grantee abstracts

ABSTRACT
Project Title: Patient Navigator Project
Organization Name:
Lutheran Family Health Centers of Lutheran Medical Center
Address: 6025 6th Avenue, Brooklyn, NY 11220
Project Director: Kathy Hopkins
Email: khopkins@lmcmc.com http://www.lmcmc.com
Phone: 718-630-7171 Fax: 718-630-7295

Abstract Narrative:
The proposed initiative will employ the services of Patient Navigators to build upon the services
provided to high risk diabetic patients by Lutheran Family Health Centers’ existing Care
Management program, that has utilized a community health worker and care management
framework to serve adults and children with Diabetes and Cardiovascular conditions.
The Patient Navigators (PN) hired for this initiative will play an essential role in helping high
risk patients access quality health services, embrace positive health behaviors, and navigate
complex treatment regimens. Hired because of their unique access to Southwest Brooklyn
communities and the trust they enjoy with community residents, PNs will be able to integrate
health information about prevention/management of disease and the health system into the
community’s culture, language, and value systems.
The PN model has been found particularly effective in programs that seek to create positive
change in health seeking behaviors among vulnerable and underserved populations, such as the
one served by LFHC.
The proposed PN program will serve the medically underserved,
ethnically diverse contiguous southwest Brooklyn neighborhoods of Sunset Park, Bay Ridge,
Dyker Heights, and Bensonhurst. There are approximately 25,000 individuals who have
diabetes. Another 59,000 individuals are obese while 74,000 have high blood pressure, two
obvious risk factors for type II diabetes. Of particular concern for the target population is the
apparent rise in the prevalence of childhood diabetes. The appearance of a spike for the service
population is consistent with recent projections by the Centers for Disease Control (CDC) that
one in three children born in the US in 2001 is expected to become diabetic, with even worse
outcomes for Hispanic and Asian children
The proposed program will employ the services of seven patient navigators to serve an
anticipated 650 patients belonging to two high risk cohorts– Adult diabetics with an A1c
value > 9.0 and children with a family history of diabetes and a probable diagnosis of obesity.
The primary goals of this initiative are to eliminate barriers to care, ensure timely delivery of
services and reduce the morbidity and mortality associated with diabetes among this high-risk
patient population.
The program will partner with Columbia University’s Mailman School of Public Health and the
1199 Training Fund to train patient navigators and to evaluate the outcomes of this initiative.
The program is requesting funding preferences due to a high proportion of its target patient
population being culturally, linguistically and socio-economically marginalized, resulting in
significant barriers to accessing adequate care to effectively managed their diabetes.

ABSTRACT
Project Title: Chronic Disease Prevention & Management (CDPM) Patient Navigator Program
Organization Name: Goodwin Community Health Center, Inc., dba Coastal Medical Access
Project (CMAP)
Address: 900 Bay Street, P.O. Box 1357, Brunswick, Georgia 31521
Project Director: Patricia J. Kota, RN, MSPL, Chief Executive Officer
Phone: 912-554-3559, ext. 11 Fax: 912-554-8344
Email: pkota@cmapga.org
Website address: www.cmapga.org
Project Period: October 1, 2008 through September 30, 2010
______________________________________________________________________________
Abstract Narrative: Goodwin Community Health Center, Inc., dba Coastal Medical Access
Project (CMAP), in Brunswick, GA proposes the establishment of a Chronic Disease Prevention
and Management (CDPM) Patient Navigator (PN) program designed to improve health care
outcomes for uninsured adults residing in Camden, Glynn and McIntosh counties in southeast
Georgia. CMAP operates two free primary and specialty health care clinics that serve uninsured
adults in the three target counties since 2002, and CMAP provides access to free and low-cost
medications. CMAP is the only provider of these services in the target area. The three counties,
with a population of 151,880, are partially rural and have significant rates of poverty and lack of
health insurance. The area faces significant health issues that contribute to poor health outcomes
of residents. Obesity, tobacco use and physical inactivity are lifestyle concerns that contribute to
the development of chronic diseases. The region also has health disparity concerns, such as
higher rates of diabetes among African Americans, and higher death rates from cardiovascular
disease than both state and national rates. More than 15% of residents in the three counties do not
have health insurance.
The CDPM PN program is building on a long history of informal and successful chronic disease
case management by nursing staff at the clinics. To increase the impact of the case management
services on the population of patients with chronic disease, CMAP is developing a formal and
comprehensive CDPM program for patients with chronic disease, including implementation of a
patient navigator model. The CDPM pilot program was launched at the St. Marys clinic early
this year with 16 clinic patients with diabetes. Patient navigators are a critical part of the CDPM
program’s future growth. CMAP plans to incorporate both social workers and trained lay persons
in the patient navigator role. The Patient Navigator program will initially focus on patients with
diabetes or cardiovascular disease, and will expand to other chronic diseases based on the
incidence of those diseases among the CMAP patient population. The CDPM Patient Navigator
program targets uninsured adults with chronic disease within the 200% Federal Poverty Level
guidelines and residing in the three counties. Plans to expand services to include employer
groups and large employers that are self-insured are also under development and are key to the
program. Revenue from contracts with employers will generate funds that will support the
program by 2011. The PN program will recruit, train, employ, assign and manage six patient
navigators over the two-year grant period. The patient navigators will provide patient
assessment, case management, health literacy and education, psychosocial support, and selfmanagement education and support (Stanford Model and Motivational Interviewing). CMAP
requests statutory funding preference on the basis of the targeted population that will be served
(low income, uninsured with limited transportation alternatives).

