either a Health Professional Shortage Area or a Medically Underserved
Area.
T he network partners are the Central Vermont Community Action Council, the lead applicant, the Central
Vermont Community Partnership, the Central Vermont Medical Center, Vermont Department of Health,
Kellogg-Hubbard Library, Prevention, Assistance, Transition and Health Access, People’s Health and
Wellness Clinic, the Area Health Education Center, and the Wheels Public T ransportation Services.
VERMONT
Southern Vermont Area Health Education Center
Program Director
TOPIC AREAS
Obesity
PROJECT PERIOD
May 1, 2006 – April 30, 2008
N ANCY L ANOUE , MEED
SOUTHERN VERMONT AREA H EALTH
EDUCATION C ENTER
365 R IVER STREET
SPRINGFIELD, VT 05156
PHONE : (802) 885-2126
E-MAIL: NLANOUE @VERMONTEL. NET



Year 1 - 149,717.00
Year 2 - 124,947.00
Year 3 - 99,959.00
AREAS SERVED
Springfield and Windsor, Vermont
T he 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.
SOUTHERN VERMONT AREA H EALTH
EDUCATION C ENTER
SPRINGFIELD, VT 05156
PROJECT SUMMARY
T he Precision Valley Physical Activity and Nutrition Consortium will
ORHP Contact:
increase youth and family access to physical activities and increase
N ISHA PATEL
PROJECT OFFICER
opportunities for healthy food choices in Springfield and Windsor,
HRSA/ORHP
Vermont. T his will be accomplished through an interdisciplinary
5600 F ISHERS L ANE
consortium that has put together a services network called the "30+5"
Nutrition and Physical Activity Intervention. "30+5" is short for a
301-443-6894
NPATEL@ HRSA. GOV
recommendation to children and families to get at least 30 minutes of
exercise and eat 5 fruits and vegetables daily. T he target population is youth 10-13 and their parents.
T he intervention combines school nursing and primary care expertise and judgment in clinical assessment
with varied community resources for referral. T hese practitioners will have more levels of service
available. T he 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 lowcost 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. T he 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
VERMONT
Southern Vermont Area Health Education Center
another 17 percent are already overweight. T his target group was chosen because the consortium believes
that youth represent the most sustainable, long-term potential for obesity-prevention efforts.
VIRGIN IA
Carroll County Public Schools
Program Director
TOPIC AREAS
School health, Primary care
PROJECT PERIOD
May 1, 2003 – April 30, 2005
L YNN D AVIES
C ARROLL C OUNTY PUBLIC SCHOOLS
605-9 PINE STREET
H ILLSVILLE , VIRGINIA 24343
PHONE : (276) 728-3191
F AX : (276) 728-3195



Year 1 - 66,094.00
Year 2 - 111,263.00
Year 3 - 113,080.00
Carroll County Public Schools, T win County Regional Healthcare
Center, and the Mount Rogers Health District.
AREAS SERVED
Carroll County is a rural, economically challenged Appalachian
County located in Southwest Virginia in the Blue Ridge Mountains.
C ARROLL C OUNTY PUBLIC SCHOOLS
H ILLSVILLE , VA 24343
Carroll County Public Schools proposes to continue and expand a
school-based health care program that targets approximately 4,000
students.
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
ORHP Contact:
PROJECT SUMMARY
Carroll County Public Schools proposes to continue and expand a school-based health care program that
targets approximately 4,000 students. T he current program employs 10 registered nurses who work at
least part of each day in each of the 10 schools. Physical exams and dental services are offered through a
mobile health unit for children with parental permission. T he goals and objectives for the program
incorporate selected Healthy People 2010 objectives associated with risky behavior by students.
Carroll County is a rural, economically challenged Appalachian County located in Southwest Virginia in
the Blue Ridge Mountains. Of the student population, 45 percent are on free or reduced lunch, and
33 percent of the population is Medicaid-eligible. More than 45 percent of County residents age 25 and
older do not have a high school diploma. T he target population of 4,000 students for the project is
96.5 percent Caucasian, 3 percent Hispanic, and 0.5 percent African American. Poverty, illiteracy, lack
of insurance, and a rural isolation with no public transportation source are inhibitors to routine preventive
care. In addition, the County has a growing Hispanic migrant worker population. T here are cultural and
language barriers for these students, along with a lack of insurance and inadequate income for preventive
health care. T he Laurel Fork region of Carroll County is designated as a Health Professional Shortage
Area.
T he network partners are Carroll County Public Schools, the lead applicant, Twin County Regional
Healthcare Center, and the Mount Rogers Health District.
VIRGIN IA
Mental Health Association of the New River Valley, Inc.
Program Director
TOPIC AREAS
Mental Health
PROJECT PERIOD
May 1, 2003 – April 30, 2005
AMY F ORSYTH-STEPHENS
MENTAL H EALTH ASSOCIATION OF THE
N EW R IVER VALLEY , I NC.
303 C HURCH STREET
B LACKSBURG, VIRGINIA 24060
PHONE : (540) 951-4990
F AX : (540) 951-5015



