Western Colorado AHCM Narrative · Western Colorado includes communities with some of the highest...

Western Colorado AHCM: Project Narrative 1

Western Colorado AHCM Narrative A. Intervention Design – Core Elements

A-‐1. Background

Rocky Mountain Health Plans (RMHP) is submitting this Accountable Health

Communities Model (AHCM) proposal on behalf of a Western Colorado consortium. The

consortium is proposing a model that uses the existing care coordination and case management

services in the region and creates new connections within and between the healthcare and social

services sectors. The model proposes three major strategies to address these disconnected

systems and make the best use of community-based services to improve health: (1) develop a

social needs screening tool that integrates easily into the clinical workflow; (2) improve the

region’s 2-1-1 database (community service inventory) and enable it to send customized

referrals; and (3) establish a navigation network, so high-need clients have assistance in

connecting with the health-related social services they need.

AHCM funds will be dedicated to the community infrastructure ($1 million), the

community navigation system ($1.37 million), the resource management and IT infrastructure

($1.1 million), and strong program management and administration ($1 million).

By prioritizing community funding and building on pre-existing leadership and

structures, the Western Colorado AHCM will provide an initial investment to establish enduring

systems that connect community dwelling beneficiaries to health-related social needs.

There is a unique opportunity in Western Colorado to test the Accountable Health

Communities Model. Like other rural communities in the U.S., Western Colorado communities

have more fragile economies based on tourism, agriculture and natural gas production. There is

higher unemployment and a safety net infrastructure fragmented by geography. Its residents are


more likely to suffer the health consequences of inadequate housing, food insecurity, lack of

economic opportunity, and the stress that comes with facing these daily challenges.

Notwithstanding these challenges, Western Colorado has the community leadership and

motivation required to pursue a comprehensive health strategy that includes social and emotional

well-being, in addition to effective healthcare delivery. Western Colorado’s ethos of

independence and self-reliance supports innovation, and its history of drawing strength from

community creates fertile ground for cross-sector initiatives.

Western Colorado has been building its health communities infrastructure for the last five

years through the Medicaid Accountable Care Collaborative, so this is an opportune time to test

the AHCM in the region. RMHP, a Regional Care Collaborative Organization (RCCO),

administers the program in Western Colorado. RMHP has adopted a care coordination model

that assesses medical and non-medical needs. The program has prompted conversations about the

region’s challenges: How will physical and behavioral health work together? How will multiple

care managers work together for a person-centered plan of care? In the last five years we have

had these important conversations, identified new questions, tested options and built relations to

pave the way for solutions that work. Western Colorado has also developed a robust, self-

sustaining, community-based health information exchange (Quality Health Network), building

upon the successful execution of significant federal cooperative agreements, such as the

HHS/ONC Beacon Communities initiative (2010-13).

Western Colorado is also engaged in other collaborative efforts to develop a strong

network of whole-person care for individuals with multiple medical, behavioral and social needs.

These programs include complementary federal initiatives focused on prevention and integrated

behavioral health, such as the Comprehensive Primary Care (CPC) initiative and the State


Innovation Model (SIM) cooperative agreement. Western Colorado stakeholders are also

engaged in the Colorado Opportunity Project, an effort to improve the social and economic

prospects of Coloradans.

In 2015, Mesa County, the highest density county, was ranked fifth out of the 60 counties

in Colorado for clinical care by the County Health Rankings and Roadmaps. However, Mesa’s

health outcomes score (36 out of 60 counties) highlights the need for a more comprehensive

strategy.

Our goal is to make the most of regional strengths while maintaining fidelity to the

AHCM design. Through a networked, regional structure, RMHP will support five distinct

communities in implementing the AHCM. The consortium will ensure clear processes and

accountability structure, a full-time project leader and clear channels of communication between

the five regions and the Bridge Organization, RMHP (which, as a private, nonprofit health

insurance entity, will participate actively as a payer in the development of aligned payment,

measurement, data sharing and population management models). The consortium intends to

demonstrate that AHCM can be successful in a rural environment with multiple systems, diverse

partners and geographic barriers.

A-‐2. Geographic Target Area

Western Colorado is approximately 40,000 square miles— an area the size of Maryland,

Massachusetts, New Jersey and Connecticut combined—with great geographic, economic and

community diversity. The area comprises almost half of the land area of Colorado but only about

one-tenth of the population, with roughly 530,000 people residing in the entire region. It includes

the city of Grand Junction (population 60,000) as well as small mountain towns, sparsely


populated frontier areas and large wilderness areas. The Western Colorado AHCM comprises

half of Colorado’s 42 rural counties.

Western Colorado includes communities with some of the highest rates of poverty in the

state, notwithstanding the resort destinations and a small number of high-income residential

areas that dot the landscape, such as Aspen and Vail. The majority of Western Colorado is

Caucasian with a small Latino population and two American Indian tribes, the Ute Mountain Ute

and Southern Ute, which have very different needs, challenges and histories. The Western

Colorado AHCM will be structured to ensure high quality service provision in all areas but

flexible enough to adapt to the unique needs of each population and community.

The Western Colorado AHCM will include five Colorado Health Statistics Regions: 9,

10, 11, 12 and 19:

• Region 9: Archuleta, Dolores, La Plata, Montezuma and San Juan counties, all of which are

mountainous rural or frontier counties. A 2012 community health assessment of these

counties indicates growing older adult and Latino populations.1 This region also includes

both of Colorado’s American Indian tribes. The major employers are Centura Health, which

has a hospital in Durango, the Ute Mountain Casino, and the Sky Ute Casino Resort.

• Region 10: Delta, Gunnison, Hinsdale, Montrose, Ouray and San Miguel counties, all of

which are rural or frontier counties. Montrose is the most populous. Delta is primarily

agricultural while Gunnison, Hinsdale, Ouray and San Miguel are resort mountain

communities containing the Crested Butte and Telluride ski areas. Montrose has a mixed

agricultural and tourism-based economy.

1 Archuleta and La Plata County Community Health and Capacity Needs Assessment. San Juan Basin Health Department. May 2012.


• Region 11: Jackson, Moffat, Rio Blanco and Routt counties, all of which are rural or frontier

counties. The Northwest corner region is defined by rivers, mountains, and geographic

isolation. The Northwest Colorado Visiting Nurse Association operates two federally

qualified community health centers in the region – one in Craig and one in Steamboat

Springs. Data from the Colorado Health Access Survey found that the uninsured rate in the

region was cut nearly in half in the two-year period following implementation of the

Affordable Care Act; however, the Northwest region still has the highest uninsured rate in

the State as of 2015.2

• Region 12: Eagle, Garfield, Grand, Pitkin and Summit counties, all of which are

mountainous rural or frontier counties. Located in the heart of the Rocky Mountains, the

region’s economy has transformed over time from a combination of mining and agriculture

in its early history in the 1800s to recreational tourism today, with its unique high-alpine

environment and world-class ski resorts. The region has some of the highest healthcare costs

in the country.

• Region 19: Mesa County, the sole urban county. It contains a regional medical center that is

the sole source for tertiary-level medical care between Denver (242 miles to the east) and

Salt Lake City (283 miles to the northwest). RMHP is headquartered in Mesa County

Using these regional areas fits with delivery systems, patterns of care, community

leadership structures and aligns with public health data that can be used to inform program

activities. Working regionally is vital for the initiative’s success because the communities of

Western Colorado place high value on local control. Working regionally is also essential because

of the realities of natural geographical (distance) and geological (mountain passes) divisions. To 2 A New Day in Colorado: Health Insurance Reaches Record High. September 2015. A publication of the Colorado Health Access Survey, published by the Colorado Trust and the Colorado Health Institute.


support local control and allow for nuanced differences across the region, RMHP will provide

funding to one respected organization within each health statistics region to hire a Community

Lead.

Figure 1: Geographic Target Area for Western Colorado AHCM

Health-Related Social Needs of the Targeted Geographic Area

Below is a description of the core health-related social needs (housing instability, utility

needs, food insecurity, interpersonal violence and transportation needs) as well as two

supplemental health-related social needs (substance use and physical inactivity).

Western Colorado has significant socio-economic disparities. In 2013, the poverty rate

ranged from 10 percent to over 15 percent. Unemployment ranged from 6.5 percent to over 8

percent. Mesa County, the largest county in the region, has relied heavily on the oil and gas

industry; many companies are now closing or moving out of the area due to the “boom and bust”

nature of extractive industries. The labor force in Grand Junction, the primary city in Mesa


County, has shrunk by 12,000 people and there has been an increase of 138 percent in public

assistance caseloads from 2009 to 2012.3

The communities in the five regions of the Western Colorado AHCM experience similar

risks to their health and well-being. A review of community health needs assessments showed

that the top health risks are chronic disease, suicide and unintentional injuries. Mental health and

substance abuse, air and water quality, suicide, unintentional injury prevention and infectious

disease prevention were consistently listed as top areas of focus. Below are details about the

challenges Western Colorado faces with health-related social needs.

Housing prices in the region are high. In 2013, 15,122 households (roughly ten percent)

in Western Colorado spent more than 50% of their income on rent. During school year 2013-14,

1,187 students in this region did not have stable housing, and were instead in shelters,

temporarily staying with friends or relatives, unsheltered, or in motels or hotels, according to the

McKinney Education Housing Data.4 Making matters worse, the recent downturn in the energy

industry, one of the region’s top industries, means fewer families can afford housing.

For families spending significant portions of their income on housing, utility costs in the

harsh winter climate can be significant. Unlike urban areas, where many low-income people live

in congregate housing of some sort, many people in Western Colorado live in isolated locations

in housing that may not have gas or electric heat. Last year, Energy Outreach spent $243,000 on

firewood for Colorado homes that use it for heat, and another $1,000 on coal for coal-heated

homes. Most of these homes are in the rural parts of Colorado.5

3 Harmon, G. Assistance cases put stress on county | GJSentinel.com. March 5, 2016. Retrieved from http://www.gjsentinel.com/news/articles/assistance-cases-put-stress-on-county 4 Colorado Homeless Education Data (based on data collected by the US Department of Education for Title X of No Child Left Behind), 2013-2014. Colorado Department of Education McKinney-Vento Homeless Education. Accessed at https://www.cde.state.co.us/dropoutprevention/homeless_data. 5 Energy Outreach Colorado 2015 Annual Report. Retrieved from http://www.energyoutreach.org/about/annual-financial-reports.


