Build Your Nest Postpartum Navigator Pilot Project With Baby Blues Connection as Fiscal Sponsor

The Build Your Nest Postpartum Navigator Pilot Project is a community-based program that improves the health of parents and babies. It aims to build family resiliency by supporting maternal mental health, lactation, bonding and social connections. The goal of this work is to connect parents with the resources they need while addressing the individual or collective barriers that families often face.

Columbia Memorial Hospital: Connected Care For Older Adults

Connected Care for Older Adults is a pilot program that uses community health workers (CHWs) who work in partnership with primary care clinicians to improve care for frail older adults in rural areas. It was collaboratively developed by members of the Older Adult Working Group of the Columbia Gorge Health Council’s clinical advisory panel. The Columbia Gorge Health Council partners with primary care clinics to test and refine the Connected Care for Older Adults model.

Coquille Valley Hospital: Medical Social Needs Access Project (M-SNAP)

Coquille Valley Hospital (CVH), an established Critical Access Hospital (CAH) serving east Coos County, is implementing a “Food Farmacy” program to address the health-related social needs of the underserved areas of Coquille, Myrtle Point and Powers. This program will address food insecurities and increase access to primary care and mental health services. The Food Farmacy will provide access to fresh food and dry pantry items for patients. Additionally, the program will provide wrap-around nutritional education and support to help patients change behaviors and incorporate healthy habits into their day-to-day lives. 

Good Shepherd Health Care System: Doula Services in Eastern Oregon

Good Shepherd Health Care System (GSHCS) is committed to enhancing the quality of prenatal care and labor support for expectant mothers within the community. GSHCS recognizes the vital role that doulas play in providing emotional, physical and informational support throughout pregnancy, childbirth and the postpartum period. This program will expand doula services, including introducing group classes to provide education and foster connections among expectant mothers, and providing essential items to assist with prenatal care and labor coping.

Jefferson County Public Health: Jefferson County Public Health Rural Health Equity Integration Coordinator 

This grant supports the funding of the Rural Health Equity Integration (RHEI) coordinator position at Jefferson County Public Health. The RHEI coordinator will lead a comprehensive systems approach to tackle modifiable risk factors in Jefferson County in order to improve rankings in state health metrics. They will emphasize fostering collaboration between county and non-county entities to minimize health disparities and improve access to health resources. They will guide and support multifaceted community health initiatives, working closely with staff, community partners and stakeholders to align efforts across various sectors. 

Adventist Health Columbia Gorge: Enhanced Care Coordination Project

Through the Incubator grant, Adventist Health Columbia Gorge (AHCG) will fund salary and benefits expenses for a 0.5 FTE CHW/patient navigator over a 12-month grant period. This funding enables AHCG to better serve all patients and caregivers within their service area, using intervention strategies that emphasize populations of focus with complex medical and social needs. The project will prioritize patient-centered, population-based care for those experiencing health disparities due to race/ethnicity, predominantly Latinx residents of the Columbia Gorge region, as well as migrant and seasonal farmworkers. Enhancing AHCG care coordination services will help to ensure that patients' individual needs are met across the full continuum of care, thereby optimizing and advancing care integration across the health system and community-based partner network.

Elkton Community Education Center (ECEC): Rural Wellness: Bringing a Nutrition-Forward Model to Rural Communities

The Elkton Wellness Initiative will take a nutrition-forward approach to address local health challenges through health education and modifications to the local food system. Through this program, ECEC is developing the first-ever CHW-led nutrition program, teaching Food Is Medicine principles using inexpensive pantry staples. The program will address common knowledge gaps by answering the questions: “how does my body work, what nutrients do I need, and how can dietary changes help me manage my chronic conditions?” through a six-month campaign of bite-sized lectures and recipe samples, taught by a CHW. The curriculum will be adapted from an existing nutrition program, FAMILIAR, into a new format of 12 mini-lectures and a weekly goal-setting workbook. Lectures will be held during an existing senior lunch program, providing a built-in community support structure.  