Year 1 - 196,609.00
Year 2 - 199,552.00
Year 3 - 199,780.00
Mental Health Association of the New River Valley, Inc., the
Virginia Rural Health Resource Center, the New River Health
District, and the New River Valley on Aging.
AREAS SERVED
T hree of the counties (Floyd, Giles, and Pulaski) are classified as
Medically Underserved Areas and as Mental Health Professional
Shortage Areas.
T he Rural Mental Health Outreach Program is a new collaborative
network of four non-profit organizations designed to expand access
to mental health care for the residents of the rural New River Valley
region of southwest Virginia.
MENTAL H EALTH ASSOCIATION OF THE
N EW R IVER VALLEY , I NC.
B LACKSBURG, VA 24060
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Rural Mental Health Outreach Program is a new collaborative network of four non-profit
organizations designed to expand access to mental health care for the residents of the rural New River
Valley region of southwest Virginia. T he Outreach program will expand the Pro Bono Counseling
Program of the Mental Health Association of the New River Valley by taking mental health service
delivery outside of the two current clinic sites and providing services in an array of community settings,
including five rural health district offices, five senior centers, the homes of the home-bound elderly,
public schools in all five school districts, and physicians’ offices. T he target population for the Outreach
Program is low-income, uninsured adults, children, and families living in New River Valley, which
comprises Floyd, Giles, Montgomery, and Pulaski counties and the city of Radford. The target
population is 91.6 percent Caucasian, 4.2 percent African American, 2.2 percent Asian/Pacific
Islander/Alaska Native, 1.3 percent Hispanic, 0.5 percent other, and 0.2 percent American Indian.
Local needs assessment data indicate that the service area has unmet mental health service needs based on
the number of households reporting a family member with mental health or emotional problems and
suicide rates in Giles and Pulaski counties and the city of Radford that are well above the national and
state rates. Access barriers to services for the target population include the lack of mental health
resources, cultural and ethnic barriers to accessing needed mental health care (lack of Spanish-speaking
mental health professionals and the stigma associated with mental health problems by many in
Appalachian America), and physical/transportation barriers. T hree of the counties (Floyd, Giles, and
VIRGIN IA
Mental Health Association of the New River Valley, Inc.
Pulaski) are classified as Medically Underserved Areas and as Mental Health Professional Shortage
Areas.
T he network partners are the Mental Health Association of the New River Valley, Inc., the lead applicant,
the Virginia Rural Health Resource Center, the New River Health District, and the New River Valley on
Aging.
VIRGIN IA
Augusta Regional Free Clinic, Inc.
TOPIC AREAS
Oral health
PROJECT PERIOD
May 1, 2003 – April 30, 2005
Program Director
SCOTT L ITTEN
AUGUSTA R EGIONAL F REE C LINIC, I NC.
343 MULE ACADEMY R OAD
P.O. B OX 153
F ISHERSVILLE , VIRGINIA 22939
PHONE : (540) 332-5611
F AX : (540) 332-5610