Interpersonal violence is higher in Western Colorado than the rest of the state. Child

maltreatment rates are higher than the state average (about 8 per 1,000 per year), ranging from an

annual rate of almost 11 per 1,000 children to a rate of over 14 per 1,000 children. Elderly

maltreatment is also higher than the state average (4.5 per 1,000 older adults per year) with rates

as high as 10 incidents per 1,000 older adults in parts of the Western Colorado.

Some parts of the Western Colorado have inadequate access to high-quality, affordable

food. Seven counties on the Western Slope do not have a grocery store.6 Over 15 percent of

residents in Mesa, Delta, Gunnison, Montrose, Montezuma, Dolores and San Juan counties were

food-insecure in 2013. In the rest of the region, anywhere between 11 and 14 percent of families

had experienced food insecurity in 2013. Food insecurity is defined as “lack of access, at times,

to enough food for an active, healthy life for all household members and limited or uncertain

availability of nutritionally adequate foods.”7

With the exception of a few resort towns, rural communities lack access to even basic

public transportation. Even Mesa, the sole urban county, has no substantial public

transportation system in place. A 2006 report by the Colorado Department of Transportation,

Mobility Needs of Low Income and Minority Households Research Study, found that little

research has been done on rural transportation, which seems to depend largely on personal

vehicles or finding rides from family and friends.

Almost all local public health agencies in the region have identified mental health and

substance use as a priority. RMHP intends to address substance abuse, with a specific focus on

alcohol abuse, as a supplemental social need. As many as 23 percent of adults in several Western

6 U.S. Department of Agriculture. Food Environment Atlas. (n.d.). U.S. Department of Agriculture Economic Research Service. Retrieved from http://ers.usda.gov/data-products/food-environment-atlas.aspx. 7 Map the Meal Gap: Food Insecurity in Garfield County, CO. (n.d.). Feeding America. Retrieved from http://map.feedingamerica.org/county/2013/overall/colorado/county/garfield.


Colorado counties report binge or heavy drinking.8 In the resort communities, clinicians have

observed “overdose seasons” during the fall and spring when many seasonal workers are not

working, people leave, relationships end and substance abuse increases. Rural opiate addiction

rates across the country have been shown to exceed those of urban areas, and 17 of the 21

counties involved in the Western Colorado AHCM region report suicide as a leading cause of

death in their county. RMHP has elected to focus this project on alcohol abuse rather than the

opioid crisis because a focus on alcohol abuse will address a much broader population and will

likely include many opioid users within this focus population.

A lack of physical activity contributes to increasing rates of obesity in Western

Colorado. Though Western Colorado is known for outdoor sports and recreation, few

opportunities are accessible to low-income individuals, or those with physical conditions that

make outdoor activity difficult. Only 58 to 74 percent of people in Western Colorado are able to

walk, run or bike in their neighborhood, compared with over 80 percent of people in the state as

a whole. Only 60 to 70 percent of residents in Western Colorado have access to a public exercise

facility. In addition, the 21 rural counties report prevalence of diabetes between 5.5 and 21

percent9. To align with local efforts and this clear need, this proposal will address physical

activity as a supplemental social need.

Western Colorado is ready to build on the population health management work it has

already initiated within its medical communities to tackle the clear health-related social needs of

the region. The network of strong relationships and existing county collaborations make Western

8 County Health Rankings and Roadmaps, Colorado 2016. Retrieved from http://www.countyhealthrankings.org/app/colorado/2016/measure/factors/49/data?sort=desc-1 9 HRSA Health Center Data, 2013. Diabetes rates by state and county.


Colorado an ideal combined community in which to develop an integrated system that connects

healthcare and social services in order to demonstrate meaningful results.

Available Needs Assessments and Existing Community Action Groups

Each of these regions already has a wealth of data about community needs and gaps. All

local (county) public health agencies conduct community public health assessments and develop

improvement plans using the Colorado Health Assessment and Planning System. Additionally,

the nonprofit hospitals conduct regular community health needs assessments for their

communities. Federally qualified health centers also conduct needs assessments. All of these

assessments are readily available and used to guide community priority setting.

Western Colorado contains passionate and committed leaders that are working to solve

problems across a vast geographic area, and who are accustomed to reaching across municipal,

county and sector lines to form coalitions, collaboratives and alliances. Health-related

collaboratives and alliances include Healthy Mesa County, West Mountain Regional Health

Alliance, Northwest Colorado Community Health Partnership Summit, Health Care

Collaborative, Total Health Alliance of Eagle County and Valley Health Alliance. Some action

groups advocate for a specific population, such as Latino, cross-disability and aging groups. The

commitment of these alliances and their members to AHCM vision and goals has been visible in

the heavily attended webinars (over 50 attendees), the over 100 memorandums of understanding,

and the many people from various community based organizations and clinical sites who offered

to review some or all of this document. The AHCM would provide an overarching strategy and

structure to coordinate these groups.


Community-Dwelling Population Served by Clinical Sites

The AHCM network spans all of Western Colorado. The table below lists all of the

clinical providers who have signed MOUs thus far, which region they fall into and their count of

clients.

Table 1: Community-Dwelling Population Served by Participating Clinical Sites

Clinic/Hospital Region Mcare Mcaid Dual Total 2+ ER Visits

A Kidz Clinic 10 0 316 0 316 12* Axis Health System 9 756 2,488 0 3,244 157* Castle Valley Children's Clinic 12 0 775 15 790 18 Delta County Memorial 10 21,851 17,963 6,588 46,402 2,055 Ebert Family Clinic 12 2 797 0 799 25* Foresight Family Physicians 19 979 741 78 1,798 156 Grand River Health 12 2,454 5,824 527 8,805 1,092 Gunnison Valley Health 10 UNK UNK UNK 3,393 UNK Juniper Valley Family Medicine 19 195 290 23 508 UNK

Marillac Clinic 19 169 3,194 124 3,487 144 Memorial Hospital-Craig 11 729 1,422 129 2,280 UNK Mid Valley Family Practice 12 214 228 0 442 16 Midwestern Colorado Mental Health Center, Inc 10 199 2,730 332 3,261 186

MindSprings, Inc 11,12,19 448 6,689 770 7,907 0 Moffat Family Clinic 11 375 352 32 759 44* Montrose Memorial Hospital 10 4.991 7,872 UNK 12,863 2,431 Mountain Family Health Centers 12 329 5,783 258 6,370 201

New Castle Family Health 12 0 90 0 90 10* Northwest Colorado VNA-Community Health Center 11 230 953 58 1,241 240

Peach Valley Family Medical Center 19 306 328 50 684 UNK

Peak Family Medicine 10 131 484 83 698 4* Pediatric Associates of Durango 9 0 2,104 0 2,104 34

Pediatric Associates 10 0 6,191 0 6,191 66 Pediatric Partners of the SW 9 0 3,723 0 3,723 342* Pioneer Medical Center-DBA Meeker Family Health Center 11 574 405 18 997 7

Primary Care Partners, Inc 19 6,825 11,341 253 18,419 1,059


Clinic/Hospital Region Mcare Mcaid Dual Total 2+ ER Visits

Rangely District Hospital 11 210 404 33 647 106 River Valley Family Health 10 342 1,118 144 1,604 124* Roaring Fork Family Practice 12 1,027 1,074 67 2,168 UNK Southwest Medical Group 9 5,594 5,398 UNK 10,992 UNK St. Mary’s Family Practice 19 153 2,007 201 2,361 UNK St. Mary’s Hospital 19 812 9,219 236 10,267 4,026 Summit Community Care Clinic 12 120 1,905 28 2,053 48

Surface Creek 10 962 1,232 120 2,314 171* Telluride Medical Center 10 6,716 1,066 22 7,804 151 Uncompahgre Medical Center 10 316 714 47 1,077 17* Valley View Hospital 12 998 2,945 198 4,141 980 Whole Health 10,12,19 5 100 20 125 125 Yampa Valley Hospital 11 29 1,023 0 1052 360

Total 58,200 101,046 10,218 184,176 14,407

Note: These numbers are based on provider self-reported data, except for those numbers

noted with an asterisk (*), which were developed using RMHP and Colorado Medicaid claims

data. Due to some entities providing total numbers instead of detailed by category, the final total

is not the sum of the list row, but a total for the column. We anticipate that in some cases the

numbers are over-reported and in some they are under-reported. Once implemented, RMHP will

create Business Associate Agreements to get accurate counts by soliciting identifiable client

information.

While there are some inaccuracies in the self-reported data, the providers have executed

MOUs serve enough clients to exceed the 75,000-person screening requirement and meet the 51

percent penetration rate. The region has a total of 66,995 Original Medicare enrollees and 18,974

Medicare Advantage enrollees, and 127,774 Medicaid enrollees in the region. The only Medicaid

Managed Care plan in the area is RMHP’s Medicaid Managed Care Plan (RMHP Prime), which

currently has about 32,730 members. The total number of community dwelling beneficiaries (not


served by Medicare Advantage plans) is 194,760, and 51 percent of this is 99,328 enrollees. We

are well over that minimum, even with a very healthy margin of error.

A-‐3. Systematic Screening for Health-‐Related Social Needs

Options for Capturing Screening Information

Western Colorado is committed to capturing and transmitting screening information in a

manner that provides needed information to all partners, is minimally disruptive to existing work

flows, and meets the testing and evaluation needs of the model. All clients will be screened when

they solicit clinical care from a participating site. This may mean that they are screened multiple

times; we have decided to err on the side of duplicative screening rather than missing individuals

because for low income families and seniors, social needs can fluctuate quickly. Clinical sites

will have a number of options for clinical screening protocols (largely dictated by which

solutions below is selected.) We will work flexibly with the Center for Medicare and Medicaid

Innovation (CMMI) and its contractors to capture and report necessary data for a successful test

of AHCM.

Participating clinical sites may integrate screening into their existing workflow in the

manner that works best for them. Sites will be afforded at least three options for recording

screening data:1) an open secure web form; 2) through established clinical systems integration

(electronic health record or the Care Coordination Platform); or 3) a secure community Health

Information Exchange Portal. Each one is discussed in detail below.

