New 3-year grant improves healthcare system for high-needs individuals

WATERTOWN, NY - Fort Drum Regional Health Planning Organization (FDRHPO) has been awarded a 3-year Health Resources and Services Administration (HRSA) Northern Border Regional Commission grant that will improve the healthcare system for high-needs individuals in the North Country.
The grant titled “Using the Community Health Worker Model to Improve Clinical and Social Outcomes of Rural High-Needs Individuals,” will deploy Community Health Workers, employed by the Northern Regional Center for Independent Living (NRCIL), in six rural hospital-based primary care sites (Clifton-Fine Hospital, River Hospital, Samaritan Medical Center’s Clayton clinic, and three Carthage Area Hospital/Claxton-Hepburn Medical Campus clinics located in Ogdensburg and Canton).
“NRCIL is honored to partner with FDRHPO on this important project,” said Aileen Martin, Executive Director at NRCIL. “Community Health Workers give the people in our community a non-judgmental neighbor to turn to for guidance to learn how to navigate the new steps being added to the dance we call life.”
Community Health Workers foster trusting relationships with the populations they serve and function as a link between healthcare providers and patients. Three full-time Community Health Workers, along with a supervisor, will be deployed and assigned at practices that they will remain working in for the entirety of the grant period.
"Carthage Area Hospital and Claxton-Hepburn Medical Campus are grateful for the ongoing support and commitment of the Fort Drum Regional Health Planning Organization in ensuring healthcare remains local and accessible,” said Richard Duvall, President & CEO of North Star Health Alliance. "This initiative to integrate Community Health Workers into rural practices is a vital step forward in improving care and outcomes for our high-needs populations."
The Community Health Workers will conduct outreach to rural residents who are elderly, disabled, and/or low-income to engage them in physical, behavioral, and social services, for example facilitating engagement in wellness visits, chronic care management, immunizations, cancer screenings, and other primary care services; assisting patients in securing transportation services in preparation for their next appointment; linking individuals to recommended specialty, social care, or behavioral services; conducting health-related social needs screenings with patients; assisting individuals in learning how to use telehealth technology in preparation for an upcoming visit; assisting individuals who have literacy or health literacy barriers in completing forms; and participating in primary care appointments alongside individuals deemed as appropriate; and other interventions as identified.
"To reach any community there must be an ability to understand, on an individual level, the lives, the challenges, and the success of that community,” said Heather Petrie, Practice Transformation Specialist with FDRHPO and the North Country Initiative. "Community Health Workers belong in all places where change or understanding is needed; they are the roots of their community."
Ms. Petrie has first-hand experience as a Community Health Worker in her past role with the North Country Family Health Center (NCFHC) and her work has revolved around addressing patient barriers to care, including social determinants of health.
"With their lived experience and passion for listening to the “small things,” Community Health Workers can hear the human story and collaborate with individuals to support the changes they want to see in their lives,” she said.
Ms. Petrie explained, "Every story, every need is different. Our rural communities face challenges with their healthcare that can be diverse; knowledge of services can often be scarce. The rural Community Health Worker is an expert on services that are available in their communities and help ensure people receive the care and services that many are not aware are available to them."
“Helping people gives me a sense of purpose and fulfillment," said Dyna Eastman, Community Health Worker at Clifton Fine Hospital and Canton Health Center in Canton. "Community Health Workers are in place to build relationships with both the patients and the providers which in turn helps to provide better access to healthcare and community resources."
“Community Health Workers are so important in healthcare. They live and work in the communities they are serving and often are the experts on the needs of those communities,” said Felicia Parker, Operations Manager at the Samaritan Family Health Center in Clayton. “Community Health Workers help patients navigate the healthcare system, helping to find primary care services, providing education on disease management, and breaking down barriers to accessing healthcare services such as housing and transportation. Most importantly, Community Health Workers advocate for an equitable healthcare system to meet the needs of patients as well as educate healthcare providers and community stakeholders about the communities being served to help bridge the gap. Our Clayton patients will greatly benefit from this role being embedded into their care. We are fortunate to have this opportunity in rural healthcare.”
The project will measure the number of target population members engaged in Community Health Worker interventions, participating members’ health outcomes (e.g., rates of preventable inpatient admissions and emergency department visits, care gap closure, and social care referral closure), and reimbursement volumes for project-related services (e.g., Transitional Care Management, Chronic Care Management, Social Determinant of Health Risk Assessment, Community Health Integration services, and Principal Illness Navigation services).
By the end of the 3-year grant, the goal is for the target population who engaged with Community Health Workers to have 10% fewer potentially preventable inpatient admissions and emergency visits; the closure of at least 35% of care gaps that have been identified, and the closure of at least 50% of the identified health-related social needs referrals.
The project will conclude in September 2027.
This program was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $250,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Comments