Year 1 - 199,900.00
Year 2 - 199,900.00
Year 3 - 199,900.00
Augusta Regional Free Clinic, Augusta Health Care, Inc., the local
hospital, Central Shenandoah Health District, Augusta County
Schools, Staunton City Schools, and Waynesboro City Schools.
AREAS SERVED
Rural Augusta, including the municipalities of Staunton and
Waynesboro.
T he target population for the program is elementary school children
and adults whose income is less than 175 percent of the poverty
level and adults without insurance who live in rural Augusta,
including the municipalities of Staunton and Waynesboro. Services
will include educational, preventive, and restorative care for
elementary school children on the Free Lunch program as well as
low-cost services for adults at the Free Clinic and through a newly
formed network of 20 volunteer dentists.
AUGUSTA R EGIONAL F REE C LINIC, I NC.
F ISHERSVILLE , VA 22939
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Augusta Regional Free Clinic will add dental services (staff and four dental operatories) to its facility
to serve low-income adults and children. T he target population for the program is elementary school
children and adults whose income is less than 175 percent of the poverty level and adults without
insurance who live in rural Augusta, including the municipalities of Staunton and Waynesboro. Services
will include educational, preventive, and restorative care for elementary school children on the Free
Lunch program as well as low-cost services for adults at the Free Clinic and through a newly formed
network of 20 volunteer dentists.
T he target population is 92 percent Caucasian, 7 percent African American, and 1 percent Hispanic.
Access barriers to services include virtually no access to a dentist accepting Medicaid patients and the
lack of dental insurance for low-income adults. T he service area has an application pending for a Health
Professional Shortage Area designation.
T he network partners are the Augusta Regional Free Clinic, the lead applicant, Augusta Health Care, Inc.,
the local hospital, Central Shenandoah Health District, Augusta County Schools, Staunton City Schools,
and Waynesboro City Schools.
VIRGIN IA
Augusta Regional Free Clinic, Inc.
VIRGIN IA
Radford University
TOPIC AREAS
Oral Health
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
MICHAEL VANL UE
R ADFORD U NIVERSITY
D EPARTMENT OF C OMMUNICATION
SCIENCES AND D ISORDERS
C AMPUS B OX 6961
R ADFORD, VIRGINIA 24142
PHONE : (540) 831-7635
F AX : (540) 831-7669
Year 1 - 200,000.00
Year 2 - 181,573.00
Year 3 - 164,051.00
Radford University, the Free Clinic of New River Valley, the New
River Health District, Group of 20 Dentists in the New River Valley,
Wytheville Community College, Virginia Western Community
College, and the Virginia Department of Social Services.
AREAS SERVED
T hree of the counties (Floyd, Giles, and Pulaski) are classified as
Medically Underserved Areas.
Increasing access to oral health services for uninsured, low-income
adults (18 and older) who are at 150 percent of the poverty level and
lack dental insurance in the New River Valley area.
PROJECT SUMMARY
The Expansion of Oral Health Care Services in Rural
R ADFORD U NIVERSITY
R ADFORD, VA 24142
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
Southwest Virginia T hrough an Integrated Network of Community Resources proposes to address the
expansion of existing preventative and primary oral health services at the Free Clinic of the New River
Valley. T he project addresses the Healthy People 2010 Oral Health Goal by increasing access to oral
health services for uninsured, low-income adults. T he target population for the project is adults (18 and
older) who are at 150 percent of the poverty level and lack dental insurance in the New River Valley area.
T he target population is 70 percent Caucasian, 26 percent African American, 3 percent Asian/Pacific
Islander/Alaska Native, and 1 percent Hispanic. T he New River Valley consists of four counties in the
southwestern part of Virginia (Floyd, Giles, Montgomery, and Pulaski) and the city of Radford.
Although there are more than 70 private dentists in the project service area, the majority (73 percent) will
not treat the target population because of lack of reimbursement, leaving the Free Clinic as the only
significant dental provider for the target population. The state of Virginia Medicaid program does not
cover dental services for adults, and Medicare does not cover dental services for older adults. Although
the Virginia Department of Health provides funding for local public health clinics, the clinics do not offer
adult dental services. Other access barriers to services include lack of dental insurance, lack of financial
resources, and low educational level. T hree of the counties (Floyd, Giles, and Pulaski) are classified as
Medically Underserved Areas.
T he network partners are Radford University, the lead applicant, the Free Clinic of New River Valley, the
New River Health District, Group of 20 Dentists in the New River Valley, Wytheville Community
VIRGIN IA
Radford University
College, Virginia Western Community College, and the Virginia Department of Social Services.
VIRGIN IA
People Incorporated of Southwest Virginia
Program Director
TOPIC AREAS
Physician Education
PROJECT PERIOD
May 1, 2005 – April 30, 2007
R OBERT G. GOLDSMITH
PEOPLE I NCORPORATED OF
SOUTHWEST VIRGINIA
1173 W EST MAIN STREET
ABINGDON, VA 24210
PHONE : (276) 623-9000
F AX : (276) 628-2931



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
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. T he 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.
T he 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.
PEOPLE I NCORPORATED OF
SOUTHWEST VIRGINIA
ABINGDON, VA 24210
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
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’ selfefficacy, and provide community-based experience to medical residents. T he 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.
T he consortium also will host an information exchange forum for human service providers and physicians
in the four counties. T he project will link physicians, medical residents, local health districts, and human
service providers.
T he 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,
VIRGIN IA
People Incorporated of Southwest Virginia
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.
VIRGIN IA
Bath County Community Hospital
Program Director
TOPIC AREAS
PROJECT PERIOD
May 1, 2006 – April 30, 2008
D EBBIE L IPES
B ATH C OUNTY C OMMUNITY H OSPITAL
P.O. D RAWER Z
H OT SPRINGS , VA 24445
PHONE : (540) 839-7059
E-MAIL: BCCHDL@BCCHOSPITAL. ORG



