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Arizona Community Health Workers Association, Inc.ArizonaCommunity Health Workers (P)Big Sandy Health Care, Inc.KentuckyCommunity Health Workers (P)Hopewell Health Centers, Inc.OhioCommunity Health Workers (P)Mercy Medical Center – NewtonIowaCommunity Health Workers (S)Northeast Oregon NetworkOregonCommunity Health Workers (P)Purchase District Health Department, Inc.KentuckyCommunity Health Workers (P)Randolph County Caring Community, Inc.MissouriCommunity Health Workers (P)Sky Lakes Medical Center Foundation, Inc.OregonCommunity Health Workers (P)Union County Health and Wellness Network, Inc.New MexicoCommunity Health Workers (P)Westchester-ellenville Hospital, Inc.New YorkCommunity Health Workers (P)Indiana University Health Bedford, Inc.IndianaDementia (S)Northeast Nebraska Public Health DepartmentNebraskaObesity Prevention (P)Rural Health Works, Inc.GeorgiaObesity Prevention (S)Sacred Heart Health ServicesSouth DakotaPalliative Care (S)Strength in Peers, Inc.VirginiaPeer Recovery SpecialistsDublin City SchoolsGeorgiaSchool-based Health (P)HSHS Good Shepherd Hospital, Inc.IllinoisSchool-based Health (S)Rural Health Works, Inc.GeorgiaSchool-based Health (P)Well Being DevelopmentMinnesotaSchool-based Health (S)Mendonoma Health AllianceCaliforniaSocial Determinants of Health (S)Mercy Medical Center – NewtonIowaSocial Determinants of Health (P)Tri-County Health NetworkColoradoSocial Determinants of Health (S)Unity HealthcareIowaSocial Determinants of Health (P)Bay Rivers Telehealth AllianceVirginiaTelehealth (P)Critical Access Hospital NetworkWashingtonTelehealth (P)Delta Health Alliance, Inc.MississippiTelehealth (S)HSHS Good Shepherd Hospital, Inc.IllinoisTelehealth (P)Kansas Clinical Improvement Collaborative, LLCKansasTelehealth (P)Palmetto Care ConnectionsSouth CarolinaTelehealth (P)

Paris-Henry County Health Care Foundation, Inc.TennesseeTelehealth (P)St. Johns River Rural Health Network, Inc.FloridaTelehealth (P)Virginia Rural Health AssociationVirginiaTelehealth (S)Wilderness Health, Inc.MinnesotaTelehealth (P)Bright Future Foundation For Eagle CountyColoradoWorkforce Development (P)Critical Access Hospital NetworkWashingtonWorkforce Development (S)Eastern Plains Healthcare ConsortiumColoradoWorkforce Development (P)Montana State University, Inc.MontanaWorkforce Development (P)Oregon Washington health NetworkOregonWorkforce Development (S)Sacred Heart Health ServicesSouth DakotaWorkforce Development (P)St. Claire Medical Center, Inc.KentuckyWorkforce Development (S)St. Claire Medical Center, Inc.KentuckyYouth Opioid Prevention (S)

Grantee ProfilesThe following section contains contact information and brief descriptions of the 44 Rural Health Network Developmentgrantees funded during the 2020-2023 grant period. These descriptions may include program approach, program goals,and/or key activities for project/program implementation and further development of the engaged networks as they seek toimprove the quality of health care in their communities.

PrevTOCGlossaryNextArizonaArizona Community Health Worker Association, Inc.Grant Number:Organization Type:GranteeOrganization:Primary Contact:Secondary Contact:Expected fundinglevel for each budgetperiod:Network Members:D06RH37493Nonprofit Network OrganizationProject Name: Rural Arizona CHW Workforce Development NetworkAddress: 424 N Christine Ave .City: DouglasState: ArizonaZip code:85607Tel #: 928-366-3016Website: https://www.azchow.org/Name: Floribella RedondoTitle: Project DirectorTel #: 928-366-3016Email: floribella@azchow.orgName: Betsy SorensonTitle: Network DirectorTel #: 520-626-7864Email: elizabeth@azchow.orgMonth/Year to Month/YearAmount Funded Per YearJul 2020 to Jun 2021 300,000Jul 2021 to Jun 2022 300,000Jul 2022 to Jun 2023 300,000Partner OrganizationCountyStateOrganization Type*Indicates partners who have signed aMemorandum of UnderstandingChiricahua Community Health Center*North Country Health Care (Flagstaff)*Cochise County Health Department*Yuma County Health Department*Navajo Nation Department of Health andHuman Services*Hualapai Health Department*Southeast Arizona Area Health EducationCenter*Campesinos Sin Fronteras*Arizona Community Health WorkerAssociation/AzCHOW*Arizona Department of Health Services*University of Arizona Prevention ResearchCenter*Arizona Advisory Council on Indian HealthCare*Arizona Complete QHCFQHCHealth Dept.Health Dept.Tribal Health Dept.MohaveSanta CruzAZAZTribal Health Dept.AHECYumaCochiseAZAZNonprofit Org/CBONonprofit Org/CBOMaricopaPimaAZAZState CommissionPayer