Open Secure Web Form. AHCM funds will be used to create a secure web form that

can securely collect personal screening information but does not require a login. The user will

complete and submit the screening tool data online and will then receive a list of customized


referrals. The open secure web form is highly versatile. It is web-based and will not require a

login. It is also easy to connect the open secure web form to EHRs or other electronic systems,

via embedded links to the web form. If the form is connected to other applications, some fields

of the screening tool can be auto-populated, so the patient or clinician does not have to type

information multiple times. This minimizes the impact on the workflow and improves data

quality.

The web form could also be placed within something the patient would use, such as a

tablet or kiosk using I-Frame technology. Some AHCM funds will be committed to modifying

tablets that are currently in use. For a few locations—likely rural health clinics that serve

primarily Medicaid populations—AHCM funds will be used to provide tablets or kiosks that can

include the clinic’s own check-in forms as well as the social needs screening. RMHP will

analyze the effect of patient completion of the form versus clinician interview to understand if

the clinician interaction is an important part of the intervention. Of the 24 clinical sites with

MOUs thus far, 5 intend to use the open secure web form as one of their methods.

Electronic Health Record, Care Coordination Platform, or Clinical Systems

Integration. Sites with configurable EHRs or other clinical systems can modify their systems

(with financing support from this cooperative agreement) to complete the survey within their

EHR and submit as structured data. Once the survey is completed the data would be transferred

to the Health Information Exchange through an HL7 or other structured message type. Because

the EHR methodology is more resource intensive, it will likely be used in a limited number of

sites. Of the clinical sites that have submitted MOUs, 9 intend to use EHR and 6 plan to use the

Care Coordination Platform.


Health Information Exchange Secure Portal. Sites that use the Health Information

Exchange (HIE) Secure Portal can use a form within the portal. The HIE Secure Portal will be

easy to use and will be able to auto-populate form fields. The HIE portal supports single sign on

from capable systems, which provide additional accessibility options. Of the clinical sites with

signed MOUs, 6 intend to use the Health Information Exchange Portal.

Some clinical sites have not yet indicated which of the above methods is most conducive

to their existing workflows and supported by existing technologies. We will work closely with

the clinical sites to identify the means that would yield the most accurate data supported by

streamlined processes.

Supporting Workflow Change

Workflow changes can be a challenge. Clinical sites will have a strong support team

including the AHCM project manager, the Health Information Exchange staff, the Rocky

Mountain Health Practice Transformation Team, and practice transformation support provided

by the two ACOs in the region. The AHCM Project Lead, the RMHP staff member responsible

for AHCM, will coordinate with all of these partners to ensure all practices receive hands-on

workflow analysis and planning as needed. The Health Information Exchange staff will set up

the flow of data from one site to another and will support EHR modifications and other ways to

build screening, reporting and referrals into the workflow.

Transmitting the Data

All three data collection methods support the immediate transfer of the data to the

Western Colorado Health Information Exchange, Quality Health Network, which will interface

with the 2-1-1 database (community resource inventory) to capture the referrals and send


community resource information back to the practices. Quality Health Network will retain a

record of all screenings and will also transfer the screening data to an Accountable Health

Communities Data Warehouse managed by RMHP and linked to other RMHP data tables. All

data from the screening will be transmitted from Quality Health Network to the Care

Coordination Platform that supports community navigation services, and to CMS in any format

or through any interface required.

A-‐4. Risk Stratification

Risk stratification will be part of the social needs screening. The screening will ask

clients to report the number of emergency room visits in the last 12 months and ask questions to

identify any health-related social needs. Clients who report two or more emergency room visits

in the last 12 months, in addition to an identified social need will be immediately flagged as high

risk and requiring navigation. Those who do not meet these criteria will still receive referrals for

all relevant resources, as well as instructions about using 2-1-1, a hotline for locating social

services, on their own.

Within the high-risk group, the Western Colorado AHCM will further stratify the

population into two groups based on the screening:

• High-Risk, High-Need clients: These clients have a health-related social need and one of the

following other criteria: four or more emergency room visits in the 12-month period, severe

and persistent mental illness and a chronic disease, or at risk of placement in a nursing

facility. These clients will be asked to sign a release of information so the navigator can

communicate with the clinical site about the status and focus of the community navigation.

• High-Risk, Low-Need clients: These clients have a health-related social need and have two

or more emergency room visits in the 12-month period. These clients will receive community


navigation services but the navigator will focus primarily on creating access and connections

with community services. This is due to a need to target limited navigation resources, as well

as feedback from clinicians that they may not have the capacity to work with the navigators

for low-need clients.

The potential risks to successfully stratifying clients into the above categories lie in data

collection, not in the data analysis. First, practices may struggle to incorporate the screening into

their workflow and successfully screen all enrollees. Creating multiple pathways to incorporate

screening into the workflow and supporting workflow change will reduce the risk that screenings

are not conducted. Second, client provided information could be unreliable. RMHP will work

with CMMI to study and develop procedures that maximize the accuracy of client response by

evaluating factors such as question wording and clinician administration vs client completion of

a form.

Any client who meets the criteria will be offered navigation, regardless of coverage type

or program enrollment even if they participate in other Medicare or Medicaid programs. AHCM

navigation will be coordinated with any other care coordination services the client may receive

(for example, through the Accountable Care Collaborative). Currently, the vast majority of care

coordination initiated by clinical sites is medically oriented.

In the start-up phase, RMHP will compare the client self-reported data with Colorado

Medicaid claims data, the RMHP Medicare claims data, and the Medicare claims data provided

to the participating ACOs. This comparison will identify any systemic gaps or issues with using

the screening process as the method for risk stratification. We will address these gaps in

partnership with CMMI.


After the start-up phase, RMHP will implement a monthly reporting process that uses

Medicare and Medicaid claims data to identify high-risk clients who were not identified through

the screening process. The monthly reporting process will also track and report clients who were

identified as needing community navigation but declined it, or those who did not complete the

assessment. Clients with deteriorating health status will again be offered community navigation.

A-‐5. Community Resource Inventory

RMHP will leverage the existing 2-1-1 database to provide comprehensive, timely and

accurate information to clients about available community resources. Colorado 2-1-1 is an

information referral system in operation since 2003 and funded by United Way, local

government and others. The 2-1-1 database has over 13,000 low and no-cost resources listed.

Although the phone number is statewide, the call centers and data management process are

locally administered. The Community Resource Inventory will include the entire list of

community resources identified by 2-1-1.

Resource Inventory Data Source: Colorado 2-1-1

In Western Colorado, 2-1-1 is administered by three separate organizations. The 2-1-1 for

most of the region is administered by Western Colorado 2-1-1, housed at Mesa County Health

and Human Services. This system is highly regarded in the community and a trusted source of

information for clinics. Larimer United Way administers 2-1-1 for the northwest region of

Colorado, and Mile High United Way administers Summit County 2-1-1. Western Colorado 2-1-

1 will be the lead organization responsible for ensuring that cooperative agreement activities are

completed for the entire region.


These regional 2-1-1 centers manage and update resource information for their own

region. Currently, 2-1-1 staff update the resources annually by calling and speaking with each

organization listed in the database. The 2-1-1 staff also flag organizations known to have

fluctuations in available resources (for example, organizations that only having housing vouchers

during certain parts of the year). All 2-1-1 centers are trained in resource management and

certified by the Alliance of Information and Referral Systems (AIRS) to ensure that the data in

the resource directory is consistent, high quality and accurate. Colorado 2-1-1 centers are

sanctioned by the Public Utilities Commission in Colorado. Their data is the most economical,

consistent, and comprehensive community resource data in Colorado.

Currently, the 2-1-1 data is primarily accessible by calling the hotline, although a

resource list is also online with limited search capability. The 2-1-1 data is housed in an open and

flexible database platform hosted by VisionLink. Resource lists can be modified for specific

programs or geographic areas, thus presenting an opportunity for individual regions or programs

to modify the data set to meet their needs. VisionLink also has the technology to support

interactive searchable community resource information.

Currently, Colorado 2-1-1s are creating a taxonomy of all resources using the AIRS/2-1-1

LA County Taxonomy, which sets a standard for indexing and accessing the wide variety of

human services available in communities across North America. Coding Colorado’s over 13,000

resources by the AIRS/2-1-1 LA County taxonomy returns more specific results than searching

by keywords. Colorado 2-1-1s are also working to standardize demographic data collection and

data entry across the state. The advisory board will be able to draw on this information gap

analysis and community resource alignment.


Community Resources Available Through Colorado 2-1-1

Currently the 211 database indicates that the following resources are available.

Table 2: Community-Based Resources by Region

Food Housing Transportation Utilities Interpersonal Violence

Total Resources in 211

Region 11 33 29 21 27 36 393 Region 10 0 6 6 4 0 739 Region 19 19 18 9 3 9 575 Region 12 21 24 11 17 30 805 Region 9 0 8 5 1 0 477

This information is not a complete representation of available resources because the 2-1-1

agencies are still classifying their resources and putting them in the correct category. The

supplemental social needs are missing from the above chart because they are not categorized in

the 2-1-1 taxonomy. Part of the 2-1-1 AHCM funding is to support the inclusion of new tags and

resources so that the supplemental needs are fully represented in the resource list. Contrary to the

data above, feedback from the potential Community Leads and other stakeholders indicates that

across all of Western Colorado there are shortages in housing and transportation assistance, but

adequate food assistance.

In some cases, resources within the region may not serve the community in which the

client lives or may serve multiple communities. Long distances and geography (for example, a

rockslide in Glenwood Canyon making passage impossible) sometimes split communities.

The 2-1-1 database is stronger in some parts of the region and weaker in others. It is

currently weakest in Region 9 and 10 because these counties are rural with few services, and

because there was a recent change in management of the 2-1-1 service. Enhancing the

relationship and quality of the data in these regions will be a priority for 2-1-1.


Expanding and Enhancing the 2-1-1 Database in Western Colorado

Although the 2-1-1 system is highly regarded in the region, there is need for expansion,

improvement, and increased utilization—especially in the rural areas. The first six months of the

program, we will focus on expanding and enhancing the resource list so it is as useful to the rural

areas at it is to the urban center in Mesa County.

