Riverside Community Health Access Initiative

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Executive Summary

Riverside Community Health Access Initiative is a nonprofit in Louisiana that helps patients follow their care. Patient navigators meet patients in the hospital and at home, arrange interpreters, provide ride vouchers, use a small fund to pay vendors for food and utilities that affect health and follow up for 90 days after discharge.

Patients who leave the hospital often face barriers that have nothing to do with medicine, such as a language they do not speak, a ride they do not have or a bill they cannot pay. Patients who cannot follow their care plan are more likely to get sicker and return.

With this grant we will serve about 200 patients in Year 1 in 2 neighborhoods. Navigators are not clinicians and do not give medical advice, we never give cash to patients and we call 911 or the care team in an emergency. We do not promise any health outcome. We promise respectful help, careful privacy and honest records.

Our Year 1 budget is about $254,000, growing to about $437,000 by Year 5 as we add sites, coaches and participants. Each year's budget is planned to balance, with a small surplus each year. We have 5 staff in Year 1 (an Executive Director, a Program Director and two Patient Navigators) and 9 by Year 5.

We are asking the Riverside Health Equity Foundation for $80,000 for two Patient Navigators. Our other income and startup support cover the rest. These numbers are estimates based on the assumptions listed at the end of this proposal, and we do not promise any result beyond what we describe.

Company Description

Riverside Community Health Access Initiative is a nonprofit organization in Louisiana. We are a registered charity with a volunteer board of directors, a written conflict-of-interest policy and a yearly budget the board reviews.

Our mission. No one should avoid care because they cannot get there, cannot understand it or cannot pay for the basics that keep them well.

What we do.
- Employ patient navigators who meet patients in the hospital and in the community and help them with follow-up care.
- Provide interpreter services for patients who speak languages other than English.
- Arrange transportation to appointments through vouchers paid to partner services.
- Help patients with social needs such as food, utilities and housing through a small fund paid to vendors.
- Help patients enroll in Medicaid, coverage and financial assistance.
- Work with the hospital and clinics to share care plans with patient permission.

Our values. Respect for every participant, honesty with families and partners, safety first and a place for everyone who wants to belong.

What we do not do. Navigators are not clinicians and do not give medical advice. They follow the care team's plan and call 911 or the care team in an emergency. We never give cash to patients; payments go to vendors. We follow health privacy rules. We do not promise any health outcome. We follow the rules of our partner sites and our insurer.

How we got here. A group of nurses, social workers and community leaders began following up with patients who left the emergency room without a plan. Many came back sicker and many had needs that were not medical. We kept simple records of who we helped and what happened. This proposal asks for support to move from phone follow-up to a steady program with paid, trained staff and the materials to match.

Problem & Opportunity

Patients who leave the hospital often face barriers that have nothing to do with medicine: a language they do not speak, a ride they do not have or a bill they cannot pay.

Cost. Missed appointments, repeat emergency visits and avoidable hospital stays cost patients and the health system money.

Access. Many patients live far from clinics, speak limited English or do not know what coverage they qualify for.

Safety and trust. Patients want trusted help with privacy, and the hospital and funders want to see that care plans and money are used well.

Missed benefits. Patients who cannot follow their care plan are more likely to get sicker and return to the hospital.

What we hear.
- A patient says she was told to see a specialist and did not know how to book or get there.
- A nurse says patients leave with papers they cannot read.
- A social worker says the same patients return every month with the same unmet need.
- A navigator says a ride voucher changed a man's year.

We do not claim that a program can solve every challenge. We believe that a navigator who solves the nonmedical problems can help patients follow their care and stay well.

Products & Services

Riverside Community Health Access Initiative gives patients at high risk of missing care or returning to the hospital a safe, welcoming place to follow their care and stay healthy.

How the program works.
1. Referral. Hospital teams and clinics refer patients before discharge, and patients may also refer themselves.
2. Meeting. A navigator meets the patient in the hospital or at home and learns what gets in the way.
3. Plan. The navigator and patient write a simple plan to reach appointments and get what they need.
4. Interpreters. We arrange an interpreter at visits and calls for patients who need one.
5. Transportation. We provide ride vouchers paid to partner services.
6. Social needs. A small fund pays vendors for food, utilities and similar needs that affect health.
7. Follow-up. The navigator contacts the patient after each visit and for 90 days after discharge.

