Program Information
The HRSA Rural Health Care Coordination (RHCC) Network Program funds the Chronic Disease Care Coordination Network (CDCCN). The grant program is for a period of four years that began on September 1, 2023, and runs through August 31, 2027. The grant consists of five network members who will build an expanded care coordination system in the North Country.
These network members include the Adirondacks Accountable Care Organization, UVMHN – Champlain Valley Physicians Hospital, UVMHN – Alice Hyde Medical Center, and the Heart Network.
The CDCCN is a continuation of the HRSA-funded North Country Care Coordination Collaborative (NCCCC), a network convened in 2020 to improve post-acute transitions of care through better integrated care coordination.
This grant runs from September 1, 2023, through August 31, 2027.
The CDCCN is focused on improving health outcomes for individuals with heart disease and underlying risk factors with a broad goal to lower the number of people who develop heart disease in a four-county rural region. This will be achieved through the following goals:
• Improving access to evidence-based Chronic Disease Self-Management (CDSM) programs, tobacco treatment specialists (TTSs), and nutrition programs/services through more effective care management that facilitates referrals from clinical to social care providers.
• Improve health outcomes of adults living with heart disease and/or underlying risk factors including hypertension, diabetes, pre-diabetes, or tobacco use through a multidisciplinary evidence-based care coordination strategy that equitably expands access to self-management services in rural areas.
• Identify and address barriers to participation in CDSM programs including social determinants of health barriers, such as transportation.
• Care coordination strategies will be integrated into policies, procedures, staffing, workflows, services, and communication systems to ensure long-term sustainability.
CDCCN Vision
All residents of our region will achieve optimal health outcomes through timely access to health and wellness programs and/or services via care coordinators who effectively assist patients or clients with identifying needs and referring appropriately through a well-integrated network.
CDCCN Strategic Purpose
CDCCN members will collaboratively create best practice guidelines to link clinical and community-based care providers to ensure all individuals have access to health and wellness programs and/or services.
CDCCN Regional Asset Map
The Get Healthy North Country Community Integrated Health Network is a coalition of medical and behavioral health providers, public health units, area offices for the aging, social care agencies, and other interested organizations that collaborate to bring health and wellness support programs to the people that need them most. The network includes nearly 30 member organizations and a growing number of program “hosts” from across nine counties in northern New York. Learn more about the Network by watching this video:
Contact Us
Discover how the CDCCN is transforming health outcomes for those at risk of heart disease and underlying factors. Learn more about our evidence-based self-management services and find out how you can connect, collaborate, or refer individuals in need. Join us in making a difference. If your clinic is interested in this work, contact us today!
CDCCN Network Director: Victoria Knierim, AHI, vknierim@ahihealth.org
CDCCN Project Director: Michele Pelusi-Catlin, DCCC, The Heart Network, mcatlin@heartnetwork.org
Photos
May 2025 Rural Care Coordination Conference in Lake Placid, NY
Disclaimer
This page is also supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $1,200,000 with 0% financed with non-governmental sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