ABSTRACT
Project Title: Palmetto AccessNET
Organization Name: Palmetto Project
Address: 1031 Chuck Dawley Blvd, Suite 5, Mount Pleasant, SC 29464
Project Director: Laura S. Morris
Phone: 843-577-4122 Fax 843-723-0521   E-mail ppaccessnet@aol.com
Website: www.palmettoproject.org
Project Period: September 30, 2008 – August 31, 2010
Abstract Narrative:  The Palmetto Project is a 501c(3) organization, established in 1984 by
business leaders in South Carolina to implement innovative solutions to the state’s most
pressing social and economic problems.
The purpose of this application is to secure funding through which the Palmetto Project,
utilizing its existing provider consortium and patient navigator network, can implement new
programming to (1) reduce health disparities by increasing enrollment of uninsured minorities
with risk factors for chronic disease in patient navigation, including assignment to medical
homes and participation in pharmaceutical assistance programs; (2) expand navigation services
into two rural counties with near epidemic rates of cardiovascular disease and diabetes among
its minority population; (3) create a replicable model of effective interaction between a health
care consortium with patient navigator services and a community-based health education and
disease prevention program targeted to minorities at greatest risk of cardiovascular disease and
diabetes; (4) document improved clinical indicators for navigated patients with diabetes and/or
cardiovascular disease; and (5) document reductions in costs to hospital emergency department
and in-patient visits through improved access and care coordination, combined with
community-based programming in health education, disease prevention, and self-management.
The Palmetto Project proposes to implement the project in five coastal counties with sizeable
minority populations with documented risk factors for cardiovascular disease and diabetes.
This proposal would fully engage at-risk communities in health education & chronic disease
prevention, provide care coordination and patient navigation to uninsured minorities with risk
factors for CVD and diabetes, support local collaborations among providers and at-risk
populations to reduce barriers to care, and create a replicable program model.
Nowhere in any other state is there as compelling a need for immediate, dramatic intervention
to reduce health disparities. The Palmetto Project’s extensive track record in creating
innovative, nationally recognized health initiatives makes it an ideal candidate to implement
the legislated goals of the Patient Navigator Outreach & Chronic Disease Prevention Act of

