Saline for patient with patient in bed background.

Funding is imperative to address the emerging focus on health disparities.

On Jan. 11, the National Institutes of Health (NIH) posted a significant funding opportunity for communities and healthcare organizations to address health disparities for individuals with multiple chronic conditions (MCCs), saying that “the goal of the initiative is attainment of optimal treatment and health outcomes to advance healthcare towards health equity.”

You will want to search for PAR-22-092 online to find the direct link and details. Application submissions open on Feb. 17 and close on March 18. Application reviews and notifications will go out in July, and the earliest start date for projects will be Sept. 22.

This funding is imperative to address the emerging focus on health disparities, but also the growing research of individuals with MCCs being impacted by varying levels of care because of their race, poverty level, or geographic location. The number of people with MCCs continues to increase, and currently represents 42 percent of the U.S. population age 65 and older. The highest number of adults with MCCs are those living in poverty. In addition, the prevalence of MCCs is highest for minority populations ages 45 to 64.  

The U.S. Department of Health and Human Services (HHS) is specifically looking for ways to address MCCs for impacted populations by targeting their top concerns, which include:

  • Suboptimal care coordination;
  • The collaboration of primary and specialty care services;
  • Subspecialty referrals;
  • Patients’ limited understanding of coexisting conditions;
  • Polypharmacy; and
  • Payment or reimbursement issues for clinicians and healthcare systems.

They are hoping that applications will include a design centered around the Chronic Care Model (CCM), which emphasizes the importance of patient and healthcare team interactions to enhance patient self-management and healthcare provider decision support. This would be a great add-on project if your organization has a community needs assessment highlighting top issues in your area.

If your health system already provides transitional care management, chronic care management, or has primary care medical home designation, you are already ahead of the game and can likely just expand on existing services for your target populations. HHS also encourages any organizations that are in value-based care models to apply so they could expand on existing programs that may not have had the necessary funding or resources originally.

Here are some examples of programs that may be helpful in your community. I would consider projects that would help patients obtain health insurance if they are uninsured, cover out-of-pocket expenses such as vital medications that patients often have trouble affording, provide support for transportation to needed appointments, and maybe offer greater integration with primary care and cardiology for PT/INR clinics. It could be something as simple as sending home a meal package for your patients diagnosed with malnutrition who recently had a significant hospitalization; the food in their fridge will likely be bad by the time they discharge home.

Finally, you could pull data on your top DRGs w/MCC capture to look at the diagnoses that are having the greatest impact on your community.   

Programming Note: Listen to Tiffany Ferguson’s live reports on SDoH Mondays on Monitor Mondays, 10 Eastern.

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