What a typical session looks like. Participants arrive and check in with a staff member, settle in together, work on the day's activity in small groups and finish with a short talk about what went well. Staff praise effort, correct mistakes kindly and make sure no one is left out.

Staff. Our navigators are trained, pass a background check, complete our training in health privacy and boundaries and are paid for their time. Many are bilingual.

Access and fairness. Programs are free. Services are free. We welcome every referred patient regardless of insurance, and we offer services in several languages.

Market Analysis

Who we serve. Patients referred by our partner hospital and clinics who face barriers to care and live in our service area. Eligibility is referral from a care team or self-referral and a barrier to care, and no patient is turned away for lack of insurance.

How we estimate need. We cannot count every young person who could benefit, so we plan from what we can see. In our phone follow-up we reached more patients than we could help and kept a waiting list. The hospital told us that many more patients would benefit than we can serve. For Year 1 we plan to serve about 200 participants at 2 neighborhoods. By Year 5, with more staff and sites, we plan to serve about 600.

Where participants come from.
- Hospital emergency and inpatient teams.
- Community clinics and pharmacies.
- Social service agencies and churches.
- Patients who tell a friend.

Who else benefits. Patients get better care. The hospital has fewer avoidable returns. The community gains healthier neighbors.

What the numbers mean. Every number here is a patient who made it to the follow-up visit. We keep our early counts modest and honest so we can do the work well.

Competitive Landscape

What young people can find today, and how we are different.

1. Hospital case managers. Essential, with large caseloads and limited time after discharge. We continue the work.

2. Community health workers. Strong, with limited reach in many areas. We add capacity.

3. Insurance care coordinators. Help members of certain plans. We serve everyone referred.

4. Social service agencies. Provide resources and are not linked to the care team. We connect them.

5. Patient portals. Convenient for some and not for others.

What makes us different.
- Navigators in the hospital and the community.
- Interpreters and transport vouchers.
- A social needs fund paid to vendors.
- Follow-up for 90 days.
- Shared care plans with permission.

Why this gap matters. Existing programs do good work, and most serve people who can already pay or who live close to them. The people we serve are the ones left over: they live in the wrong neighborhood, have the wrong schedule or have no one to ask. We are built to reach them.

We have spoken with hospital care teams, community clinics and other navigation programs to make sure we are filling a gap and not duplicating services. Their letters of support are in the attachments.

Marketing & Sales Strategy

How young people and partners will find us.

Reaching young people.
- Hospital teams. We will give staff a short referral form and a named contact.
- Community clinics and pharmacies. We will share flyers and information.
- Social service agencies and churches. We will talk with leaders who know patients.
- Local media in several languages. We will share information.
- Word of mouth. Patients tell friends.
- A simple website and a phone line with a text option.

Reaching staff and sponsors.
- Recruit navigators through community colleges, health systems and community groups.
- Offer an orientation, a background check and training in safety, privacy and respectful practice.
- Give partners a short report each quarter with counts of participants and what they said.

How we decide who joins. We use a simple sign-up form and enroll participants in the order received, with priority for those with the greatest need and for people new to the program. We keep a waiting list when the program is full.

What we watch. Sign-ups, attendance, patients served, appointments kept and how many participants return for a second season.

Operations Plan

How the program will be carried out.

Timeline for Year 1:
- Months 1 and 2 (July and August): Hire the staff, buy equipment and materials, finalize the waiver, consent form and privacy policy with our attorney and sign site agreements.
- Month 3 (September): Hire navigators and begin hospital referrals.
- Months 4 to 10: Meet patients, provide support and follow up for 90 days.
- Months 11 and 12: Survey patients and the care team, report to funders and plan Year 2.

Space. Navigators work from a small office near the hospital and visit patients at home and in clinics.

Safety and privacy.
- Navigators follow health privacy rules and share information only with patient permission.
- Social needs payments go to vendors and are reviewed by two people.
- Every staff member and volunteer passes a background check and completes safety training.
- Staff work in pairs or in view of others whenever participants are minors or in a vulnerable situation.
- We keep an emergency plan at every site, and participants complete an emergency contact form.
- We keep records private, share them only with a participant's permission or as the law requires and follow a written policy.