AHCM dollars will fund additional 2-1-1 staff (1.5 FTE) for the full five years of the

cooperative agreement. In the first six months of the project, the Project Lead and Community

Leads (AHCM leads in each of the five Western Colorado regions) will work with these staff to

thoroughly assess the 2-1-1 database. The team will cross-reference the 2-1-1 database with

Eldercare.gov as well as other community or region-level resource lists. The team will also

ensure all Single Entry Points, Community Centered Boards and No Wrong Door pilot

organizations are listed. In addition, the AHCM consortium and other partners will evaluate

whether 2-1-1 needs to add data elements or taxonomy codes to the organization descriptions.

By the end of year 1, Colorado 2-1-1 will implement a formal feedback process with the

Community Leads to continuously improve the community resource listings and ensure that all

resources are updated a minimum of every six months. Community Leads will solicit feedback

on the resource from community members and help 2-1-1 with any challenges. The Community

Leads will meet regularly with community-based organizations and clinical sites to ensure that

issues with the 2-1-1 database are quickly identified and addressed. Conversely, if the 2-1-1 staff

members are having difficulty reaching a community-based organization, the Community Leads

will provide support.


A-‐6. Tailored Community Referral Summary

The Health Information Exchange (where screening information is uploaded) will

connect with the 2-1-1 database to generate a tailored community referral summary. After the

screening data is entered electronically, the 2-1-1 database will automatically generate a list of

referrals appropriate for the client’s age, gender, location and need. In the time it takes a patient

to be roomed or walk from the exam room to the front desk, the clinical site will receive the list

of referrals. All referral summaries will include organization name, address, website, hours,

intake procedures, eligibility, ADA access and languages spoken.

Clinical sites have multiple options for how to receive the referral list, including fax,

secure email, file drop, directly to the EHR as a data element, or input into the EHR as a

formatted file. Some clinical sites already provide clients with a written summary of the visit and

may choose to incorporate this referral data into the visit documentation.

The format and design of the referral summary will be developed with input from the

consortium, the Advisory Groups, and the Rocky Mountain Health Plan’s Client Advisory

Group. RMHP will ensure that the referral summary is client-friendly and culturally sensitive.

RMHP will send the community-based organizations monthly reports summarizing

number and demographics of clients who have been referred to them. If community-based

organizations note that there were more clients referred than clients served, it may signify

barriers to accessing services. Due to privacy considerations, the Western Colorado consortium

will not provide lists of referred clients to the community-based organization. Only community

navigators will receive lists of referred clients. As approaches to data sharing and release-of-

information processes evolve, Western Colorado will revisit how to support referral follow-

through and coordination with the community-based organizations.


A-‐7. Navigation Services

Care coordination and case management services are available in some form in most

parts of the region, especially for high-risk clients. That said, most do not focus on bridging the

gap between healthcare and community services. AHCM community service navigation will

create this bridge. Navigation will ensure that clients identified in a clinical setting are assessed

for health-related social needs and given a plan to meet those needs. Navigators will be

community-based and representative of the client population.

Community navigation in rural areas requires specific skills to operate in an under-

resourced environment and specific knowledge of the rural health systems, which may be

informal or organized differently than in urban areas.10,11 We will support AHCM navigators in

acquiring these skills and coping with the unique challenges of working in this environment.

Navigators contend with resource challenges daily, and therefore have a valuable and unique

perspective on where gaps exist in the continuum of services. Navigators will be asked to share

their recommendations with their regional Advisory Boards in, so they are part of continuous

improvement of the systems and social conditions that create barriers for their clients. This will

improve the quality of the Advisory Board’s understanding of social system and may improve

job satisfaction of navigators. Knowing they are addressing the root of the systemic issues they

see routinely is important for navigator morale.

10Duggeby, W. et al. Developing Navigation Competencies to Care for Older Rural Adults with Advanced Illness.Duggleby. Canadian Journal on Aging. April 2016, 19:1-9. 11Palomino, H. et al. Barriers and Challenges of Cancer Patients and Their Experience with Patient Navigators in the Rural US/Mexico Border Region. Journal of Cancer Education, September 2015: 1-7.


Establishing the Navigator Network

The Western Colorado AHCM will contract with current care coordinators and

navigators to build a navigation network focused on health-related social needs. Our goal is to

ensure that every beneficiary who is eligible for AHCM navigation receives such services. The

AHCM will build on their current capabilities to address a range of psychosocial needs including

all five core social needs and the two supplemental social needs (substance use and physical

activity).

The consortium will select members of the navigation network once an award is made,

and members will sign an MOU for navigation activities. We will design the community

navigation model with enough flexibility to adapt to varying community resources and protect

the autonomy of navigator organizations. Many RMHP care coordination partners have already

expressed interest in becoming a navigation site. A navigation network site can be a peer

navigation model or a community navigator model (bachelors-level professionals), or are a

program staffed by licensed social workers and related disciplines.

The program will be designed and overseen by a Navigation Program Manager

(potentially a function of one of the navigation sites). The Navigation Program Manager will

work with the consortium and the navigation network to ensure the network delivers consistent

and high quality services throughout the region. The consortium will ensure consistency in

services despite the significant range of experience through 1) orientation and ongoing training;

2) standardized policies and procedures; and 3) robust oversight by the Navigation Program

Manager.


Process for Conducting Interviews

Navigation services will follow a structured process for interviews, action planning and

follow-up.

Eligible clients will be offered navigation at the clinical site after the screening. Clinical

sites will be encouraged to have the conversation about the navigation program verbally but will

also have materials that they can hand to the client to help the client make a decision about

navigation services.

Once the client chooses to use community navigation services, the client will connect

with the navigator in one of two ways:

1. If the clinical site offers navigation services, the clinical site will immediately offer the

client an appointment with a navigator. Whenever possible, the clinician will introduce

the client to the navigator right there in the clinic.

2. If the client has to be connected with another organization for navigation services, the

clinic site will help the client set up an appointment with the navigator before the client

leaves the visit. To ensure easy access to navigation contact information, navigators will

be listed in the resource director and on each client’s tailored referral document.

If the community navigation assessment cannot be scheduled while the client is in the

office, the navigator will make three attempts to contact the client by phone within 48 hours of

the visit. If those attempts are not successful, the navigator will make an attempt to reach the

client through email, text or, in some cases, a home visit.

The first interview will be at a place of the client’s choosing, with a preference for the

client’s home when possible. Navigators will have flexible schedules with evening and weekend


availability so that clients who are working are able to meet with them at both a convenient time

and location.

Assessment Tool

The AHCM needs assessment tool will be based on the assessments currently in use in

the community. While assessment tools from all of the navigation sites will be reviewed, the

starting point for a standardized assessment will be the Coordinate the Coordinators Western

Slope Needs Assessment.

Coordinate the Coordinators is an RMHP-sponsored effort in Mesa County to coordinate

both clinical and non-clinical care coordinators who serve individuals with multiple bio-psycho-

social needs. The Western Slope Needs Assessment was collaboratively developed with

multidisciplinary partners. The assessment was carefully designed for a broad range of clients

and for providers with diverse backgrounds and training. The assessment is currently used by

several community organizations, and RMHP intends to expand it to other parts of the region in

the upcoming year. A list of assessed clients is routinely uploaded to a common IT platform that

allows community partners to identify all care team members.

The AHCM Project Lead will work with the navigation network to review and revise the

assessment. At a minimum, it will include an assessment of the five core health-related social

needs and the two supplemental needs. It will also assess social supports, environmental issues,

health behaviors, occupational and intellectual needs, cultural and spiritual needs, life planning

and client goals.

The assessment will be captured in an approved care coordination IT platform. Currently,

RMHP has two care coordination platforms, Essette™ and Crimson Care Management™.

RMHP will maintain at least one platform and will offer that platform to all AHCM navigation


sites. Navigation sites may use their own platform as long as they can assure that data will be

captured and extracted consistently.

Process for Designing Action Plans

The assessment will drive the development of a strengths-based client-centered action

plan that uses SMART goals (specific, measureable, achievable, relevant, and time-bound). The

plan will include the assessment results, as well as the client’s expressed preferences and needs.

The plan will reference the specific barriers that the client has encountered (or may encounter) in

accessing community services that address health-related social needs, and offer clear steps for

overcoming the barriers.

AHCM will give community navigators guidelines, pathways and rubrics to help them set

timeframes and action steps. In addition, the Advisory Board will be a resource for when

systemic issues or community gaps are a barrier to addressing individual client goals.

Process for Follow-Up

Navigators will follow up with clients a minimum of once per month, and up to daily

visits, depending on the need. Clients will receive navigation services anywhere from 3 to 12

months.

Follow-up meetings include a check-in on goals and status, and may also be a time for

the navigator to directly support the client in accomplishing the tasks in the action plan. For

example, the navigator might accompany the client to a low-income housing facility to submit an

application or help the client learn how to shop for healthy food on a food-stamp budget.

Community navigators will be expected to spend the majority of the time in the community

rather than in office settings.


When the client has achieved their stated goals or the client and community navigator

determine that no further progress can be achieved together, there will be a process for the client

to “graduate” and acknowledge any successes made.

To evaluate the experience and outcome of navigation, we will work with community-

based organizations and clients to design a survey. Clients will be asked to anonymously provide

feedback on the process through a client survey that includes questions regarding satisfaction,

outcomes, and whether the life changes are sustainable.

Navigation Network Program Oversight

Flexibility and strong program oversight will maximize community resources while

promoting consistent and high-quality services. All navigation sites will have a designated

clinical supervisor responsible for program development and execution. All navigation

supervisors across the region will form the Community Service Navigator subcommittee, which

is responsible for discussing policies and procedures, addressing systemic issues, providing

training and obtaining feedback from the community. Additionally, the Community Leads will

meet with all partners (clinical and community-based) regularly to identify and address AHCM

implementation concerns.

RMHP will randomly review at least 10 navigation charts each quarter. The Navigation

Program Manager and AHCM Project Lead will address concerns or discrepancies, and may use

blinded examples of good charts for training purposes. If a major issue is identified, the Program

Manager will have a collaborative conversation about the issue to develop an informal resolution

plan. If the problems persist, the AHCM Project Lead will write a formal corrective action plan

and ask that the navigation site agree to correct the issue. If the corrective action plan is not


successful, the Navigation Program Manager will work with the consortium to determine next

steps.