Year 1 - 147,318.00
Year 2 - 114,436.00
Year 3 - 99,954.00
T he 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
T hese services are especially targeted to people for whom the cost of
a medical exam is a barrier, primarily those who are uninsured (1520 percent of the population) or underinsured, and whose incomes
fall below 300 percent of the poverty level.
B ATH C OUNTY C OMMUNITY H OSPITAL
H OT SPRINGS , VA 24445
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-0837
LSMITH2@ HRSA. GOV
PROJECT SUMMARY
T he 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." T hese 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.
VIRGIN IA
Bath County Community Hospital
T hese 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.
VIRGIN IA
Shenandoah Memorial Hospital
Program Director
TOPIC AREAS
Elder Care
PROJECT PERIOD
May 1, 2007 – April 30, 2010
F LOYD H EATER
SHENANDOAH MEMORIAL H OSPITAL
759 SOUTH MAIN STREET,
W OODSTOCK, VA
540-459-1100
F AX –540-459-1121
FHEATER@ VALLEYHEALTHLINK. COM



Year 1 - 149,914.00
Year 2 - 124,999.00
Year 3 - 99,999.00
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
It will specifically serve the health needs of older adults and seniors,
children and underserved minority residents.
SHENANDOAH MEMORIAL H OSPITAL
W OODSTOCK, VA 22664
ORHP Contact:
N ISHA PATEL
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
(301) 443-6894
NPATEL@ HRSA. GOV
PROJECT SUMMARY
T he “ 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. T he 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. T he 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. T he 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).
VIRGIN IA
Giles Community Health Access Project (G-CHAP)
Program Director
TOPIC AREAS
Mental Health
PROJECT PERIOD
May 1, 2007 – April 30, 2010
TAMMY B LANKENSHIP
C ARILION GILES MEMORIAL H OSPITAL
1 TAYLOR AVENUE
PEARISBURG, VA
540-921-6877
F AX –540-921-6858
THBLANKENSHIP @ CARILION. COM



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
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
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.
C ARILION GILES MEMORIAL H OSPITAL
PEARISBURG, VA 24134
ORHP Contact:
K RISTI MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T he need is evidenced by the high proportion of emergency room visits for nonemergency 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). T he program headquarters and clinic will be located in Giles
County which is in an officially designated rural census tract.
T he 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.
VIRGIN IA
Giles Community Health Access Project (G-CHAP)
CGMH will contribute the program’s clinic building located in central Giles County. T he 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. T he 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. T o 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.
WAS HINGTON
Klickitat Valley Health Services
Program Director
TOPIC AREAS
Diabetes
PROJECT PERIOD
May 1, 2003 – April 30, 2005
JEFF TEAL
K LICKITAT VALLEY H EALTH SERVICES
711 EAST C OLLINS
P.O. B OX 5
GOLDENDALE , W ASHINGTON 98620
PHONE : (509) 773-4017
F AX : 509-773-4543



Year 1 - 200,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
Klickitat Valley Health Services, and Skyline Hospital.
AREAS SERVED
Rural mountainous area in south-central Washington state.
T he purpose of the Klickitat County Diabetes Management Program
is to provide a comprehensive approach to managing diabetes
throughout the county. T he public education component of the
program, which will include glucose screenings and media insertions,
will target Native Americans, Hispanics, youth, and seniors.
K LICKITAT VALLEY H EALTH SERVICES
GOLDENDALE , WA 98620
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Klickitat County Diabetes Management Program will serve the residents of a rural mountainous area
in south-central Washington state. T he area is far from large health delivery systems that provide
specialty services in diabetes and training opportunities for health care professionals. Distance, road
conditions, and limited public and private transportation options frequently cause area residents to cancel
their medical appointments. T he nearest pharmacy that accepts Medicaid payments is a 70-mile roundtrip
from Goldendale, Washington, the county seat. Furthermore, 10 percent of county residents younger than
age 65 are uninsured, 16 percent of residents live below the Federal poverty level, 41 percent of students
are eligible for free or reduced lunch, and 12 percent of adults in the area are unemployed. The training
level of current primary health care providers and the availability of specialty services and consultation
are other barriers to diabetes services. Approximately 12 percent of the target population is Hispanic and
American Indian, groups with a high incidence of diabetes. In addition, Klickitat County is a Health
T he purpose of the Klickitat County Diabetes Management Program is to provide a comprehensive
approach to managing diabetes throughout the county. The public education component of the program,
which will include glucose screenings and media insertions, will target Native Americans, Hispanics,
youth, and seniors. Self-management activities, including diabetes support groups and an underinsured
assistance fund for purchasing diabetes supplies, will focus on persons who are newly diagnosed with
diabetes or who have recently had additional diabetes complications. Medical management activities will
focus on training health care providers and using specialist consultation through telehealth options. T he
WAS HINGTON
Klickitat Valley Health Services
project is a formal collaborative effort of the health, cooperative extension, and senior services
departments of Klickitat County, whose primary role will be public education about diabetes; Klickitat
Valley Health Services, the lead agency for the diabetes management program; and Skyline Hospital, the
primary health facility for the western portion of Klickitat County. T hese three entities have collaborated
successfully in the past on a teen health enhancement program and a community needs assessment.
WAS HINGTON
Lincoln County Health Department
Program Director
TOPIC AREAS
Health promotion/disease prevention (specific: breast cancer,
cardiovascular disease/stroke and multiple sclerosis)
PROJECT PERIOD
May 1, 2003 – April 30, 2005
ED D ZEDZY
L INCOLN C OUNTY H EALTH
D EPARTMENT
90 N ICHOLLS
D AVENPORT, W ASHINGTON 99122
PHONE : (509) 725-9213 EXT. 24
F AX : 509-725-1014



