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Caring Community Network of the Twin Rivers Project
| Topics |
Health insurance and uninsured
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| States served |
New Hampshire
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| Description |
The Caring Community Network of the Twin Rivers (CCNTR) is a recognized nonprofit organization in the State of New Hampshire formed in 1996. CCNTR has been working as a collective to create a coordinated, accessible system of care across the region. This project will enhance existing mechanisms and expand the capacity of the network to provide effective, coordinated, and accessible services throughout the region that improve health outcomes of uninsured clients with chronic illness and provide appropriate services such as emergency room care.
Individuals in the Twin Rivers face higher rates of many health risk indicators than the rest of the state. There are disparities among chronic disease factors, and socio-economic indicators. In addition, residents face significant barriers to access service and prevention programs including: geographic or social isolation, lack of transportation, lack of awareness of services, uncertainty of how to access service, lack of insurance, not enough insurance, and fear of stigmatization or reprisal. These barriers reduce use and inhibit the continuity of care, decreasing the overall effectiveness of the service delivery system.
There are three target groups who will benefit from the activities in this proposal: (1) low-income and uninsured adults, (2) low-income, uninsured and underinsured elderly, and (3) individuals with chronic illness such as diabetes and CVD/hypertension. These populations overlap and are inter-related.
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| Services offered |
The proposed project develops roles that will support several models that have been proven effective in this and other areas, will replicate those models for new populations, and will expand the reach of mechanisms that work well in other parts of the country for use here. These staff positions include:
175 days of contracted outreach care coordination each year will be arranged with existing network staff to work with residents that need to be connected to primary care and other supports;
One FTE disease manager who will work with primary care providers, nutritionists, and other health care professionals to provide health education, counseling, and coordinated care planning to people living with chronic disease;
.25 FTE project manager to integrate care coordination and disease management with the system of uncompensated care, and overall project management.
A CCNTR staff evaluator will be contracted. A small amount of consulting time will be used to develop modifications to telehealth tools.
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| Results |
The proposed project will positively impact service delivery in the region. It will: (1) identify best practices in disease management, planned care visits, and coordination currently used by medical providers to implement them region-wide, (2) incorporate the use of electronic tools, developed with an outside source of revenue, to use a shared client data base for health education, coordination, referral, and chronic disease registry (3) enhance client access to the above services and to other services available in the region, and (4) increase the level of disease and care management available, resulting in improved patient health outcomes.
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| Source |
Rural Health Outreach Grantee Directory, 2006
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| Contact person |
Richard D. Silverberg
The Caring Community Network of the Twin Rivers
841 Central Street,
Franklin, New Hampshire 03235
Phone: (603) 934-0177, ext. 107
E-Mail: rsilverberg@ccntr.org |
| Date added |
January 22, 2007 |
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