Equipment. We buy about $7,000 of equipment once at the start: laptops and secure phones for navigators ($3,500), tablets for interpretation and visits ($2,000), locking file storage and printer ($1,500). Later years replace or add a few items.

Staffing. In Year 1 I serve as Executive Director. The Program Director, paid $52,000 a year, manages navigators and partners. Two Patient Navigators, each paid $40,000 a year, work with patients. We add navigators as we add neighborhoods.

Management & Organization

Dr. Michelle Landry, Executive Director. I lead the organization, report to the board and am responsible for budgets, partnerships and reporting. I came to this work as a nurse who saw how often the same patients returned for the same unsolved problem. I will complete the training we require of our navigators so I understand the program from the inside. (Replace this paragraph with your own background.)

Staff. The Program Director manages navigators and partners, and patient navigators work with patients. Each passes a background check. These positions are part of our grant request.

Board of directors. Our volunteer board includes a nurse, a physician, a patient, a banker who serves as treasurer, an attorney and a pastor. The board meets every other month, approves our budget and reviews our safety plan. No board member is paid, and members with a conflict of interest step out of related decisions.

Advisory partners. A hospital case management director, a community clinic director and a social worker give guidance twice a year.

Staffing and pay in this plan: Executive Director, paid $56,000 a year; program Director, paid $52,000 a year; patient Navigator, paid $40,000 a year.

Milestones Narrative

Our goals, how we will measure them and when we plan to reach them.

Year 1 outcomes (July 2027 through June 2028):
- Serve about 200 participants at 2 neighborhoods.
- Run at least two full seasons and a summer session.
- Have at least 85 percent of participants attend most sessions.
- Have at least 80 percent of participants return for a second season.
- Receive positive feedback from at least 90 percent of families who answer our short survey.

What we count and how.
- Participants enrolled, sessions and games attended, from our records.
- Skills learned and goals met, from the coach's checklist.
- Equipment issued and returned, from our log.
- Participant and family feedback, from a short, confidential form.
We report what we find, including what did not work, and use it to improve.

Growth over five years.
- Year 2: About 300 participants at 2 neighborhoods.
- Year 3: About 400 participants at 3 neighborhoods.
- Year 4: About 500 participants at 3 neighborhoods.
- Year 5: About 600 participants at 4 neighborhoods.

Learning along the way. At the end of each quarter, the director and the board review the numbers and decide whether we are on track. If we are behind, we will adjust our outreach, our sites or our schedule before asking for more money.

After the grant. By Year 5, grants make up about 48 percent of our budget, down from about 49 percent in Year 1, as partners and donors give more. We will keep building those relationships every year.

Funding Request

What we are asking for, and how the money will be used. Our request: $80,000 from the Riverside Health Equity Foundation for two Patient Navigators, for July 2027 through June 2028.

The request is spread across these budget lines:
- Personnel: Patient Navigator salaries, two positions, $80,000.

Other money in the program. This request is about 65% of our Year 1 grant income. Other grants and the income lines below pay for everything it does not cover.

Year 1 budget: about $254,000, planned to balance with a small surplus (about $10,600 after the yearly wear on equipment). Year 1 money coming in: Grant Revenue $124,000; hospital Community Benefit Funding $80,000; state Health Equity Funding $40,000; individual Donors $10,000. Year 1 costs: executive Director $56,000; program Director $52,000; patient Navigator $40,000; interpreter Services about $10,000; transportation Vouchers about $12,000; social Needs Fund about $10,000; data System and Evaluation about $8,000; navigator Training about $4,000; administration and Insurance about $10,000; about $3,000 a year for the wear on equipment.

One-time startup costs. Startup costs of $16,000 are paid once from startup money, not from the yearly budget: $3,500 for laptops and secure phones for navigators; $2,000 for tablets for interpretation and visits; $1,500 for locking file storage and printer; $2,500 for attorney review of the consent form, privacy policy and vendor agreements; $1,800 for multilingual flyers and a simple website; $2,200 for navigator training and background checks; $2,500 for first insurance payment.

How we got our startup number. The Funding Need Calculator in this plan adds the startup costs ($16,000), the cash the program uses before it balances (about $0) and a cash cushion of about $60,500, which is about three months of Year 1 costs. In all, that comes to $76,500. We start with $8,000 from our founding board and $71,000 in startup support from a community foundation and a hospital partner, $79,000 in all, which covers that amount with room to spare.

