(i) achieve efficiencies; (ii) expand access to, coordinate, and improve the quality of essential health care services; and (iii) strengthen the rural health care system as a whole. The program provides resources to help rural communities develop partnerships and jointly address health problems that affect the Delta region. The program will also place an emphasis on population health due to the geography of the service areas (see Appendix A for definitions). HRSA recognizes the importance of identifying and implementing an evidence-based or promising practice model (see Appendix A for definitions). Therefore, all recipients are required to adopt an evidence-based or promising practice approach that proves demonstrated outcomes and may be replicable in other communities. An example of a promising practice would be a small-scale pilot program that has generated positive outcome evaluation results that justify program expansion to new access points and/or to new service populations. HRSA also requests applicants to propose multi-county/multi-parish projects that address the delivery of preventive or clinical health services for individuals with, or at risk of developing chronic health diseases that disproportionately affect rural Delta communities. Due to the high disparities in the region,1 applicants are strongly encouraged to propose a program based on no more than two of the following focus areas: 1) diabetes, 2) cardiovascular disease, 3) obesity, 4) acute ischemic stroke, or 5) HIV/AIDS. Chronic disease initiatives may be a focus in programs when addressing prevention, self-management, care coordination, or clinical care and must be outcomes oriented. Programs should also include activities focused on producing changes in wellness screening measures (e.g., BMI, weight, A1c, blood pressure, waist circumference, HIV testing) in addition to one or more of the following areas: • Knowledge (e.g., understanding of effective self-management strategies, understanding of key disease risk factors or prevention strategies) • Attitudes (e.g., increased self-efficacy in prevention or self-management strategies) • Behaviors (e.g., increase in level of physical activity, increase intake of fruits and vegetables, HIV medication adherence) • Policies and procedures (e.g., improved health care services delivery model, changes to school physical activity and/or cafeteria policies, HIV) 1 Gennuso KP, Jovaag A, Catlin BB, Rodock M, Park H. Assessment of Factors Contributing to Health Outcomes in the Eight States of the Mississippi Delta Region. Prev Chronic Dis 2016;13:150440. DOI:http://dx.doi.org/10.5888/pcd13.150440 HRSA-20-087 2 • Systems (e.g., improved coordination among health and social services agencies) HRSA anticipates that recipients will coordinate services and activities related to chronic disease management, and consider an integrated care approach for chronic diseases (see Appendix A for definitions). Recipients are encouraged to explore reimbursement mechanisms for chronic care management and align care management strategies with the appropriate reimbursement mechanisms, to improve overall health outcomes and reduce costs.2 Because individuals who live with chronic disease(s) are at risk for comorbidities such as depression and other mental health conditions, applicants are encouraged to include activities addressing mental health and substance use disorder, including opioid use disorder, for a more comprehensive approach to care.3 Consideration of an integrated care approach is highly encouraged as it creates an opportunity to address the Department of Health and Human Services’ (HHS) and HRSA clinical priorities of mental health and substance use disorder. Recipients will receive targeted technical assistance throughout the period of performance to assist in achieving the project’s desired outcomes and to ensure program sustainability after the period of federal funding. This additional support is provided at no extra cost to recipients, as this is an investment made by HRSA to assist in the success of the project. If funded, recipients will learn more about the technical assistance support.