Orientation and Ongoing Training

The initial orientation, prior to program implementation, will be provided by the

Navigation Program Manager and will be at one location in the region. Throughout the course of

the contract, as newly hired navigators will receive an orientation provided by another navigator

in the region within six weeks of starting. This approach will help the new navigator learn while

also reinforcing the trainer’s knowledge and expertise.

The orientation will be developed in partnership with the network of community

navigators will cover these topics: safety; strengths-based approach12; client rights; advocacy;

ethics and boundaries; confidentiality and legal issues; culturally sensitive communication

(including culture of poverty); trauma-informed care13; healthy eating and active living;

Medicaid and Medicare eligibility and coverage; self-care and stress management;

documentation and program expectations (use of the care coordination tool); and mental health

first aid.

The orientation will use a range of learning methods, including didactic methods,

shadowing, and direct observation. After didactic experiences, new employees will join trainers

at their sites for one or two days to shadow. Finally, trainers will accompany trainees to their

organizations in order to mix lecture and discussion with joint client visits.

12 Tong, M. The Client-Centered Integrative Strengths-Based Approach: Ending Longstanding Conflict between Social Work Values and Practice. Canadian Social Science, Vol. 7, No. 2, 2011: 15-22. 13 Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.


Navigators will also have ongoing training and support. All navigators will have monthly

one-on-one supervision meetings with someone trained in behavioral health and social service

navigation. Supervision may be provided by the navigator’s own organization or, for

organizations that do not have that capacity, may be provided by the Navigation Program

Manager. The Program Manager will also supervise monthly phone-based case reviews, during

which community navigators have the opportunity to present challenging cases and receive

feedback. Also, navigators will have quarterly opportunities to shadow care coordinators in

different settings. These shadow opportunities will strengthen the relationship between the

navigators and community-based organizations, and give navigators additional experience.

Further, the annual Western Colorado AHCM Summit will offer special skills-focused learning

opportunities for navigators, for example, motivational interviewing.

B. Bridge Organization Background

The bridge organization for this project is Rocky Mountain Health Plans (RMHP), an

independent nonprofit organization committed to social responsibility and community. RMHP

has a long history of providing the resources to support local innovation and infrastructure

building, well beyond its role as an health insurance organization. All RMHP programs are held

to the standards of its organizational values: respect, compassion, fairness, innovation and

continuous quality improvement. Underlying all activities and values is a deep appreciation for

all partners and a belief in the power of trusting relationships. These relationships are what

enable RMHP to solicit the support of its community partners to submit this proposal for

Western Colorado.


RMHP currently serves approximately 80 percent of Medicaid clients as well as a

significant portion of Medicare beneficiaries in Western Colorado communities. RMHP offers a

Medicare Health Plan with 13,000 enrollees. In addition, RMHP is the designated Western

Colorado Regional Care Collaborative Organization (RCCO) for the state’s Accountable Care

Collaborative, with 133,822 members14. As the RCCO, RMHP is responsible for coordinating

efficiently with all state and federal programs, including the State Innovation Model initiative

and the No Wrong Door grant, as well as long-term services and supports and local public health

agency initiatives. In establishing and supporting community-based care teams, RMHP has

developed strong relationships with community providers. Within the ACC, RMHP has the

distinct opportunity to act as a community convener rather than a payer, as ACC clients are still

reimbursed within fee-for-service Medicaid. In the ACC, RMHP has focused on bringing

together the siloes within the healthcare system—a strategy to incorporate community based

organizations is a natural next step.

RMHP has significant experience in activities relevant to AHCM. In the Beacon

Communities project, a cooperative agreement with the Office of the National Coordination for

Health IT (ONC), RMHP supported the adoption of EHRs and the expansion of a community

health information exchange, Quality Health Network.15 In this effort, RMHP gained specific

experience in the program and financial management required by a federal cooperative

agreement.

RMHP is a CMS-aligned payer in the Comprehensive Primary Care Initiative, and also

provides practice transformation and regional learning faculty support for participating Western

Colorado primary care practices. This effort strengthened the data collection and transparent

14 Colorado Medicaid ACC Region 1 Roster Report April, 2016. 15 http://qualityhealthnetwork.org


reporting activities necessary for value-based payment models. RMHP has also participated in

the Sustaining Health Across Practice Environments (SHAPE) effort to test a global budget

payment methodology to sustain behavioral health services in integrated primary care practices.

These activities necessitate infrastructure, data and relationships that can now be leveraged in

RMHP’s capacity as the Bridge Organization for AHCM.

RMHP was awarded authority to implement Colorado’s first Medicaid Payment Reform

Pilot, pursuant to Colorado House Bill 12-1281. As part of this effort, participating practices

implemented the Patient Activation Measure (PAM) to assess the patient engagement with their

health. The experience of supporting practices in adding PAM to their workflow is directly

translatable to supporting practices as they incorporate the social needs screening for AHCM.

To oversee the AHCM project, RMHP will hire one full-time senior staff lead to be the

AHCM Project Lead. The Project Lead will be responsible for overall program management and

coordination (internally and externally). This person will be recruited with a goal of identifying

someone with specific skills in developing high-functioning collaborative processes. The Project

Lead will retain ultimate responsibility for program data collection and quality control but will

share that responsibility with the Community Leads and the Navigation Program Manager, as

well as with the regional health information exchange.

RMHP will supplement their current in-house data capacity with a partial FTE dedicated

to AHCM. This person will coordinate data collection for internal quality control and CMS

monitoring and evaluation. All screening and referral data will be collected via the Health

Information Exchange. Community-based organization data and care navigation data will be

extracted and submitted directly to the AHCM data warehouse, facilitated by RMHP. RMHP has

significant capacity and expertise managing different types of data sets to support this partial


FTE in their work. As in other collaborative projects, RMHP will fulfill bridge organization

responsibilities by providing leadership and guidance while creating space for collaborative

problem solving and partnership.

C. Stakeholder Engagement

C-‐1. State Medicaid Agency

Colorado Department of Healthcare Policy and Financing (HCPF), the single state

Medicaid agency, has a commitment to innovative approaches to supporting whole-person care

for Medicaid clients. HCPF has adopted the World Health Organization definition of health:

“Health is a state of complete physical, mental and social well-being and not merely the absence

of disease or infirmity.” Both the Chief Medical Officer, Judy Zerzan and Medicaid Director

Gretchen Hammer have committed to oversee a potential Colorado AHCM. This strong support

is indicative of the HCPF’s interest in developing and scaling this type of program in Colorado.

HCPF has demonstrated its commitment to a vision of community-connected clinical care

through the Colorado Opportunity Project, the State Innovation Model and the Accountable Care

Collaborative Phase II vision.

The Colorado Opportunity Project is a multi-agency effort to support interventions that

create opportunities for all Coloradans to remove roadblocks to health, self-sufficiency and well-

being. The project is taking a proactive, prevention-based approach to making this vision a

reality. HCPF is funding a staff member in each region of the state to form community

partnerships and build new infrastructure to minimize and remove these roadblocks. Western

Colorado is one of the regions for the project, and RMHP has housed a Colorado Opportunity

Project staff member.


Another initiative led by HCPF is the State Innovation Model. Colorado, with HCPF’s

leadership, articulated a vision to have public health support clinical health transformation, and

to promote an approach focused on the social determinants of health.

Finally, the person-centered Accountable Care Collaborative (ACC) is Colorado

Medicaid’s primary delivery system. Within the ACC, the program is administered by seven

Regional Care Collaborative Organizations, one of which is RMHP. The ACC has spent the last

five years building the infrastructure and the will for communities to share data, information and

accountability for the care and health outcomes of Medicaid clients. Now entering Phase II of the

ACC, HCPF has committed to better integrating all aspects of healthcare and supporting

seamless coordination between clinical delivery systems and health-related social services.

One of HCPF’s priorities is improving the long-term services and supports system. To

support alignment with this priority, RMHP has solicited and received MOUs from at least one

Community Center Board, Single Entry Point, County Department of Human Services, , Area

Agency on Aging and Independent Living Center, for a total of 12 organizations committed to

providing long-term services and supports.

Colorado Medicaid has the vision and capability to successfully partner with RMHP on

the AHCM. The Department successfully implemented the Full Benefit Medicare-Medicaid

Enrollee Demonstration project and has been an engaged payer in the Comprehensive Primary

Care Initiative. In both of these programs, HCFP has gained experience in ensuring funds are not

duplicative and programs are compliant with CMMI parameters and intent. HCPF also gained

experience in submitting claims data to CMS for monitoring and evaluation purposes.

HCPF is currently in the process or implementing a new MMIS vendor. This is part of an

effort called “iCommit,” which includes upgrades to claims systems (MMIS and Pharmacy


Benefits Management System) and a new Business Intelligence Database Management System,

an analytics data warehouse. Colorado Medicaid is at the cutting edge of Medicaid data and

analytics.

In addition to these HCPF changes, the Governor’s Office recently created the Office of

eHealth Innovation, which is leading an open and transparent statewide effort to establish

common policies, procedures and technological approaches to improve Colorado’s health

information network. It will leverage public and private sector resources and strengthen

Colorado’s health IT foundation.

In addition to having a vision that aligns with AHCM and the skills, experience and

infrastructure to successfully monitor the program, HCPF has a long history of working

successfully in partnership with RMHP. The personal relationships between RMHP and HCPF

staff enable open, honest communication and rapid troubleshooting if program issues arise.

C-‐2. Consortium

Consortium Participants

The Western Colorado AHCM consortium, which is submitting this proposal, consists of

a subset of community partners that have agreed to participate in the AHCM project. These

consortium members are all eligible to participate in this cooperative agreement. No consortium

members have any conflict of interest for participating in this cooperative agreement.