The next five years. Our budget grows from about $254,000 in Year 1 to about $437,000 in Year 5. Grants are planned at $124,000, $145,000, $166,500, $188,500 and $211,000 in Years 1 to 5. Other income grows: hospital Community Benefit Funding from $80,000 to $128,000; state Health Equity Funding from $40,000 to $72,000; individual Donors from $10,000 to $26,000. Our surplus is planned at about $10,600 in Year 1, about $12,800 in Year 2, about $15,300 in Year 3, about $18,200 in Year 4 and about $21,400 in Year 5. We grow from 2 neighborhoods to 4 by Year 5, adding a part-time coach for each new site.

Savings. We plan to keep several months of costs in savings. The lowest year-end balance in the plan is about $73,800, at the end of Year 1. Some grant payments and partner payments arrive after we bill, so we plan for about $10,160 owed to us at the end of Year 1.

Cost per patient. In Year 1, our total costs are about $1,217 per patient served, which includes setting up the program. By Year 5, with more patient served and a trained team in place, that falls to about $693 per patient.

After the grant. Hospital community benefit funding, corporate sponsors and individual donors grow every year, so grants become a smaller share of our budget. Participants and families share their stories, and businesses can sponsor a team or a season by name. We will look for partnerships with schools and the city that want a safe, free health care access option for every child.

Risks and how we will handle them:
- An injury. Certified coaches, proper equipment, groups matched by age and skill, a written emergency plan and insurance.
- A site is no longer available. We keep agreements with more than one site and a plan for bad weather.
- A coach leaves. We keep a list of trained backup coaches and share lesson plans.
- Low attendance. We adjust sites, times and rides based on family feedback.
- A privacy problem. We follow a written policy, use secure systems and train every staff member and volunteer.
- A grant ends. We keep savings and grow partner and donor support each year.

If you are just starting. A new organization can begin before it has its own 501(c)(3) status through a fiscal sponsor: an established nonprofit that receives grants for you and passes them to your program, usually for a fee (commonly around 5% to 10% of the grant, sometimes more; ask before you agree). Another way is to start smaller: one neighborhood, a handful of patients and a small team, tracked carefully. Strong results from a small start make larger grants easier to win.

Appendix Notes

Documents to attach with this proposal:

- Your IRS 501(c)(3) determination letter, or your fiscal sponsor agreement.
- Your most recent financial statements and your current year budget.
- A list of your board members and what each one does.
- Signed letters of support from partner schools, agencies and sites.
- Your site agreements and your insurance certificate.
- Your consent, waiver and privacy policy.
- Your safety plan and background check policy.
- Your program outline and schedule.
- Quotes for equipment and materials.
- Resumes for your Executive Director and key staff.
If you don't have any of this yet, no worries - let's continue.

The assumptions behind our numbers (change them in the Financials section to match your own):
- Grant Revenue: $124,000 in Year 1, growing to $211,000 in Year 5.
- Hospital Community Benefit Funding: $80,000 in Year 1, growing to $128,000 in Year 5.
- State Health Equity Funding: $40,000 in Year 1, growing to $72,000 in Year 5.
- Individual Donors: $10,000 in Year 1, growing to $26,000 in Year 5.
- Pay (a full year, per person, including payroll taxes and workers' compensation): executive Director $56,000; program Director $52,000; patient Navigator $40,000.
- Other yearly costs in Year 1: interpreter Services $10,000; transportation Vouchers $12,000; social Needs Fund $10,000; data System and Evaluation $8,000; navigator Training $4,000; administration and Insurance $10,000. These grow between 4% and 5% a year.
- Equipment: $7,000 at the start, then $1,500 to $2,500 a year.
- Startup costs: $16,000, paid once from $79,000 in startup money.
- Participants served: about 200 in Year 1, growing to about 600 in Year 5. Sites: 2 in Year 1, growing to 4 by Year 5. Navigation is available year-round, with 90 days of follow-up for each patient.
- About 4% of each year's income is still owed to us at year end.
- Tax: none, as a nonprofit.
- Every dollar amount is an estimate. Replace them with your own quotes and real budget.

Startup Costs