It Takes a Village Colorado’s Health Connectors Workforce Safety Net Advisory Committee (SNAC) Lab July 26, 2017

Objectives Leverage our collective focus on vulnerable populations. Provide a forum for opportunities and lessons learned. Share the latest strategies for using data to measure effectiveness. Synthesize input from the group and develop a shared body of knowledge. 2

What We Will Cover Introduction Colorado’s Clinical Connector Workforce Kathy Orr, Opportunity Liaison, RCCO 7, Community Care Darlyn Miller, Regional Health Connector, El Paso and Teller counties, Community Health Partnership Ashley Hill, Regional Health Connector, Park, Clear Creek and Gilpin counties, Central Colorado AHEC Facilitated Discussion 3

Clinical-Community Linkages: Partnerships between clinical and community organizations to address the social determinants of health.

Colorado Opportunity Project

What We Will Cover Introduction Colorado’s Clinical Connector Workforce Kathy Orr, Opportunity Liaison, RCCO 7, Community Care Darlyn Miller, Regional Health Connector, El Paso and Teller counties, Community Health Partnership Ashley Hill, Regional Health Connector, Park, Clear Creek and Gilpin counties, Central Colorado AHEC Facilitated Discussion 7

Colorado Opportunity Project Aligning Government Investments to Support Economic Opportunity Murielle Romine, MPH Department of Health Care Policy and Financing 1/1/2017

Colorado Opportunity Project The Need: Many Coloradans face roadblocks that keep them from having the opportunity to be healthy, economically-secure members of society. What We Do: The Colorado Opportunity Project is taking a prevention-based approach to identify and remove these roadblocks so that Coloradans can succeed across the life-span.

Colorado Opportunity Project Goal To deliver evidence-based initiatives and community-based promising practices that remove roadblocks for all Coloradans, so that everyone will have the opportunity to reach and maintain their full potential.

Colorado Opportunity Project The Colorado Opportunity Project is a life cycle model with life stages and benchmarks of success for each life stage.

Colorado Opportunity Steering Committee (COSC) Subject matter experts from HCPF, DHS, CDPHE, Education and Non-profits Opportunity Framework: vetting evidence-based indicators for the opportunity framework. Identifying interventions that align with the indicators. Currently expanding to many more partners: Providers, Hospitals, Advocacy Groups, Community Partners

Colorado Opportunity Project Creates a shared understanding of what opportunity looks like in Colorado. Common performance indicators & evidence based interventions. INDICATORS (measures) include: Intended Pregnancies Emotional Well-being of Parents Access to Affordable Food School Readiness & High School Graduation Family Income Grade Level Advancement INTERVENTIONS (programs) may include: Family Planning Nurse Home Visiting Programs SNAP, WIC, EITC, TANF Prevention programs Early Literacy and Math Programs Workforce Development & Job Training Percentage of Colorado children living in Poverty : 17%

Indicators and Performance Measures lead to… Clearer discussions about goals Higher-quality data collection More evidence-based, strategic programs Collaborations across institutions Commitment toward achieving long-term goals

The Opportunity Framework Successful outcomes in one life stage creates successful outcomes in the next life stage.

COLORADO OPPORTUNITY PROJECT Project Goal: To deliver evidence-based initiatives and community-based practices that remove roadblocks for all Coloradans, so that everyone will have the opportunity to reach and maintain their full potential. THE OPPORTUNITY FRAMEWORK LIFE STAGES INDICATORS1 FAMILY FORMATION Rate of low birth weight Family income Maternal depression Single-or dual-parent household Intendedness of pregnancy Early screening and intervention - maternal Planned pregnancy, born at healthy birth weight to a dual parent household without maternal depression Family-directed planning Living in the community Access to assistive technology Receiving needed services Conception to birth EARLY CHILDHOOD % of parents concerned about child’s emotions, concentration, behavior or ability to get along with others % of families relying on low cost food School readiness Early screening and intervention - child School readiness, healthy social and emotional skills & family access to affordable, nutritious food INDIVIDUALS LIVING WITH DISABILITIES2 Ages 0 – 5 MIDDLE CHILDHOOD Standardized test: math scores Standardized test: reading scores % of parents concerned about child’s emotions, concentration, behavior or ability to get along with others Math/reading skills & healthy social emotional skills Ages 6 – 11 - Continued Next Page - 1 Indicators in the Colorado Opportunity Project Framework have been vetted and finalized by the Departments of Public Health and Environment, Human Services and Health Care Policy & Financing with the support of the Brookings Institution (indicators of Family Formation through Early Adulthood are based on available statewide data and quality measures). 2 Living well with disabilities, including effective support and services. Last Update Nov. 2016