2005.
A Funding Preference is requested in the format requested.

ABSTRACT
Project Title: Transformacion Para Salud: Using Promotores to Improve Chronic Disease
Management
Organization Name: The School of Nursing, Texas Tech University Health Sciences Center
Address: 3601 4th Street, Lubbock, TX 79430
Project Director: M. Christina R. Esperat, RN, PhD, FAAN
Phone : 806-743-3052 Fax 806-743-1622 E-mail Christina.esperat@ttuhsc.edu
Website Address: www.ttuhsc.edu/son
Project Period:
Abstract Narrative:
The purpose of this application is to implement the Transformacion Para Salud (TPS)
Program to improve health care outcomes for vulnerable individuals in Lubbock county. Using a
cadre of certified Promotores with Community Health Worker Certification as Patient Navigators,
the application aims to coordinate comprehensive health services for patients in need of chronic
disease care and management for the following health conditions: cancer, diabetes, hypertension,
obesity and asthma. The nexus of this application emanates from the Larry Combest Community
Health and Wellness Center (LCCHWC), a 501c3 primary care center owned and operated by the
School of Nursing (SON) at the Texas Tech University Health Sciences Center (TTUHSC). The
target population to be served is economically and medically vulnerable patients with the identified
health conditions. Using 4 (four) trained Promotores, the proposal aims to serve a maximum of 250
patients currently enrolled in the LCCHWC chronic disease management programs over the two
year project period. The Transformation for Health conceptual framework developed in the SON
will be used as a foundation for the enhanced Promotores training curriculum, and layered on will
be the Chronic Disease Management curriculum that will serve to provide the knowledge base
required for the Promotores practice.
During the second year of the funding period, the project team will investigate the potential for
disseminating the CHW/Promotores training program to surrounding rural counties. Starting with
needs assessments, for outreach using community health workers, of selected rural communities,
the team will issue reports to stakeholders within those communities to determine program
priorities, and if indicated, will work with those stakeholders to develop the training program for
those communities.
Funding preference is requested for this application, on the basis of the medically-underserved
populations and areas, targeted for the program. In addition, the Center is located in a health
professions shortage area of the county of Lubbock, which is a designated partial-HPSA county.
NON-FEDERAL EXPENDITURES
FY 2007 (Actual)
FY 2008 (Estimated)
Actual FY 2007 non-Federal funds, including
Estimated FY 2008 non-Federal funds,
in-kind, expended for activities proposed in
including in-kind, designated for activities
this application. If proposed activities are not
proposed in this application.
currently funded by the institution, enter $0.
Amount: $____0_________
Amount: $_____0_________

Abstract

Northeast Valley Health Corporation
Patient Navigator Outreach and Chronic Disease
Prevention Demonstration Project - HRSA-08-130

Project Title: Cancer Patient Navigator Program HRSA-08-130
Organization Name: Northeast Valley Health Corporation (NEVHC)
Address: 1172 North Maclay Avenue, San Fernando, California 91340
Project Director: Debra Rosen, MPH, RN
Phone: (818) 898-3467 ext. 41517 Fax: (818) 365-4031 E-Mail:DebraRosen@nevhc.org
Web Site Address: www.nevhc.org
Project Period: January 1, 2009 through December 31, 2010
In operation for 35 years, Northeast Valley Health Corporation (NEVHC), a Joint Commission
Accredited Federally Qualified Health Center (FQHC) requests $500,000 to develop and
implement a Cancer Patient Navigator Program (CPNP). If approved, this CPNP will a) target
low-income, under/uninsured and predominately Latino adult residents of Los Angeles County
Service Planning Area (SPA) 2, the San Fernando and Santa Clarita Valleys, and b) help
facilitate 6,000+ female and male patients/users of NEVHC into preventive screenings for breast,
cervical and colorectal cancer (per NEVHC clinical protocols and the recommendations of the
U.S. Preventive Service Task Force, the Centers for Disease Control and Prevention, and the
American Cancer Society).
NEVHC seeks to recruit and hire four bilingual (Spanish/English)/bicultural promotora-type
patient navigators. Taking into consideration widely documented obstacles to health care, i.e.
lack of health insurance, limited English proficiency, and/or transportation, as well as cultural
stigma, we anticipate that the utilization of culturally sensitive promotoras will increase the
likelihood that our targeted patients (including those considered to be high-risk) will not only
follow through with the aforementioned screening services, but will also comply with further
diagnostic/specialty care services, i.e. colposcopies, colonoscopies, X-ray services and/or
surgical biopsies, and/or cancer treatment protocols, if necessary.
Our proposed CPNP will primarily utilize an inreach strategy to meet its overall goal of
reducing cancer-related mortality in SPA 2. In doing so, an updated disease management
registry, i2iTracks, and our Interactive Voice Response (IVR) telephone system will be
programmed in such a way that, together, they will automate [what otherwise would be
extremely time consuming and labor intensive] processes of identifying as well as notifying
NEVHC patients who are due or overdue for mammography, pap smear and/or fecal occult
blood test (FOBT)services, which will be available across five licensed NEVHC Health Centers
in Canoga Park, Pacoima, San Fernando, Sun Valley and Valencia. Our four patient navigators
will be immediately assigned to patients who –even after being notified by IVR – remain noncompliant with these important preventive services.
The NEVHC Cancer Patient Navigator Program will be geared towards the needs of medically
indigent, primarily Spanish-speaking Latino residents of SPA 2 - a community where there is a
documented overuse of hospital emergency room services and minimal access to affordable
transportation.1 Therefore, a statutory funding preference is requested.

1

Valley Care Community Consortium, Assessing the Community’s Needs: A Triennial Report on San Fernando and
Santa Clarita Valleys, 2007.