Year 1 - 176,835.00
Year 2 - 176,835.00
Year 3 - 181,606.00
Lincoln County Health Department, Lincoln County Hospital District
#1 and #4, Odessa Memorial Health Center, Lincoln Hospital and
North Basin Medical Clinic; Lincoln County Counseling Center; and
the Area Health Education Center at Washington State University–
Spokane.
AREAS SERVED
Lincoln County is a designated Health Professional Shortage Area,
and part of the county is designated as a Medically Underserved Area.
T he Lincoln County Health Coalition will develop and implement a
prevention and outreach program targeting three major health risk
benchmarks identified in a 2001 Lincoln County Health Assessment:
breast cancer, cardiovascular disease/stroke, and multiple sclerosis.
L INCOLN C OUNTY H EALTH
D EPARTMENT
D AVENPORT, WA 99122
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Lincoln County Health Coalition will develop and implement a prevention and outreach program
targeting three major health risk benchmarks identified in a 2001 Lincoln County Health Assessment:
breast cancer, cardiovascular disease/stroke, and multiple sclerosis. Components of the program will
include the identification of high risk populations for the targeted disease groups; the provision of
additional resources for diagnostic and preventive treatment of the target disease groups; the provision of
enhanced and new education and awareness programs to increase early detections; and the identification
and implementation of best practice models.
T he target population of all residents in Lincoln County is 95.6 percent Caucasian, 2 percent Hispanic,
1.3 percent American Indian, 0.9 percent Asian/Pacific Islander/Alaska Native, and 0.2 percent African
American. Access barriers to services include the lack of public transportation systems, including public
bus service, a less than average per capita income, a population of Germanic heritage (33 percent of
county residents) who culturally deny the need for preventive health care, and a growing number of
Hutterite Brethren Colonies and Apostolic Lutherans who do not use health care services fully. Lincoln
County is a designated Health Professional Shortage Area, and part of the county is designated as a
Medically Underserved Area.
WAS HINGTON
Lincoln County Health Department
T he network partners are the Lincoln County Health Department, the lead applicant; Lincoln County
Hospital District #1, Odessa Memorial Health Center; Lincoln County Hospital District #4, Lincoln
Hospital and North Basin Medical Clinic; Lincoln County Counseling Center; and the Area Health
Education Center at Washington State University–Spokane.
WAS HINGTON
Yakima Valley Farm Workers Clinic
Program Director
TOPIC AREAS
Diabetes, Obesity/overweight, Migrant health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
TERRI TRISLER, R.D., C.D., M.S.
YAKIMA VALLEY F ARM W ORKERS
C LINIC
P.O. B OX 190
TOPPENISH, WA 98948
PHONE : (509) 248-8602
E-MAIL: TERRIT@YVFWC. ORG



Year 1 - 150,000.00
Year 2 - 124,893.00
Year 3 - 100,000.00
AREAS SERVED
T oppenish, Grandview, and Prosser, Washington
T he Salud en Sus Manos consortium will target Hispanic, lowincome, and other underserved users with diabetes, obesity, and other
nutrition-related medical conditions in the rural communities.
YAKIMA VALLEY F ARM W ORKERS
C LINIC
TOPPENISH, WA 98948
ORHP Contact:
PROJECT SUMMARY
VANESSA H OOKER
T he goals of the Salud en Sus Manos (Health in Your Hands) project
PROJECT OFFICER
are to reduce disparities in diabetes, obesity, and other nutritionHRSA/ORHP
related medical conditions; improve access to diabetes, obesity, and
5600 F ISHERS L ANE
other nutrition-related health services; and improve the quality of
301-594-5105
diabetes, obesity, and other nutrition-related health services for
VHOOKER@ HRSA. GOV
Hispanic and rural residents in the Yakima Valley in Washington.
T he 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.
T he 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 T omando Control de su Salud (T aking 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 selfmanagement education radio shows for community members, while Prosser Memorial Hospital will
provide diabetes self-management education for community members.
WAS HINGTON
Yakima Valley Farm Workers Clinic