Table 3: Consortium Members 1. Colorado Department of Health Care Policy and Financing (Medicaid single State

agency – representative to be named) 2. Patrick Gordon (Associate Vice President, Rocky Mountain Health Plans) – bridge

organization 3. Lynn Borup (Executive Director, Tri-County Health Network) 4. Lisa Brown (Chief Executive Officer, Northwest Colorado Visiting Nurse


Association) 5. Jeremy Carroll (Executive Director, River Valley Federally Qualified Health

Center) 6. Jen Fanning (Executive Director, Grand County Rural Health Network) 7. Enrique Hernandez (Energy Outreach Colorado) 8. Christie Higgins (Director of ADRC of Mesa County, Western Colorado 211) 9. Marc Lassaux (Chief Technical Officer, Quality Health Network) 10. Jennifer Ludwig (Public Health Director, Eagle County Public Health &

Environment) 11. Kathleen McInnis (Executive Director, Southwestern Colorado Area Health

Education Center), 12. Sharon Raggio (President & CEO, Mind Springs) 13. Dave Ressler (Executive Director, Community Care Alliance, LLC) 14. Sarah Robinson (Program Integration Manager, Mesa County Health Department) 15. Julie Reiskin (Executive Director, Colorado Cross-Disability Coalition) 16. Mike Stahl (Chief Executive Officer, Hilltop) 17. Sarah Vaine (Executive Director, Summit Clinic) 18. Liane Jollon (Executive Director, San Juan Basin Health) 19. Department of Housing (representative to be named)

Flow of Funding and Data

The Western Colorado AHCM consortium plans to use funding from this cooperative

agreement to improve community infrastructure for better alignment of healthcare and social

services. The region plans to use and build on existing care coordinators and navigators to do the

additional community navigation.

Not all consortium members will receive funding. Funding will not be provided for

community-based organizations engaged in tracking clients or clinical sites in conducting the

screening. We hope to develop these tools and integrate them into the workflow seamlessly so

there is not much additional effort required. This project will result in data that will enable

community based organizations and clinical sites to have stronger grant proposals, information to

inform the design of program offerings, and be better able to serve clients. Participants tell us

that these intrinsic benefits are adequate incentive.


Some funds will be used for navigation activities. Much of the funding will be used to

develop the tools for screening, assessment and planning; improve 2-1-1 information; and create

data and information pathways that align clinics and social service providers. Consortium

members will receive program funding if they are Community Leads or community navigators,

or if they are contracted to do specific tasks, such as the IT components.

RMHP will put infrastructure in place to ensure that navigation data obtained through

different platforms are transmitted to a central AHCM data warehouse, where the data will be

aggregated and shared with CMS and the Western Colorado AHCM consortium for quality and

evaluation purposes.

Consortium Roles and Responsibilities

The Western Colorado AHCM consortium will lead and be accountable for execution of

AHCM objectives. The consortium will consist of a representative group of key community

leaders and will have two main functions: 1) strategic direction and operational oversight, and 2)

support and guidance to the local Advisory Boards.

The consortium is responsible for prioritizing and executing objectives and plans;

allocating and managing resources; overseeing policy and compliance in key areas such as risk

management, confidentiality, privacy and security; monitoring data collection and use; assessing

program performance and addressing gaps; keeping Western Colorado AHCM accountable for

achieving milestones and performance objectives.

The full consortium (all partners) will meet at least quarterly (with a remote option

available) and once annually, in person, at the AHCM Summit.

Table 4: Consortium Partner Responsibilities Program Performance: Review quarterly program performance reports such as rates of screening, clinical visits, and completed community navigation assessments; identify issues


in program operations; develop plans to address those issues.

Annual Summit: Identify collaborative learning and program direction objectives for the annual AHCM Summit

Gap Analysis and Quality Improvement: Review the Advisory Board Gap Analysis and Quality Improvement Plans for each region; identify areas of alignment and opportunities for partnership between the regions; provide the regional Advisory Boards with feedback and support.

Report to State and Federal Partners: Provide progress assessment, performance assessments, strategic feedback with state and federal partners as necessary to address state and federal policy issues that impact the Western Slope. Document successes, failures and improvement strategies and share meeting summaries and minutes publicly;

Information technology, data and measurement activities: Annually review the information technology, data and measurement infrastructure of the program; where possible, provide guidance to align the AHCM model with other state initiatives.

Program Communications: Provide guidance on project communications to ensure that community engagement remains strong, and that state and federal leaders understand and support AHCM objectives;

Program Operations: Provide guidance on AHCM policies and procedures.

The Consortium will have an executive committee that includes one representative from

each of the five health regions. The Executive Committee will set priorities and assess the

performance of the AHCM Project Lead; set standards and monitor performance of the

community navigation network; guide resource allocation and sustainability within the

community navigation system; define roles and coordinate activities fulfilled by the Community

Leads; and monitor the budget. The Consortium will have one standing subcommittee:

Community Navigation. This subcommittee will meet monthly and will include clinical

supervisors of community navigation.

C-‐3. Clinical Delivery Sites

The clinical delivery sites have expressed their commitment to the AHCM through their

engagement during the proposal development process. RMHP has hosted two webinars for the

entire region that have been widely attended. Hospital, primary care and behavioral health


representatives including physicians, office managers and CEOs have participated in a series of

interviews to assure that the required workflow changes are acceptable. Prior RMHP experience

has indicated that this level of engagement in the early planning process is necessary to

successful implementation.

Like many rural areas and other rural communities in Colorado, Western Colorado is

served by a large number of small independent practices. While this diverse network may present

a scaling challenge, it also offers an opportunity for creative thinking, unique ideas and

innovative solutions to region-specific problems. It may also lead to greater buy-in from

individual clinicians who are directly involved with the decision to participate in the project,

compared to clinicians who come from a large system that decides to participate on their behalf.

The clinical providers include the Rocky Mountain ACO, federally qualified health

centers (FQHCs) and community mental health centers. Five clinical sites make up the Rocky

Mountain ACO: Grand River Health, Pioneer Medical Center, Memorial Hospital, New Castle

Family Health and Rangely Hospital District. Almost all FQHCs in the area are participating:

Mountain Family Health Center, Marillac Clinic, Summit Community Care Clinic, River Valley

Family Health, Northwest Colorado Visiting Nurse Association and Uncompahgre Medical

Center. All three community mental health centers in the region have also signed MOUs to

participate: Mind Springs, Midwestern Colorado Mental Health Center, Inc. and Axis Health

System.

There is a wide range of practice sizes among participating clinical providers. There are

nine large clinical sites with more than 5,000 community-dwelling beneficiaries, seventeen

medium clinical sites that have between 1,000 and 5,000 eligible community dwelling

beneficiaries, and twelve small clinical sites that have seen fewer than 1,000 community


dwelling beneficiaries in the last year. All of these providers committed in an MOU to conduct

screenings and referrals.

This network of clinical sites has significant experience in implementing new workflows

and evolving their practice to meet changing health systems and better serve their clients. The

majority of the clinical delivery sites that have signed MOUs have experience with one or

multiple of the following: Cohort 1 State Innovation Model (SIM), Comprehensive Primary Care

Initiative, Sustaining Health Across Practice Environment (SHAPE), Patient Activation Measure

(PAM) implementation, and the Colorado Beacon Consortium. All of these efforts involve

practice transformation, workflow adjustments and collaboration.

Table 5: Clinical Providers Who Have Participated in Other Initiatives SIM CPC SHAPE PAM BEACON

Axis Health System X Castle Valley Children's Clinic X Foresight Family Physicians X X X X X Juniper Family Medicine X X X Marillac Clinic X X X Mid Valley Family Practice X X X X X Mountain Family Health Centers X X X X Northwest Visiting Nurse Association X Peach Valley Family Medical Center X X X Pediatric Associates X X X Pediatric Partners of the SW X Primary Care Partners, Inc. X X X X X New Castle Family Health X River Valley Family Health X X Rangely District Hospital X X X Grand River Health Pioneer Medical Center X St. Mary Family Medicine Residency Clinic X X X Surface Creek X X X Telluride Medical Center X X X Uncompahgre Medical Center X Whole Health, LLC X Yampa Valley Medical Associates X X


C-‐4. Community Service Providers

Community-based organizations are enthusiastic supporters of this proposal. To date, we

have 71 MOUs covering all of the core needs: food (31), health behaviors (18), housing (18),

interpersonal violence (13), transportation (15), and utilities (10) (note: some organizations fit

into multiple categories). Community-based organizations want to build a bridge with clinical

providers and work closely with the community to address gaps in services. For example,

domestic violence organizations have a need for better and faster healthcare access for clients

with urgent needs. They are eager to provide feedback and improve the 2-1-1 resource as a way

to increase efficiency within their own organization (reduce the number of clients who come

seeking services not offered) and to better serve their clients. Community-based organizations

are eager to receive population-level health (e.g., chronic disease prevalence) and healthcare data

about their population.

Community-based organizations on the Western Colorado vary in their capacity, but all

have committed to accept referrals and participate in the Advisory Board in their region. Western

Colorado community service providers are willing to participate in the collection of client-level

data, but will need assistance to build their capacity to do this. Our plan for tracking this data

takes this gap into consideration.

Tracking Community-Dwelling Beneficiary Utilization

RMHP plans to track community-dwelling beneficiary utilization of community services

with two data sources: data from community navigator organizations (for clients who use

navigation services) and data from the community-based organizations (for clients who do not

use navigation services).


Community navigator organizations will collect and track community navigation data in

an AHCM-approved platform. All platforms will be required to track the same type of data about

navigation activities, including referrals and referral outcomes. All community-based

organizations that have signed an MOU to date have agreed to support navigators in collecting

this data. Community-based organizations will also collect data on the utilization and costs of

community-based services.

Few community-based organizations currently share individual client-level data. This is

an opportunity to build data collection infrastructure in the social service sector, using the

lessons learned and existing infrastructure built in the healthcare sector. RMHP has created a

data collection model that meets organizations where they are. Community-based organizations

fall into three primary categories for data sharing:

1. Client-level electronic data

2. Population-level electronic data

3. No electronic client data available

Community-based organizations that can collect electronic data will extract data and

submit it to the RMHP data warehouse at either the client-level or the population-level. Concern

about client privacy is the primary barrier for these organizations in transmitting client-level

data; strategies to address this concern are discussed below

RMHP will work with the consortium to develop data governance rules that ensure the

data from community-based organizations is used in a manner that the entire community

supports. Initially, data will likely be used only for program evaluation and analysis, and not to

communicate across provider types. Many community-based organizations have some state or

federal oversight and data reporting requirements; explicit support of data sharing by these


government partners may be necessary. In addition, the Project Lead and Community Leads will

provide hands-on intensive support, including, if necessary, in-person attendance at Board of

Director meetings to solicit data sharing approval. Finally, many community-based organizations

already have or will want to implement a client release of information process.