Counties the projectserves:Target populationserved:Northern Arizona University Center forHealth Equity Research*Apache County, AZCochise County, AZCoconino County, AZMohave County, AZNavajo County, AzSanta Cruz County, AZYuma County, AZPopulationAdults (18-64 years)African AmericansCaucasiansElderly (65 )Yes Infants and toddlers (up to 3 years) LatinosNative AmericansOther:Focus Areas:Project goals ol children (3-4 years)Pacific IslandersPregnant WomenSchool-age children (elementary 5-12years )School-age children(Middle/high school 13-17 years)UninsuredOther:Other: Community Health WorkersChronic DiseaseYes Primary Focus Area:Secondary Focus Area:Goal/ ObjectiveDescriptionGoalThe Rural Arizona CHW Development Network will be a sustained., diverse, drivingforce for the CHW workforce in Arizona in order to improve access to health care,health outcomes and quality of life for rural Arizonans.ObjectiveBy June 30, 2023, participatory structure and operations will enable the Network toflourish and be sustained as a champion for Arizona’s rural CHW workforce.ObjectiveBy June 30, 2023, the Network will build the capacity of rural CHWs in all ten corecompetencies and maximize CHW voluntary certification per Arizona state law.ObjectiveBy June 30, 2023, the Network will work with health care system providers--bothcommunity-based and clinical--to assess needs and build the capacity toincorporate CHWs in care coordination and integrated behavioral health to improvehealth outcomes and reduce costs.ObjectiveBy June 30, 2023, the Network will work with Arizona policy makers, the Medicaidsystem (AHCCCS) and health plans to advance financing options to support CHWservices.Project Description:Fourteen diverse partner organizations have come together to build the Rural Arizona Community Health Worker (CHW) WorkforceDevelopment Network into a driving force for the expansion, diversity, integration, and sustainability of CHW/Tribal CommunityHealth Representatives (CHR)/ Promotores de Salud (PP) services in a seven-county region.The Network has a plan to strengthen its partnership by leveraging CHW/CHR and PP services as the catalyst for redesigning thestructure, function, planning, sustainability, and growth of its operations. With a systems focus, grant funding will be used toincrease the number of certified community health workers (CHW) based upon the successful C3 Project model, integrate CHWservices into the health care systems of targeted communities through a recruitment and training process, and identify and pursuestrategies to sustain and scale rural CHW services. The Network will work on strengthening its operational procedures to ensure

