Central Oklahoma Family Medical Center, Inc. $337,207.50
Counties covered: Garvin, Pontotoc, Seminole
Central Oklahoma Family Medical Center, Inc. will utilize a complex care model designed to target and manage chronic diseases through physicians, RNs, CHWs, and other providers. Patients receiving care at COFMC will be screened for cardiovascular disease, chronic lower respiratory disease, diabetes, and stroke prevention/management and will be flagged due to high rates of emergency room visits or primary care appointments, supported by PRAPARE results. The work will be supported by the Azara platform and include in-person appointments, telemedicine, and follow-up via telephone.
Cherokee County Health Services Council $766,244.42
Counties covered: Cherokee, Delaware, Mayes, Muskogee, Ottawa, Rogers
Cherokee County Health Services Council will launch the Empowered Living Program of Northeastern Oklahoma (ELP) - a regional chronic disease self-management initiative serving rural and underserved populations across northeastern Oklahoma. The program will create a coordinated six-county network of healthcare providers, community health organizations, and local outreach coordinators to expand access to Chronic Disease Self-Management Education (CDSME) programs. Using evidence-based Self-Management Resource Center (SMRC) models, the initiative will provide virtual workshops focused on diabetes and cardiovascular disease prevention and management, with future expansion to cancer survivorship, stroke recovery, and chronic respiratory disease support.
Choctaw Nation of Oklahoma $360,552
Counties covered: Atoka, Bryan, Choctaw, Coal, Haskell, Hughes, Johnson, Latimer, LeFlore, McCurtain, Pittsburg, Pontotoc, Pushmataha
Choctaw Nation of Oklahoma will launch the Integrated Rural Chronic Disease Access, Prevention, and Care Coordination Initiative: a system-wide program designed to improve chronic disease management, preventive wellness engagement, and maternal health coordination across rural Southeastern Oklahoma. The program expands access to Remote Patient Monitoring (RPM), digital health engagement tools, preventive wellness services, maternal care coordination, and community-based outreach activities designed to reduce barriers to care and strengthen patient engagement.
Cimarron Memorial Hospital and Rural Health Clinic $665,502
Counties covered: Cimarron, Texas
Cimarron Memorial Hospital and Rural Health Clinic will implement the Frontier Chronic Disease Early Detection and Diagnostic Access Initiative to improve access to evidence-based chronic disease diagnosis, monitoring, and early detection services for residents of Cimarron County and the surrounding frontier region.
Comanche Nation $341,307.23
Counties covered: Caddo, Comanche, Cotton, Jefferson, Stephens, Tillman
The Comanche Nation will expand its long-standing, community-based chronic disease management services for rural tribal members in southwestern Oklahoma. The initiative will stabilize and expand care by strengthening staff capacity, adding two CHR Transporter/Aides, and introducing a mobile health unit to reach remote communities. Through in-home visits, transportation support, medication delivery, and culturally grounded health education, the program will improve access to care, enhance chronic disease management, and reduce health disparities among American Indian populations in rural areas.
Fairview Regional Medical Center $1,827,444.20
Counties covered: Blaine, Dewey, Garfield, Kingfisher, Major, Woods, Woodward
Fairview Regional Medical Center (FRMC) will launch the Northwest Oklahoma Stroke and Cardiovascular Disease Management Program, a comprehensive initiative designed to improve prevention, diagnosis, treatment, rehabilitation, and long-term management of cardiovascular disease and stroke throughout rural northwest Oklahoma. The project will strengthen care across the continuum through implementation of a population health management platform, care coordination services, advanced diagnostic capabilities, emergency response enhancements, rehabilitation expansion, and chronic disease management.
Genesis Medical PLLC, dba Southern Oklahoma Pain Management $1,324,675
Counties covered: Atoka, Bryan, Carter, Coal, Garvin, Johnston, Marshall, Murray, Pontotoc, Stephens
Genesis Medical PLLC, dba Southern Oklahoma Pain Management (SOPM), will implement the Southern Oklahoma Rural Chronic Disease Management Program — a structured, multi-condition care management initiative serving patients across 10 rural counties in south-central Oklahoma. SOPM will deploy an evidence-based care management model targeting Type 2 Diabetes, cardiovascular disease and hypertension, and COPD. Program components include proactive patient outreach and enrollment, individualized care plan development and maintenance, monthly patient engagement, closed-loop referral tracking, remote physiologic monitoring, care gap closure, social determinants of health navigation, and structured patient education.
Jackson County Memorial Hospital Authority $1,316,304.74
Counties covered: Greer, Harmon, Jackson
JCMH will implement the Chronic Care Model (CCM) to improve access, quality of care and outcomes of chronic disease for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema and asthma. JCMH is the primary inpatient and emergency care facility for Jackson and four neighboring counties. Patients with chronic respiratory diseases rely on immediate access, close to home, to updated technology and immediate and effective treatment for exacerbations of their conditions. The program will address this need for a comprehensive chronic care management program with robust capacity and reach to enable access to chronic disease care close to home for rural residents.
