Rural Health Care Coordination Network Partnership Program | Apply Online

Opportunity Summary:

The Rural Health Care Coordination Network Partnership Program is a Health Resources and Services Administration (HRSA) grant opportunity designed to strengthen formal, well-developed rural health networks that can coordinate care for people living with chronic disease. The program is centered on improving how primary care practices and their partners deliberately organize patient care and share information across providers and settings, with the aim of delivering safer, more effective, and higher-value care. HRSA is targeting three high-burden chronic conditions that are especially common and costly in rural communities: type 2 diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). The underlying rationale is that rural residents experience higher rates of chronic illness and related risk factors (including smoking, inactivity, and poor nutrition), and they often face additional barriers such as limited local services and longer travel distances to specialty care.

A major theme of the opportunity is whole-person care, not just disease treatment. The announcement emphasizes that chronic disease frequently intersects with behavioral health and psychosocial needs (for example, the connection between diabetes and depression), and that many mental health concerns are first seen in primary care. Because of that, applicants are encouraged to integrate behavioral health into primary care and to use team-based approaches that research and federal reviews have linked to better outcomes. The program also reflects the broader shift in health care payment toward value, where coordination, prevention, and measurable outcomes are increasingly rewarded through models like patient-centered medical homes (PCMH), accountable care organizations (ACO), and expanded use of health information technology such as electronic health records and telehealth.

Funded projects are expected to implement practical, locally tailored care coordination strategies that fit rural realities. Examples mentioned in the notice include recruiting or training staff specifically for coordination roles, using community health workers to support patients, co-locating behavioral health and primary care when possible, and applying quality improvement methods or system redesign (such as Lean or Six Sigma). Applicants are expected to propose creative and innovative approaches, either evidence-based or strongly justified by community need, to improve outcomes in one or more of the required disease areas (diabetes, CHF, and/or COPD). Another explicit expectation is dissemination: grantees should share lessons learned and results beyond their own sites, regionally or nationally, including through partnerships with grassroots, faith-based, or community-based organizations.

Measurement and accountability are built into the program. Networks must report at least four outcome measures for each chronic condition addressed (diabetes, CHF, COPD), and they must also report at least three care coordination measures. HRSA plans to aggregate performance across funded sites to assess overall program impact, meaning applicants should be prepared to collect, manage, and report standardized data. The program also places strong emphasis on sustainability. To help projects continue after grant funding ends, grantees are encouraged to pursue third-party reimbursement for covered services and to participate in pay-for-performance and other incentive programs when feasible, leveraging billing and value-based payment opportunities to maintain care coordination infrastructure over the long term.

From an eligibility and funding standpoint, this was a discretionary HRSA grant opportunity (Funding Opportunity Number HRSA-15-123; CFDA 93.912) with an estimated total funding amount of $1.6 million and an anticipated eight awards. There was no cost-sharing or matching requirement. The lead applicant had to be a public or private nonprofit entity located in an eligible rural area (or a rural census tract within an urban county), and all HRSA-funded services under the award had to be delivered in a rural county or rural census tract. Rural eligibility was verified using HRSA’s Rural Health Grants Eligibility Analyzer (Rural Advisor). Rural faith-based and community-based organizations, Tribes, and tribal organizations were eligible to apply. In addition to the 50 states, certain U.S. territories and Freely Associated States could apply as long as they met the rural eligibility requirements. If an incorporated network did not apply as the lead, HRSA would make the award to a single member organization serving as the grantee of record, and only that organization needed to meet the lead eligibility criteria. The original closing date for applications was April 6, 2015, and the opportunity was later archived.

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