Micronesian Islander Community: Talk Stories: Healthy Conversations with Micronesian Voyagers

This program will bring together Micronesians who live in La Grande and Island City in Eastern Oregon and CHD Inc. for culture sharing through outreach, education and storytelling. Primary activities include the development of cultural classes, such as sewing and weaving, while encouraging conversations and educational workshops on several core priority areas: health, housing and food. The classes will be designed as hands-on workshops and work in partnership with CHD to bring resources, knowledge and information for Micronesians while also building community by creating cultural learning activities. 

New Horizons: Farm Workers Outreach Food Boxes and Hot Meals for People Experiencing Houselessness 

New Horizons has been working with the Latinx community and farm workers since 2003. The Food Boxes Program was developed during the pandemic to provide resources to this population. In addition to food, the boxes include health information and pamphlets to keep the community healthy. This grant will further support this program and allow it to expand to serve more migrant workers.

The Peaceful Presence Project: Community Connectors for Serious Illness Care Rural Community Toolkit 

The Community Connector Program for Serious Illness Care addresses social isolation and loneliness among residents living with or supporting someone with chronic or serious illness. The model promotes spaces where trained traditional health workers (THWs) and community members offer compassionate support, identify individuals’ strengths and assist in connecting them to available resources. By expanding the social circle and nurturing meaningful relationships, the project strives to improve its participants' quality of life and health outcomes. 

The Community Connector Toolkit will use learnings from a pilot program in Central Oregon that includes skills training, community engagement and resource coordination to develop a freely available toolkit for rural Oregon communities to use to replicate the program. The overall goal is to improve the quality of life for rural Oregonians living with serious illness and loss, as well as caregivers, by supporting connections to people and resources.

Envision EyeCare for All: EyeCare for All

The state of Oregon does not offer eye care services in Federally Qualified Health Centers (FQHCs), school-based health centers, or community health centers. This contributes to underserved populations in rural Oregon facing even greater challenges in access due to geographic isolation, limited transportation and socioeconomic factors. As a result, individuals in these communities are at higher risk of vision impairment, leading to reduced productivity, impaired educational attainment and diminished overall well-being.   

This program aims to bring comprehensive eye care directly to underserved communities by bringing a fully equipped mobile exam lane to rural communities across Oregon. Staffed by a veteran optometrist, certified optician and translator, the clinic provides comprehensive eye exams, vision screenings, prescription eyewear and referrals when necessary.  

Gender Hive: Supporting Rural Health Care Providers in Affirming Gender Diverse Youth 

Currently, there are no regular or ongoing training opportunities focused on providing gender-affirming care in a rural context, nor are there communities of practice for providers serving trans and gender-diverse youth. Guided by best practices in gender-affirming care, the ECHO Model for virtual provider education and needs assessment feedback from rural families and providers, this project seeks to increase access to gender-affirming care for youth in rural Oregon through tailored provider education. This project includes developing, piloting and evaluating a virtual training series and community of practice focused on gender-affirming care for rural pediatric providers. 

Evergreen Family Medicine and Women's Health: Evergreen Mammogram Project

Roseburg and Douglas counties' wait time for mammograms is about six to eight months and patients must travel up to an hour and a half to either Eugene or Medford. The result is that fewer women are getting mammograms regularly. With the help of the Incubator program, Evergreen Family Medicine will build the new Mammogram Program. This program will benefit over 8,000 local women who may not have the means to complete these tests if travel is required. The Mammogram Project is located in the Women's Health Department as a convenient way for women ages 40 to 75 to have all of their preventative care services done in one place.

Sky Lakes Medical Center: Understanding and Evaluating Local Impact on Social Drivers of Health

This program will use a methodology known as Ripple Effect Mapping in partnership with the Oregon Clinical and Translational Research Institute at OHSU to better understand how CHWs influence access to health, increase access to services screening and impact social drivers of health in rural communities. The learnings and experience from this project will be used and shared with other rural and frontier communities facing uncertain futures and growing barriers to accessing health and health care.  