Lighthouse Behavioral Wellness Centers, Inc. $246,457.13
Counties covered: Bryan, Carter, Garvin, Johnston, Love, Marshall, Murray, Pontotoc, Seminole
Lighthouse Behavioral Wellness Centers, Inc. (Lighthouse) will implement the Rural Integrated Lifestyle Medicine and Chronic Disease Pathway Program (RILM-CDP) across its nine-county rural service area. The project will develop and implement standardized, evidence-informed clinical pathways that strengthen chronic disease risk identification, care coordination, referral management, follow-up support, and performance monitoring for individuals receiving behavioral health services who are living with, at risk for, or experiencing barriers to managing diabetes, cardiovascular disease and hypertension, chronic respiratory disease, and stroke-related conditions.
Long Term Care Specialists $471,698.84
Counties covered: Atoka, Carter, Johnston, McCurtain, Murray, Pittsburg, Seminole
Long Term Care Specialists, Inc. will implement a comprehensive Cardiovascular Program to improve outcomes for residents of 18 rural long-term care and skilled nursing facilities in southeastern Oklahoma. The program combines evidence-based cardiovascular clinical pathways, remote patient monitoring, telecardiology services, point-of-care diagnostics, advanced vascular access capabilities, and integrated care coordination to provide proactive, facility-based management of chronic cardiovascular conditions.
Mercy Health Oklahoma Communities, Inc. $2,615,529.21
Counties covered: Blaine, Carter, Delaware, Garvin, Kingfisher, LeFlore, Logan, Pontotoc, Sequoyah
MHOC’s will expand its virtual capabilities in rural primary care clinics in accordance with the virtual patient care (VPC) chronic disease optimization model. The proposed project will support a network of 15 rural primary care clinics spanning nine counties across central, south central, and eastern Oklahoma. MHOC will provide 24/7 access to same-day acute care video visits. MHOC will expand access to its virtual chronic condition management team with an initial focus on Medicare-eligible patients.
Midwest Wellness and Wound Care, LLC $2,321,131.25
Counties covered: 75 rural counties (excluding Oklahoma and Tulsa Counties)
Midwest Rural Chronic Care Connect (RC3) is a telehealth-enabled chronic disease management program serving rural Oklahoma statewide. Operating a centralized care-coordination and telehealth hub, RC3 uses a dual model: for the many rural patients with no established medical home, RC3 connects them to primary care; for patients who already have a PCP or psychiatrist, RC3 coordinates with that provider. RC3 deploys evidence-based interventions — self-measured blood pressure monitoring (Million Hearts), Diabetes Self-Management Education and Support (DSMES), spirometry- guided COPD/asthma management (GOLD/NHLBI), and the Collaborative Care Model for co- occurring depression and anxiety, in addition to cellular-connected remote monitoring devices.
Urology Center of Southern Oklahoma $571,863.20
Counties covered: Bryan, Carter, Garvin, Jefferson, Johnston, Love, Marshall, Murray, Stephens
Urology Center of Southern Oklahoma will expand its Rural Urologic Cancer and Chronic Disease Management Program to improve timely access to cancer evaluation, diagnosis, treatment coordination, and long-term surveillance for rural patients across Southern Oklahoma. The program will support chronic urologic disease management for conditions that often overlap with or complicate cancer care, reduce referral backlogs, improve cancer care coordination, support telehealth for elderly and transportation-limited patients, and allow more rural patients to receive high-quality urologic cancer care close to home.
Wagoner Hospital Authority, an Oklahoma Public Trust, DBA Wagoner Community Hospital $2,412,325
Counties covered: Adair, Cherokee, Delaware, Muskogee, Okmulgee, Wagoner
Wagoner Community Hospital will employ the Identify–Equip–Monitor–Rehabilitate–Extend model for chronic disease management. They will identify patients and conduct care coordination through their existing staff and EHR, modernize their clinical infrastructure, launch a patient monitoring program and two rehabilitation programs: pulmonary and post-stroke, and expand access to telehealth for rural patients.
Wyandotte Nation $30,603.50
Counties covered: Craig, Delaware, Mayes, Muskogee, Nowata, Okfuskee, Osage, Ottawa, Rogers, Wagoner, Washington
Wyandotte Nation will expand its established diabetes management and prevention program for eligible patients in eleven rural northeastern Oklahoma counties. The project will increase access to diabetes and pre-diabetes education, nutrition instruction, healthy cooking classes, diabetic eye pressure screening, retinal screening, diabetic foot screening, routine monitoring, laboratory review, diabetic follow-up, and healthcare support for patients managing diabetes, pre-diabetes, and related chronic conditions.
