Challenge

The Delta Health Alliance (DHA) has a deep bench of research expertise and broad, multi-sector partnerships to serve rural, vulnerable communities of the Mississippi Delta. The Accountable Health Communities opportunity required a high level of data capture and analysis, and DHA’s partners varied in this capacity — from health centers and hospitals to grassroots advocates. CMS required that the applicants detail all of the area’s existing services, gaps and assets across multiple social determinants of health, and also required assurance that all partners could comply with regimented CMS research protocols and shared measurements across care settings and service providers. The DHA team realized that they could not require the same level of staff time and data analysis from all partners, but wanted to find a way to authentically include all collaborators in the project planning, implementation and evaluation. Essentially DHA had to conduct an exhaustive audit of available services at the application phase and demonstrate that standardized metrics could be captured across all seven rural Mississippi counties to be served. To prepare a competitive proposal, data would need to be captured, synthesized and packaged from 13 clinical site locations and across over 40 service providers addressing key social determinants of health.

Solution

• Delivered initial guiding questions and grids for capturing clinical delivery site and community partnership data
• Drafted talking points to help DHA communicate the CMS opportunity and expectations to partners of all sizes and capacities
• Conducted landscape analysis of providers addressing social determinants of health beyond DHA’s existing partnerships and collaborations
• Developed unique, tailored requests for information for key clinical and community partners
• Worked with DHA to define tiered engagement structure to allow participation of all partners
• Conducted research into evidence-based models that aligned with the approach and design of DHA’s proposed services
• Supplemented need data with additional CMS and public health data mining and analysis to demonstrate the challenges and barriers to care experienced in rural MS
• Developed iterative drafts of all proposal and budget narratives with the program, outreach and research staff to balance the community-level logistics and feasibility of enrollment numbers with the rigorous metrics and evaluation tools required by CMS

Grant Awards