Clatsop Community Action: Community Referral Desks

Clatsop Community Action (CCA) will bridge the gap in systemic inequities and serve as a vital conduit for rural populations in need to have increased access to social services promoting overall health and well-being in Clatsop County, Oregon. CCA will facilitate our Community Referral Desks onsite at Providence Seaside Hospital and Columbia Memorial Hospital. CCA’s Community Referral Desks serve as an extension of our organization’s “one-stop” operational model as we provide welcoming and personal interactions with clients who call or walk-in with various crises and we link them to the appropriate resource(s).

Southern Coos Hospital & Health Center: Meeting the Needs of an Aging Population through Chronic Care Management

Southern Coos Hospital & Health Center, located in Bandon, Oregon, is launching a Chronic Care Management (CCM) program based in its Primary Care Health Center. The incorporation of a care coordination program into clinic practices has been shown to move forward the value-based care model and achieving the triple aim: better health for the population, better care for individuals, and lower costs through improvements.

Wallowa Memorial Hospital: Wallowa Memorial Outdoor Fitness Trail Phase Two

Wallowa Memorial Hospital is working on an outdoor fitness trail for the community, with special equipment for older adults. The outdoor fitness trail, upon completion, will cater to all ages and fitness levels with a variety of equipment accessible to anyone at no charge.  This project is the first of its kind in Eastern Oregon.  The vision of utilizing our campus as a place for community members to come and engage in safe, accessible physical activity began with installing a half-mile walking path in 2019.  Today, the community heavily uses the trail 12 months out of the year.  It is the only flat, paved walking path of its kind in our community.  The successful utilization of the path was the catalyst for planning additional ways to utilize our grounds to address several identified needs in our community. 

Good Shepherd Health Care System: Parent Support and Education in Umatilla and Morrow County

The Parent Support and Education in Umatilla and Morrow County project aims to bring the Positive Parenting Program (Triple P) to Good Shepherd Health Care System. In Umatilla and Morrow Counties there are little to no resources for parents on parenting education and support. This grant will fund five Triple P parenting workshops and one Triple P 8-week parenting series to help support local families. All sessions will be offered at no cost to participants and in both English and Spanish. Triple P originated in Australia in 2001 and is one of the most effective evidence-based parenting programs in the world. Triple P gives parents simple and practical strategies to help them build strong, healthy relationships, confidently manage their children’s behavior and prevent problems developing. This program will help parents gain effective parenting skills, and provide parents with the skills, tools, and resources for positive parenting. This need has been identified by Good Shepherd providers and a number of families within the community. 

Columbia Memorial Hospital will address the primary care shortage in Clatsop County and the subsequent prolonged pharmacy wait times by initiating clinical pharmacy services at the CMH-OHSU Primary Clinics in Seaside, Warrenton, and Astoria. The Rural Population Health grant will assist with start-up costs to allow the pharmacists to provide medication therapy management to patients in rural Clatsop County.

Curry Health Network aims to address the 3.2% pre-diabetic rate in Curry County by offering a Diabetes Prevention Program (DPP) to Curry residents. This is an evidence-based lifestyle change program that features trained lifestyle coaches, a research-based curriculum, and group support. The Rural Population Health grant will assist with funding the pilot year with the intention of becoming certified by the CDC and eligible for insurance coverage in subsequent years.

Lake Health District plans on preventing moderate risk EOCCO members from becoming high risk by connecting them with a traditional health worker who will conduct social determinants of health screenings and connect the members with primary care providers and other resources.

Lower Umpqua Hospital Foundation will implement a program to monitor elevations in heart rate, blood pressure and increase in weight for patients with Congestive Heart Failure. The Rural Population Health Grant will allow LUHF to purchase monitoring equipment for patients who would not otherwise afford it with the goal of decreasing mortality related to heart failure.

St. Charles Redmond and Prineville are partnering with local EMS agencies to create a Basic Life Support Obstetrics (BLSO) course to improve the quality of emergency obstetrics and maternal health in Central Oregon. The Rural Population Health grant will help fund the first year of the pilot program.