Organizations that track client-level data but cannot overcome the barriers to sharing

client-level data can share aggregate population data. This data, paired with the navigation data

and data from the screenings will still allow for much of the same analysis to assess the impact of

the intervention.

Organizations that do not track data electronically will share with RMHP per unit costs of

their intervention and any other data they collect and share about their services. This data will be

the least effective at supporting robust analysis of the impact of the interventions, but is still

valuable to both the project and the community.

For all community-based organizations, RMHP is willing to provide licenses to use a care

coordination software platform that could be used not only for AHCM purposes but also for all

of the community-based organization’s unique client management needs.

D. Community Integrator

D-‐1. Advisory Board

We propose creating five advisory boards, one for each of the Western Colorado regions

included in this project. As Western Colorado consists of unique communities with diverse

needs, this will allow us to address the alignment needs and challenges of each community.

To the greatest extent possible, the AHCM advisory boards will be integrated into

advisory structures already in place, which can be expanded or refocused to address the needs of

the AHCM program. All individuals who have signed MOUs will be on the Advisory Board


(complete list not included due to length). Building on pre-existing forums will ensure the

engagement of partners already committed to a community process, minimize the administrative

burden for partners involved in multiple community projects, and promote alignment between

AHCM and other community initiatives.

Each region will have a Community Lead, who will be a member of the advisory board

and ensure that the advisory board meets and fulfills its responsibilities. Each AHCM advisory

board will have a charter, governance structure (with board chair) and project plan. The

Community Lead will support each region’s AHCM advisory board by maintaining an annual

meeting calendar, drafting agendas, ensuring sufficient attendance, developing meeting minutes

and tracking action items.

The advisory boards will include representation from AHCM community navigators,

participating community-based organizations, participating clinical providers, client advocates,

county officials, local public health, and long-term services and supports. They will also be

encouraged to include the not-yet-awarded Regional Health Connectors funded by SIM. Each

advisory boards will annually assess board participation to ensure that it adequately represents

the community.

Each advisory board is responsible for reviewing and advising on the data collection plan

for the Gap Analysis, reviewing the data to identify any inaccuracies and key findings, and using

the data to prepare the Gap Analysis and develop a Quality Improvement Plan. The advisory

boards will integrate feedback from the consortium into the Quality Improvement Plan. The

Community Lead will be responsible for drafting their region’s Gap Analysis and Quality

Improvement Plan. For each step in the process, each Advisory Board will determine the best

decision making model for their group. Each Advisory Board will own the development and


implementation of their Quality Improvement Plan. They will not focus their attention on the

screening, referral and navigation policies and procedures, as these activities will be overseen by

the AHCM Project Lead, Navigation Program Manager and the Consortium, as needed.

The first quarter of every grant year will be focused on developing the Gap Analysis,

interpreting the data provided by RMHP. The second quarter will be focused on developing the

Quality Improvement Plan. The third and fourth quarters will be focused on implementation of

the Quality Improvement Plan. At a minimum, the advisory boards will meet quarterly, although

regions will be encouraged to adjust that frequency as necessary. More frequent meetings will

likely be required in the start-up phase of the program.

The advisory boards will support the successful administration of a regional survey to

solicit feedback on community needs and opportunities and the AHCM program itself by

encouraging all partners to complete the survey. We will also encourage advisory boards to

engage local businesses, media outlets and other community members to raise awareness about

the project and make community connections.

Giving each advisory board responsibility to direct their community’s Quality

Improvement Plan process will ensure community buy-in and the use of existing resources in the

community. The AHCM Project Lead will participate in many of the advisory board processes

across the region in order to ensure that they are achieving the goals of the AHCM model and

have the necessary support to be successful.

Western Colorado has a rich set of advisory structures to leverage in building the AHCM

advisory model.

Table 6: Existing Regional Advisory Groups Region Advisory Group Pre-existing function Jackson, Moffat,

Northwest Colorado Community Health

Convenes community and safety net organizations, healthcare providers and government agencies to


Region Advisory Group Pre-existing function Rio Blanco, and Routt counties

Partnership (NCCHP)

develop a regional network of care. The Northwest Colorado Visiting Nurse Association provides NCCHP with fiscal sponsorship and administrative support.

Montrose, Ouray, and San Miguel counties

Tri-County Health Network

Convened primary care, behavioral health, a hospital and a nonprofit. This group has worked together to develop a chronic disease program where patient navigators/care coordinators work within each clinic to connect clients with community-based services.

Mesa County Healthy Mesa – a collective impact structure created by the Mesa County Health Department

Through Healthy Mesa, the Mesa County Local Public Health Department strives for continuous partnership of health, human service, youth development and social service agencies as well as education institutions, service clubs, recreation and environmental groups. Health Mesa County works to determine how programs complement each other, assess new programs to determine best fit for the community, align programs to reach highest risk and provide mutual accountability.

Eagle, Garfield, Grand, Pitkin and Summit counties

Four existing alliances and collaboratives

These four alliances/collaboratives work independently to address healthcare and care coordination concerns in their individual communities:

1. West Mountain Regional Health Alliance 2. Summit Health Care Collaborative 3. Total Health Alliance of Eagle County, and 4. Valley Health Alliance

Archuleta, Dolores, La Plata, Montezuma, and San Juan

Center of Excellence in Care Coordination the Southwest Colorado Area Health Education Center

This organization brings together over 60 partners to work on care coordination challenges.

D-‐2. Data Sharing

Western Colorado is unusual for a rural area in that it has a rich health IT ecosystem.

Significant investments have already been made in supporting interoperability of health data

systems.


Technology is one important part of data sharing; the other is community mobilization.

The best technology is not valuable if the community does not use it effectively. Western

Colorado has a history of working collaboratively with the community to align resources and

share information. The consortium will build on the extensive work it has already done to ensure

that data collection and sharing methods are realistic, reasonable and beneficial for providers and

community members. We are committed to ensuring that data collection continues to work for

the community, while also working flexibly with CMMI and its contractors to ensure rigorous

evaluation of the model.

Key Data

The AHCM consortium members have been engaged for many years in conversations

about how to integrate disparate data sources in order to support comprehensive community-

based care. In the past several years, Quality Health Network has significantly increased

interconnectivity in Western Colorado. As of the end of 2015, Quality Health Network was

connected to 14 hospitals, 5 labs, over 40 long-term care sites and approximately 1,080 licensed

providers, as well as Rocky Mountain Health Plans, Humana, Mesa County Health Department,

the Colorado Departments of Human Services, and the Colorado Immunization Information

System.

Quality Health Network currently has data on 676,255 unique patients. As a result, the

Western Colorado AHCM will have a robust data set for this project and plans to expand it. Key

data that will be tracked for this proposal includes claims data for Rocky Mountain Health Plan

Medicare and Medicaid enrollees; a limited set of clinical data (aligned with the clinical data

collected for the purposes of SIM and CPC); Patient Activation Measure data; community

navigation data; and community-based organization data, to the extent available.


RMHP will work with state partners to integrate the following data: long-term services

and supports data used by the Single Entry Points and Community Centered Boards (through the

Benefits Utilization System) and data for those in foster care data (TRAILS system).

In addition to the client-level data, RMHP will track community health data shared by the

Colorado Department of Public Health and Environment.

Mitigating Risks for Data Sharing

With Quality Health Network as the central data hub, we are able to mitigate many of the

potential data-sharing risks. Quality Health Network has extensive experience with protecting

private health information, and matching and distributing data securely and effectively. In

addition, Quality Health Network has a relationship with many of the participating practices, and

will therefore be able to gain the trust and buy-in needed to expand the amount and type of data

transmitted.

Reporting Key Data

Each type of consortium partner—clinical sites, community-based organizations and

community navigators—will receive unique reports. These reports will be based on the data

housed in the AHCM data warehouse. The AHCM data warehouse will include all of the

community-based organization data (described in the Community-Based Organization section),

the data from the care coordination platforms, claims data, and any clinical data captured by the

health information exchange. Full chart of data flows can be found in the Implementation Plan.

• Clinical Sites: Advance Primary Care Medical Homes in the RMHP network currently

receive a monthly report for their attributed Medicaid and Medicare enrollees. Behavioral

health providers serving these clients do not technically have clients attributed to them, but


we can provide them with similar reports for all clients with whom they have had a recent

visit.

• Community-based organizations: Community-based organizations will receive two

monthly reports. First, they will receive a de-identified, population-based report that includes

the number of referrals to their organization and the characteristics of the population referred.

Second, they will receive an identified list of all clients receiving community navigation

services who have been referred to their organization, and who have signed releases to share

this information. This report will be generated out of the care coordination platform and will

support navigation and coordination.

• Community navigators: Each community navigator will receive a Case Management

Analysis tool that lists all of the clients associated with that navigator, along with the client’s

social needs, service utilization, primary care provider and risk score. The tool will also

report the success rate at achieving goals stated in the action plan.

• CMS reporting: CMS will receive the list of reports detailed in the work plan and FOA. In

addition, RMHP is happy to provide data in whatever frequency or format requested. A

robust evaluation of the Western Colorado AHCM is a goal shared by RMHP and we are

confident we can adapt our data collection or submission in order to support federal

monitoring and evaluation.

D-‐3. Gap Analysis

The Gap Analysis will be an annual qualitative and quantitative assessment of the

adequacy of community services to meet the health-related social needs of community-dwelling

beneficiaries. To develop the Gap Analysis, the Advisory Boards will first consider three


categories of data: (1) quantitative data, including AHCM data and other available data; (2)

qualitative data; and (3) community needs assessments. These data sources are detailed below.

Quantitative Data

The foundation of the Gap Analysis is a region-specific report based on the following

AHCM data: the prevalence of each social need based on the social needs screenings, the

referrals provided and the outcomes of those referrals (to the extent that that data is available).

That AHCM specific-data will be drawn from two sources: the screenings and the community

navigation data, which will be tracked in an approved/standardized care coordination platform.