Colorado Opportunity Project What’s the Value? Support and increase access to evidence-based programs and coordination of services Thinking differently about how to get the most value out of resources Using evidence and data to spotlight what works Supporting current collaborations and building new ones Alternative payment strategies – how to pay for these services differently

Colorado Opportunity Project: Pilot Communities

Opportunity Liaisons Projects Common themes to increase referrals to enrollment and retention of evidence based programs “Buckets” Increase Utilization Create infrastructure/ expand networks Sustainability of the key concepts Utilizing evidence and data for policy decisions Alignment, Coordination, Evaluation

Colorado Opportunity Project- key concepts Aligning and leveraging resources Aligning with State/County initiatives (2Gen, SIM, ACC 2.0, 6/18 Initative, LAUNCH together) Incorporation of the Social Determinants Supporting and increasing the pool of evidence based interventions Creating economic opportunities for self- sufficiency Shared goals/data metrics Payment Reform/Family Wellness Bundle

What’s Next? Johns Hopkins University/Colorado Opportunity Project Learning Collaborative Programs for the other life stages Mature Adult Life stage CDPHE and CDHS partnerships around those “eligible but not enrolled” populations

Darlyn Miller Community Health Partnership RHC-HSR #4 - El Paso & Teller Counties & Ashley Hill Central Colorado Area Health Education Center RHC-HSR #17- Park, Clear Creek and Gilpin Counties

The Project described is supported by Funding Opportunity Number CMS -1G1-14- 001 from the US Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) and by contract/grant number 1R18HS023904-01 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS). Opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ, CMS, or HHS.

Program Structure and Goals RHC Program Structure and Goals

Colorado Regional Health Connectors OUR VISION Connected systems will lead to healthier lives for all Coloradans. OUR MISSION Regional Health Connectors improve health in Colorado by connecting the systems that keep us healthy – including primary care, public health, social services, and other community resources.

RHC Program Funding Partnership

Triple (Quadruple) Aim Improve the patient experience of care Improve the health of populations Reduce the per capita cost of health care Improve the work life of health care clinicians and staff

RHCs Focus on Systems-Level Coordination

RHCs are “Connectors of the Connectors”

RHC Scope of Work Local relationships and priorities in each region will drive the work of each RHC, throughout the following steps: Review existing initiatives and data Align local priorities with statewide target areas Develop three projects to address local priorities Implement the project plans

Host Organizations and Target Areas

RHC Host Organization Cohorts

Align Local Priorities with Statewide Target Areas ENSW Target Area Colorado SIM Behavioral Health Target Area Any Colorado SIM Target Area Comorbidity   or other linkage Local Priority 1 Local Priority 2 Local Priority 3

Align Local Priorities with Statewide Target Areas SIM Target Areas Example RHC Projects Anxiety Facilitate community social support network to address comorbidity between depression and obesity Implement follow-up referral to BH specialist after positive cancer screening Help practices establish referral networks that include support for comorbidities (e.g., joint referral for home assessment for falls and social support evaluation) Child Development Screenings Depression Substance Use – Alcohol Substance Use – Prescription Drugs Hypertension Asthma Substance Use – Tobacco Obesity Asthma Diabetes Prevention – Breast and Colon Cancer Prevention – Flu Safety – Falls

Sharing Questions?

RHC Projects for Park, Clear Creek and Gilpin

RHC Projects HSR 17 Based on the local priorities (access to primary care, mental health resources and substance abuse prevention) Access to Primary Care Utilize Action, an evaluation and progression tool used with Google Drive, at ten pertinent stakeholder meetings, alliances and collaborations in order to ensure advancement of opening two health clinics in Region 17. Awareness, Availability and Expansion of Mental Health Resources Collaborate with Regional stakeholders to bring five Mental Health First Aid Trainings to Region 17 resulting in an increased awareness and knowledge of regional mental health resources and increased ability to handle mental health crises. Safe Disposal of Prescription Drugs Coordinate the establishment of two permanent medical disposal drop box sites in Region 17 to provide a safe, convenient way of disposing of prescription drugs while also educating the public about the potential for prescription drug misuse and abuse.