YVFWC will assign Dr. Katherine Smalley 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 T omando/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 selfmanagement education.
YVFWC will participate in the Washington State Diabetes Collaborative.
YVFWC will manage the Chronic Disease Electronic Management System.
T he 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.
WAS HINGTON
Family Health Centers
Program Director
TOPIC AREAS
Minority/Cultural/HL
PROJECT PERIOD
May 1, 2007 – April 30, 2010



H EATHER F INDLAY
F AMILY H EALTH C ENTERS
716 F IRST AVENUE SOUTH
OK
509-422-7675
ANOGAN, WA
509-422-5700
F AX –509-422-7680
H F I N D L A Y @ MY F A MI L Y H E A L TH . OR G
Year 1 - 144,887.00
Year 2 - 113,077.00
Year 3 - 99,693.00
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
Latino residents and MSFW and their families in rural Okanogan
County.
F AMILY H EALTH C ENTERS
OKANOGAN, WA 98840
ORHP Contact:
L AKISHA SMITH
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
(301) 443-0837
LSMITH2@ 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. T his project was developed with the
assistance and input from the Latino and MSFW communities. Family Health Centers ‘La Futura Mama y
Su Salud’ (T he Mother to be and Her Health’) has been an existing task force program between the
consortium members. T his 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.
T his 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. T his 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,
WAS HINGTON
Family Health Centers
cultural and religious beliefs that affect willingness to access care and, there are immigration issues that
prevent this population from seeking care. T his 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) T rain 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.
WAS HINGTON
San Juan Telepsychiatry Demonstration Project
Program Director
TOPIC AREAS
T elepsychiatry
PROJECT PERIOD
May 1, 2007 – April 30, 2010
B ETH W ILLIAMS GIEGER
C OMPASS H EALTH
4526 F EDERAL AVENUE (M/S 19)
EVERETT, WA 98213
425-349-6320
F AX –425-349-6325
BETHWG@ INTERISLAND. NET



Year 1 - 150,000.00
Year 2 - 125,000.00
Year 3 - 100,000.00
T he 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
T he 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.
C OMPASS H EALTH
EVERETT, WA 98213
ORHP Contact:
K RISTIN MARTINSEN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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.
T he 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.
T elemedicine 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. T he 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
WAS HINGTON
San Juan Telepsychiatry Demonstration Project
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.
T he 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.
T he 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.
WES T VIRGINIA
Community Actions of South Eastern West Virginia
Program Director
TOPIC AREAS
Child abuse, Home health, Health education (parenting)
PROJECT PERIOD
May 1, 2003 – April 30, 2005



SHANNON ATWELL
C OMMUNITY ACTIONS OF SOUTH
EASTERN W EST VIRGINIA
C OMMUNITY C ONNECTIONS , I NC.
307 F EDERAL STREET, SUITE 305
B LUEFIELD, W EST VIRGINIA 24701
PHONE : (304) 324-0456
F AX : (304) 327-7776
Year 1 - 199,655.00
Year 2 - 196,796.00
Year 3 - 199,752.00
T he Healthy Families America Initiative, which was launched in 1992
by Prevent Child Abuse America in partnership with Ronald
McDonald Children’s Charities.
AREAS SERVED
Parts of Mercer County are considered medically underserved. T here
are Health Professional Shortage Areas in the eastern and
northeastern sections of the county as well as in the western
communities of Mercer County.
First-time parents and pregnant teens, with a focus on serving the
most challenged of the challenged: those families with children at
risk of abuse and neglect who traditionally “fall through the cracks.”
C OMMUNITY ACTIONS OF SOUTH
EASTERN W EST VIRGINIA
B LUEFIELD, WV 24701
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
Healthy Families Mercer County, which began providing services in 1999, proposes to continue a highly
successful home visiting health program, expanding services to additional low-income families in the
rural area. Healthy Families Mercer County is based on the Healthy Families America model. T he
Healthy Families America Initiative, which was launched in 1992 by Prevent Child Abuse America in
partnership with Ronald McDonald Children’s Charities, endorses a comprehensive approach to home
visiting, including information and access to health services; parenting education; intensive services
tailored to the family’s needs; close partnership with local public and private organizations; and the
maintenance of high quality, consistent services.
T he target population for the Healthy Families Mercer County program is first-time parents and pregnant
teens, with a focus on serving the most challenged of the challenged: those families with children at risk
of abuse and neglect who traditionally “ fall through the cracks.” Mercer County has high rates of teen
pregnancy, drug and alcohol abuse, juvenile delinquency, family violence and dropout rates, all of which
limit the opportunity for the children and youth of Mercer County to obtain a healthy and secure future.
T he target population is 69 percent Caucasian, 29 percent African American, 1 percent American Indian,
1 percent Hispanic, and 1 percent Asian/Pacific Islander.
Access barriers to services include a high child poverty rate and the highest caseload in the state of child
WES T VIRGINIA
abuse and neglect cases; a lack of knowledge of available resources; and the geographic isolation of the
communities and lack of public transportation. Parts of Mercer County are considered medically
underserved. T here are Health Professional Shortage Areas in the eastern and northeastern sections of the
county as well as in the western communities of Mercer County.
WES T VIRGINIA
TOPIC AREAS
Hospice care
PROJECT PERIOD
May 1, 2003 – April 30, 2005