maximum member engagement in decision making, strategic planning and sustainability planning. There will be regular processand performance measures that will inform program strategies and impact.The Rural Arizona CHW Workforce Development Network was formed out a 2018 RHN Planning grant with a vision of ensuring thatCHW/CHR/PP’s become recognized as part of the healthcare workforce solution in rural Arizona. The fourteen partnering entitieshave strong but unique histories of utilizing CHWs to increase access to health care in rural areas of Arizona, improvement of healthcare quality among rural health care providers and improvement in health outcomes among rural patients and community residents.The five rural health care sectors represented include: FQHCs, County Health Departments, Tribal Health Departments, NonProfit/CBOs, and State Government/Academic Institutions. Six of the partners are located in rurally designated communities andleadership consists of an Elected Leadership Team and the Network Director who relies on committees and task forces to ensureprogress.Evidence Based/ Promising Practice Model Being Used or Adapted:Three Evidence-Based/Promising Practice will be utilized.1) The Chronic Care Model (CCM) identifies the essential elements of a health care system that encourage high qualitychronic disease care. These elements are the community and health systems. The community includes resources andpolicies that promote self-managed support. Health systems pertain to the organization of health care, which includesdelivery system design, decision support and clinical information systems. In combination, the evidence-based practicesunder each element foster productive interactions between informed patients who take an active part in their care and theircare providers who have the resources and expertise they need.2) Community Health Worker Scope of Practice has a large body of evidence that now supports CHW effectiveness in manysettings. The C3 project recommends ten core competencies for the CHW scope of practice, in addition to 11 skills and avariety of qualities. The first five core competencies demonstrate how CHWs can improve access to care and healthoutcomes in rural communities: #1 –Cultural mediation; #2 –Culturally appropriate health education and information; #3 –Care coordination, case management and system navigation; #4 -Coaching and social support; #5 –Advocacy forindividuals and communities.3) Behavioral health integration, integrating primary care and behavioral health, is a concept many states are adopting.Arizona’s Medicaid system now requires its funded health plans to integrate both services for its health plan members, andproviders are increasingly moving toward integration. The models to integrate primary care and behavioral health focus onchanges in primary care practice roles and support for co-location or coordination to address populations with mild tomoderate behavioral health conditions. These models require significant workforce-related changes, including team-basedcare and changes in staff roles, including CHWs.Project Officer (PO):Name: Krista MastelTel #: 301-443-0491Email: KMastel@hrsa.govOrganization: Federal Office of Rural Health PolicyCity: RockvilleState: MarylandZip code:20857TechnicalName: Ann AbdellaAssistance (TA):Tel #: 404-413-0314Email: abdella@a2rh.netOrganization: Georgia Health Policy CenterCity: AtlantaState: GeorgiaZip code:30303

PrevTOCGlossaryNextVirginiaBay Rivers Telehealth AllianceGrant Number:Organization Type:GranteeOrganization:Primary Contact:Secondary Contact:Expected fundinglevel for each budgetperiod:Network Members:Counties the projectserves:Target populationserved:D06RH37494Nonprofit Network OrganizationProject Name: Eastern Shore Telehealth ConsortiumAddress: 618 Hospital Rd., Bldg. ACity: TappahannockState: VirginiaZip code:22560Tel #: 804.443.6286Website: http://bayriverstelehealth.org/Name: Donna D HaleTitle: Executive DirectorTel #:Email: execdirector@bayriverstelehealth.orgName: Mary OchsnerTitle: Network DirectorTel #:Email: director@easternshoretelehealth.orgMonth/Year to Month/YearAmount Funded Per YearJul 2020 to Jun 2021 300,000Jul 2021 to Jun 2022 300,000Jul 2022 to Jun 2023 300,000Partner OrganizationCountyStateOrganization Type*Indicates partners who have signed aMemorandum of UnderstandingBay Rivers Telehealth Alliance (BRTA)*Eastern Shore Community Service Board(ESCSB)*Eastern Shore Health District (ESHD)*Riverside Shore Memorial Hospital (RSMH)*Eastern Shore Regional Jail (ESRJ)*Accomack County, VAPopulationAdults (18-64 years)African AmericansCaucasiansElderly (65 )VAVAVAVAVANorthampton County, VAYes Infants and toddlers (up to 3 years) LatinosNative Americans Nonprofit Org./CBONonprofit Org./CBOHealth Dept.HospitalJailPopulationPre-school children (3-4 years)Pacific IslandersPregnant WomenSchool-age children (elementary 5-12years )School-age children(Middle/high school 13-17 years)UninsuredOther:Yes

Other:Focus Areas:Project goals &objectives: Other: Primary Focus Area:TelehealthSecondary Focus Area:Behavioral Health/Mental Health - Substance Use DisorderGoal/ ObjectiveDescriptionGoalDevelop a sustainable Eastern Shore Telehealth Consortium (ESTC) for thedevelopment of strategic virtual health ini

Big Sandy Health Care, Inc. Kentucky Community Health Workers (P) Hopewell Health Centers, Inc. Ohio Community Health Workers (P) Mercy Medical Center - Newton Iowa Community Health Workers (S) Northeast Oregon Network Oregon Community Health Workers (P) Purchase District Health Department, Inc. Kentucky Community Health Workers (P)