RHC Project for El Paso and Teller Counties

catch Key Programs with CHP Community Care of Central Colorado, a program of CHP, is the Regional Collaborative Care Organization (RCCO 7) in El Paso, Teller, Park and Elbert Counties. CATCH: Safety Net Clinics and Services Community work: CHP's current initiatives include: Behavioral Health, Community Detox, Opioid Abuse, Advanced Care Planning,.. Regional Health Connector: Serves El Paso and Teller and collaborates with RHCs in neighboring counties and throughout the State. Collaborates with above programs and the community. catch COORDINATED ACCESS TO COMMUNITY HEALTH

RHC Projects HSR 4 Obesity- Focus on patient engagement in their health by integrating Healthy Eating Active Living principles being available through the primary care setting. Substance Use - Address Opioids, Alcohol and other substance use in the primary care setting including: prescribing practices; chronic pain management; Screening (SBIRT); and resources/referrals for SUD treatment Multiple Behavioral Health Targets: Develop a “scaffolding” for all BH and substance abuse efforts and initiatives to better understand opportunities and resources available and promote collaboration towards common goals. catch

Questions? Darlyn Miller darlyn.miller@ppchp.org and Ashley Hill ashley@centralcoahec.org

Colorado Opportunity Project Liaison Community Project Final Update Kathy Orr, RCCO 7 El Paso, Elbert, Teller and Park Counties Thunderbirds, Air Force Academy Graduation May 24, 2017

Referral Map Colorado Springs Regional Care Collaborative Organization A Program of Community Health Partnership

Environmental Scan Problem: Evidence programs are not at capacity Referrals: Lack of tracking and follow up. Who is making referrals? What happens after a referral is made? Are some referral methods better than others? Are there missed opportunities, barriers to services? Is it a system problem, transportation, lack of knowledge or ability? What is really happening? Regional Care Collaborative Organization A Program of Community Health Partnership

Tracking Referrals by the RCCO Call Center Number of referrals from RCCO made verbally or mailed letters from 6/2106- 5/2017 SNAP: 57 WIC: 120 NFP: 32 CPCD: 239 SO What Happened? No referrals from the RCCO were reported by Nurse Family Partnership WIC reported an increase since January in enrollment SNAP reported a decrease since January in enrollment Referrals   21 2 waitlisted 5 in classroom 2 phased out 4 Incomplete 4 Zipped 3 placed in classrooms for next year 1 Ineligible

Direct Referral Link Pilot with CPCD Referral sent directly to CPCD Faster Potential for tracking Low cost

Lessons Learned It’s complicated Building trusted relationships is very important. Understanding what is IMPORTANT to our members. It takes a community approach including data sharing. Too many different program requirements, documents needed, and overlapping enrollment. Technology is needed, but not the complete answer. Regional Care Collaborative Organization A Program of Community Health Partnership

Tracking Referrals CPCD Direct Referrals 115 21 2 waitlisted 6/1 2016- 6/5, 2017* Total RCCO Call Center Direct Referrals Total Converted to Enrollment Status of Converted Referrals 115  21 2 waitlisted 5 in classroom 2 phased out 4 Incomplete 4 Zipped 3 placed in classrooms for next year 1 Ineligible   March 207: 13,126

Going Forward Increased understanding of trauma and life long effects on health and social wellbeing. Looking forward to use of referral technology to close referral loop, and provide seamless delivery of services. Applying developed framework across the lifespan to address social determinants. Partnering with ongoing community efforts including food insecurity Regional Care Collaborative Organization A Program of Community Health Partnership

Food Insecurity and Obesity Colorado Opportunity Work Building on work already started with low birth weight through addressing food insecurity. ACE education for clinics and providers to make the connection between ACES and poor social, emotional and health outcomes Community Alignment with El Paso County Public Health, Penrose-St. Francis, Regional Health Connector. Regional Health Connector SDoH Provider inventory-emphasis on food insecurity and tying in to obesity risk Integration of Healthy Eating and Active Living services in primary care practices with emphasis on patient engagement. Direct connection of healthcare providers to community organizations, public health work, and healthy food access. Regional Care Collaborative Organization A Program of Community Health Partnership

Food Insecurity and Obesity Thank you ! Darlyn Miller RN, BSN, CCM: Darlyn.miller@ppchp.org Kathy Orr RN, BSN, ACE Master Trainor: Kathleen.orr@ppchp.org Regional Care Collaborative Organization A Program of Community Health Partnership

Discussion Questions What other examples can you share about how clinical-community linkages are strengthening the safety net? What policy changes are necessary to strengthen these connections? How can researchers, philanthropists and advocates strengthen clinical- community connections?

2017 SNAC Labs October 4 (TBD) November 29