Program Director
K EVIN SMITH
B LACK R IVER MEMORIAL H OSPITAL
711 W EST ADAMS STREET
B LACK R IVER F ALLS , W ISCONSIN
54615
PHONE : (715) 284-1343
F AX : (715) 284-7166
Year 1 - 123,188.00
Year 2 - 58,610.00
Year 3 - 58,610.00
Black River Memorial Hospital, Jackson County Health and Human
Services, Krohn Clinic, Pine View Home Health, Jackson County
Interfaith Volunteer Caregivers, Pine View Care Center, Family
Heritage Care Center and Parkside Assisted Living, Ho-Chunk
Nation, David Johnson, a pastor, and a number of community
members.
AREAS SERVED
Jackson County, Wisconsin
T he Black River Hospice Development Project will provide hospice
care to terminally ill residents of Jackson County, Wisconsin, and
their families.
B LACK R IVER MEMORIAL H OSPITAL
B LACK R IVER F ALLS , WI 54615
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
T he Black River Hospice Development Project will provide hospice care to terminally ill residents of
Jackson County, Wisconsin, and their families. All hospice services in Jackson County were
discontinued in April 2000 because of staff shortages, reimbursement issues, and long travel times to the
rural area. T he lack of hospice care in the county has forced those who are ill, impaired, elderly,
uninsured, and/or living in poverty to travel more than 60 miles for essential services or to do without
critical end-of-life care. Jackson County has a high percentage of elderly residents, low annual wages in
comparison to the state average, higher unemployment rates that the state average, and a
higher percentage of residents living in poverty compared to the state average. T he target population for
the project is 89.6 percent Caucasian, 6.2 percent American Indian, 2.3 percent African American,
1.9 percent Hispanic, 1 percent other, and 0.2 percent Asian.
Access barriers to services include lack of access to Medicare certified hospice services in the county,
geographical distance from services that creates problems for family members to visit and remain in daily
contact with the hospice patient, and financial access (insurance reimbursement) for residential hospice
care.
T he network partners are Black River Memorial Hospital, the lead applicant, Jackson County Health and
Human Services, Krohn Clinic, Pine View Home Health, Jackson County Interfaith Volunteer Caregivers,
Pine View Care Center, Family Heritage Care Center and Parkside Assisted Living, Ho-Chunk Nation,
David Johnson, a pastor, and a number of community members.
WES T VIRGINIA
WIS CONS IN
Alzheimer’s Disease and Related Disorders Association, Inc.
Program Director
TOPIC AREAS
Dementia Services
PROJECT PERIOD
May 1, 2005 – April 30, 2007


