Public Health Nursing – The purpose of this Indian Health Service (IHS) grant announcement is to improve specific behavioral health outcomes of an identified high risk group of patients through a case management model that utilizes the Public Health Nursing (PHN) as a case manager. The emphasis is on reducing the prevalence and incidence of behavioral health diseases and conditions and to support the efforts of American Indian / Alaska Native (AI/AN) communities toward achieving excellence in holistic behavioral health treatment, rehabilitation, and prevention services for individuals and their families. Case management involves the client, family, and other members of the health care team. Quality of care, continuity, and assurance of appropriate and timely interventions are also crucial. In addition to reducing the cost of health care, case management has proven its worth in terms of improving rehabilitation, improving quality of life, increasing client satisfaction and compliance by promoting client self-determination. The PHN model of community based case management utilizes roles and functions of PHN services of assessment, planning, coordinating services, communication and monitoring. The goals and outcomes of the PHN case management model are early detection, diagnosis, treatment and evaluation that will improve health outcomes in a cost effective manner. This model utilizes all prevention components of primary, secondary and tertiary prevention in the home and community with patient and family. The community based case management model addresses the PHN scope of practice of working with individuals and families in a population-based practice to provide nursing care services. This project will focus on a PHN community based case management model. The project will be conducted in a phased approach, using the nursing process “ assessment, planning, implementation, and evaluation. First Phase: Assessment” Complete a generic community assessment (most PHN programs have this readily available as a part of their annual program plans). Current Closing Date for Applications: May 15, 2017.