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

2. 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

3. 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

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

6. Colorado Opportunity Project

7. 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

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

9. 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.

10. 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.

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

12. 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

13. 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%

14. 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

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

16. 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

18. 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

19. Colorado Opportunity Project: Pilot Communities

20. 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

21. 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

22. 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

23. 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

24. The Project described is supported by Funding Opportunity Number CMS -1G from the US Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS) and by contract/grant number 1R18HS 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.

25. Program Structure and Goals
RHC Program Structure and Goals

26. 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.

27. RHC Program Funding Partnership

28. 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

29. RHCs Focus on Systems-Level Coordination

30. RHCs are “Connectors of the Connectors”

31. 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

32. Host Organizations and Target Areas

33. RHC Host Organization Cohorts

34. 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

35. 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

36. Sharing
Questions?

37. RHC Projects for Park, Clear Creek and Gilpin

38. 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.

39. RHC Project for El Paso and Teller Counties

40. 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

41. 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

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

43. 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

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

45. 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

46. Tracking Referrals by the RCCO Call Center
Number of referrals from RCCO made verbally or mailed letters from 6/ /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

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

48. 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

49. Tracking Referrals CPCD Direct Referrals 115 21 2 waitlisted
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

50. 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

52. 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

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

54. 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?

55. 2017 SNAC Labs
October 4
(TBD) November 29