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JUDITH D URKEE
ALZHEIMER’ S D ISEASE AND R ELATED
D ISORDERS ASSOCIATION, I NC.
203 SCHIEK PLAZA
R HINELANDER, W ISCONSIN 545013364
PHONE : (715) 362-7779
F AX : (715) 362-1879
Year 1 - 191,577.00
Year 2 - 189,964.00
Year 3 - 192,758.00
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
T his 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. T he project service area
includes seven sovereign tribal nations.
T his 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.
ALZHEIMER’ S D ISEASE AND R ELATED
D ISORDERS ASSOCIATION, I NC.
R HINELANDER, WI 54501-3364
ORHP Contact:
EILEEN H OLLORAN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-443-7529
PROJECT SUMMARY
T his 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. T his 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. T he project will not only build service capacity but will
also affect service quality and availability.
T he 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
WIS CONS IN
Alzheimer’s Disease and Related Disorders Association, Inc.
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. T he target population is older adults, especially those
with Alzheimer’s disease.
T his 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. T he 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.
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.
WIS CONS IN
Ho-Chunk Nation
Program Director
TOPIC AREAS
Diabetes, Obesity
PROJECT PERIOD
May 1, 2005 – April 30, 2007
L INDA L OWERY
H O-C HUNK N ATION
N6520 GUY R OAD
B LACK R IVER F ALLS , W ISCONSIN
54615-5405
PHONE : (715) 284-9851, EXT. 5343
F AX : (715) 284-5150
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Year 1 - 189,902.00
Year 2 - 184,220.00
Year 3 - 188,762.00
Consortium partners include the Ho-Chunk Division of Health, HoChunk Education Department, Ho-Chunk Social Services, and T omah
and Black River School Districts.
AREAS SERVED
T omah and Black River Falls areas.
T he target population is 400 Ho-Chunk youth age 6 to 18 and their
parents.
H O-C HUNK N ATION
B LACK R IVER F ALLS , WI 54615-5405
ORHP Contact:
VANESSA H OOKER
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
301-594-5105
VHOOKER@ HRSA. GOV
PROJECT SUMMARY
An estimated 15 percent of children age 6 to 19 in the United States
are overweight. T he 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.
T he 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. T his
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 T omah/Wyeville area, which has not
received these services; and (5) implement the new program in Black River Falls. T he 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.
T he target population is 400 Ho-Chunk youth age 6 to 18 and their parents who reside in the T omah and
Black River Falls areas. T he jurisdictional lands of the Ho-Chunk Nation, a federally recognized Indian
T ribe, cover a 16-county area in central Wisconsin. T he 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.
WIS CONS IN
Ho-Chunk Nation
T he 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 T omah. T reatment 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, HoChunk Social Services, and T omah and Black River School Districts.
WIS CONS IN
Wood County Health Department
Program Director
TOPIC AREAS
Minority health, Occupational health
PROJECT PERIOD
May 1, 2006 – April 30, 2008
K AREN B REWER
W OOD C OUNTY H EALTH D EPARTMENT
184 N. 2° D STREET
W ISCONSIN R APIDS , WI 54494
PHONE : (715) 421-8911
E-MAIL: KBREWER@CO. WOOD. WI. US



Year 1 - 150,000.00
Year 2 - 200,000.00
Year 3 - 200,000.00
T he 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.
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.
W OOD C OUNTY H EALTH D EPARTMENT
W ISCONSIN R APIDS , WI 54494
ORHP Contact:
SHEILA W ARREN
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T he 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.
T he 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, nonprofit organizations, faith-based groups, Latino service providers, and community volunteers both
Hispanic and non-Hispanic.
T he model that will be used to provide health and safety outreach for this proposed project is founded on
the community health outreach model. T he 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
WIS CONS IN
Wood County Health Department
counties are Wood, Marathon, Clark, and Lincoln counties. T he 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;
T rain 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.
T his 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.
WIS CONS IN
Northeastern Wisconsin Area Health Education Center, Inc.
Program Director
TOPIC AREAS
PROJECT PERIOD
May 1, 2006 – April 30, 2008



MARTIN SCHALLER
N ORTHEASTERN W ISCONSIN AREA
H EALTH EDUCATION C ENTER, I NC.
804 JAY STREET, STE . 201A
MANITOWOC, WI 54220
PHONE : (920) 652-0238
F AX : (920) 652-0617
E-MAIL: MARTYS @NEWAHEC. ORG
Year 1 - 149,886.00
Year 2 - 124,944.00
Year 3 - 99,994.00
Know Your Numbers, High School Peer Health Education,
Manitowoc County Network for Child Passenger Safety, and Healthy
T eeth Healthy Kids.
AREAS SERVED
Manitowoc County
T his is an overarching project that touches many health care issues.
N ORTHEASTERN W ISCONSIN AREA
H EALTH EDUCATION C ENTER, I NC.
MANITOWOC, WI 54220
ORHP Contact:
PROJECT SUMMARY
T his 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
SONJA TAYLOR
PROJECT OFFICER
HRSA/ORHP
5600 F ISHERS L ANE
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. T he 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.
T his 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.
T he 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
WIS CONS IN
Northeastern Wisconsin Area Health Education Center, Inc.
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. T he
Fourth Initiative, Healthy T eeth 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.

ALABAMA Bayou Clinic, Inc. DBA Bayou La Batre Rural Health Clinic

Transcription

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