AHCM model data will be augmented with the following data sources:

Table 7: Quantitative Data Sources Source Rocky Mountain Health Plan Claims Medicaid Claims Data Clinical Data – Quality Health Network Patient Activation Measure Data CDC Diabetes Interactive Atlas Colorado Behavioral Risk Factor Surveillance System USDA Food Environment Atlas, Map the Meal Gap Comprehensive Housing Affordability Strategy (CHAS) Colorado Child Health Survey Healthy Kids Colorado Survey

Qualitative Data

Using a community-based participatory research methodology, Western Colorado will

work with clients, community-based organizations, the consortium and CMS to develop a survey

or other mechanism to capture data on the experience and outcomes of community service

navigation. We are hoping to capture information about barriers, accuracy of the identified

resources, waiting lists for services, needs met and needs not met.


We will also provide a way for navigators and community-based organizations to share

observations on system barriers, frustrations and successes that they and their clients are

experiencing. We will use this qualitative data as part of the Gap Analysis.

Needs Assessments

To help them create the Gap Analysis and Quality Improvement Plan, the advisory

boards will receive the community health assessments completed by their local public health

agencies. They will also receive any community health needs assessments done by hospitals in

their region.

Each advisory board is responsible for reviewing the data provided and identifying

community gaps. The Community Lead will synthesize the advisory board’s analysis and

discussion into the Gap Analysis report. The Project Lead will then combine these community

Gap Analysis reports into one Western Colorado Gap Analysis report.

During the implementation phase a Gap Analysis report template will be developed and

reviewed by the advisory boards and consortium. This review is to agree upon a standard

template and measures that will be included in the report every year.

Bridge Organization Experience with Similar Efforts

RMHP has extensive experience in analyzing needs and gaps in regional services. RMHP

is a Regional Care Collaborative Organization for the Medicaid Accountable Care Collaborative,

and is responsible for maintaining information about social services to meet the non-medical

needs of clients. In this role, RMHP also notes gaps in these services. RMHP has worked with

both local public health agencies and local hospitals on community health needs assessments to

understand the needs and gaps in the community and how it can help address these gaps.


RMHP has experience assessing needs and gaps for medical practices through its work in

practice transformation, a community resource scaled as part of the Colorado Beacon

Consortium and through serving as regional learning faculty for the Comprehensive Primary

Care Initiative and the Colorado SIM. As with the AHCM Gap Analysis, practice transformation

requires us to meet practices where they are, note the gaps and create a plan to move forward

realistically. In addition, RMHP’s own organization is built on quality and continuous

improvement. Our Quality Improvement Program regularly monitors and assesses services for

gaps and creates plans to address those gaps.

RMHP has also participated in analyzing needs and gaps for projects that cross the health

services and social services sectors. We have worked with projects such as Region 11’s Health

Equity Advocacy Initiative, United Way’s Bridges Out of Poverty programs (Moffat and Routt

counties), the Prescription Drug Abuse Task Force have given RMHP experience with both the

challenges and rewards of working together to analyze gaps in community services. RMHP also

participated in the Institute for Healthcare Improvement’s Pathway to Pacesetter initiative, in

which they worked with other community leaders to improve the health and well-being of

people, and to identify and close equity gaps.

D-‐4. Quality Improvement Plan

Successful navigation in rural areas requires community building and mobilization to

create resources where few or none exist. The Quality Improvement Plan process is the

mechanism to ensure community accountability for health outcomes. By agreeing to submit a

proposal for the Accountable Communities Model, all of the regions of Western Colorado have


agreed to community accountability for the key drivers identified in the AHCM. This Quality

Improvement Plan process will be owned by each community through their Advisory Board.

Goal

Our ultimate aim, as detailed in our driver diagram, is to bend the healthcare cost curve

(reduce healthcare spending) and reduce the number of adults and children reporting fair or poor

health to less than 12 percent in all participating counties. Our primary drivers for achieving that

goal are increasing awareness of social needs and resources through screening and referral,

increasing use of social resources by providing assistance to clients through community

navigation, and increased community alignment.

The goal of the Quality Improvement Process is to create a clear process for communities

to identify and address gaps in process and services that inhibit individuals within the community

from having their basic needs met. Engaging in these structured conversations as a community

will strengthen community ties and further the ultimate goal of community alignment.

The Quality Improvement Plan Process will not address program adherence or quality of

AHCM administration. Program adherence and the quality of individual clinical providers,

community based organizations or community navigators will be addressed through ongoing

feedback processes between the bridge organization and each participating provider under the

oversight of the Consortium.

Measuring Success

The Western Colorado AHCM will measure program performance through a set of

measures capturing both the intervention population and the community at large. For the entire

screened population, we will implement measures of healthcare cost, health outcomes, social


determinants of health, patient engagement, and quality of healthcare. For the subset of that

population who receives community navigation, we will have additional data from our

coordination platform that will allow for additional social determinants of health measures. In

addition to these measures, we will measure overall impact of AHCM on the health of the

community through a number of population-based measures that cross health outcomes, social

determinants of health and health behavior domains. These measures are predominantly process

measures with a few outcomes measures—we hope to improve our methodology for capturing

health outcomes. We believe that improving the health of the most vulnerable communities will

generate changes that will improve the health of the entire community.

These metrics and their data sources are detailed in the Implementation Plan.

These measures align with other statewide and national initiatives, including the Colorado SIM

program, the Comprehensive Primary Care initiative (and the newly announced phase II,

Comprehensive Primary Care+), the Colorado Opportunity Project, the Accountable Care

Collaborative and Colorado Medicaid managed care measures.

Quality Process

The differences in terminology and experience with quality improvement within the

healthcare, social service and behavioral health fields necessitate the development of a shared

understanding of the terms, techniques and strategies. This quality improvement framework will

provide a platform for a conversation about community readiness that will be a thread throughout

the entire process. For the Advisory Board to be successful in engaging in quality improvement

projects, open conversations about necessary changes in culture and in relationships will be

necessary. Participants may have to set aside organizational interests and focus on the needs of

the community. Historic perceptions of potential solutions and options will likely need to


challenged. New pathways for communication will be necessary. This broad discussion about the

group’s readiness for change will prime the group for more specific conversations about

readiness for change within each identified quality improvement project. We will rely on the

Assessment Desire Knowledge Ability Reinforcement (Prosci® ADKAR® Model) model to

assess the group’s readiness and potential barriers to change.

The process of change will begin with the Advisory Board reviewing the gap data and

interpreting that data. The Community Leads and RMHP AHCM leads will use this process as an

opportunity to strengthen skills in data analysis and interpretation in all Advisory Board

Members. Ensuring that all organizations have internal data analysis and interpretation skills will

strengthen the community as a whole-organizations with data skills are better able to make data

driven improvements to programs, and will be better able to contribute data to enhance the

community’s overall knowledge of needs and gaps. Once the gap data is understood by the

Advisory Board it can begin to prioritize gaps and develop a quality improvement plan. Each gap

will likely have several associated quality goals. For example, a lack of adequate transportation

might require expanding programs to provide clients with bus passes or tokens so they can

access public transportation, coordinating with health systems or payers to expand transportation

services and fleet vehicles, working with the governmental entities on the adequacy of public

transportation, better communication between the non-emergent transportation services and

clinical providers to maximize that resource, and a separate strategy for individuals with

disabilities who need additional accessible transportation. Advisory Boards will be asked to

exclude from the list of prioritized quality goals any goal where there is already community

activity underway.


For each specific quality goal, a quality improvement team leader will be identified.

Quality improvement team leaders will be selected from the people who are closest to the

activity needing improvement or closest to the need that the activity is addressing. In addition to

the quality improvement team leader, other roles on the projects will be clearly defined. Tackling

large and systemic community issues such as shortages in affordable housing could quickly

become unwieldy or subsume those who volunteer to assist. Setting clear roles will allow

Advisory Board members to participate and engage within the bounds of their time and ability.

As leaders for this work, quality improvement team leaders will be responsible for

updating the board on the progress on their specific goal at each Advisory Board Meeting. The

Community Lead will be responsible for conveying that information to the Consortium. In

addition to the in-person updates, Community Leads will develop a system for updating the

Board in the interim that works best for that community. Those updates could be emails, an open

or closed website that contains information, a Facebook page or any methodology that would

work for the community.

Projects will entail a range of scopes and forms. Some projects may require support from

state partners and will be anticipated to take the entire duration of the pilot. Some projects will be

smaller and will be achievable in short periods of time.

For the smaller initiatives, such as those around process improvements for coordination

amongst the community, we will use the Plan, Do, Study, Act (PDSA) cycles, process mapping,

and basic data use to improve/develop and implement skills, processes and infrastructure to make

improvement. RMHP has extensive experience training community partners in these

methodologies to make measurable improvements and to enhance efficiency and efficacy of


business processes. RMHP can pair this methodology with other strategies such as LEAN to

improve the efficacy of processes and procedures.

For larger projects, where Plan Do Study Act may not be as effective, the Western

Colorado AHCM pilot will enhance community shared data and knowledge. We hypothesize that

an increase in data interpretation skills, data-driven decision making, and monitoring and

evaluation systems that produce more robust data will become a mutually reinforcing cycle. For

larger issues (e.g., housing shortages), we will rely on systems theory to map the interrelated

variables impacting the issue in order to determine a solution. Depending on the identified

problem, we may use a variety of different systems tools such as causal loop diagrams to map the

relationship between different elements of an issue or change management history mapping to

examine the history of an issue (thus hopefully illuminating potential future opportunities).

Experience with Similar Quality Improvement Efforts

RMHP has more than 35 years of experience partnering with community entities to

identify and fill gaps in healthcare in the community and achieve quality improvement results.

From its inception, RMHP worked with provider groups to collaboratively establish clinical

quality goals and link payment to achieving those goals, making Western Colorado notable for

being one of the lowest cost and highest quality Medicare Hospital Referral Regions (HRR) in

the nation (Dartmouth Atlas HRR #105)16. As one of 17 selected Beacon communities, RMHP

and its partners in the HHS/ONC Cooperative Agreement Program (Colorado Beacon

Consortium) filled identified gaps in community needs by building health information

technology infrastructure as well as equipping providers and their staff with the tools to complete

16 Gawande, Atul “The Cost Conundrum” The New Yorker, June 1, 2009. Retrieved at http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum on 3/28/16.


quality improvement cycles and generate population-based Clinical Quality Measures (CQM) to

drive their improvement efforts. An Advisory Board comprised of leaders from public health,

hospitals, medical and behavioral health, and consumers guided the Colorado Beacon Initiative.

The CBC resulted in 70% of eligible providers in the region attesting to Meaningful Use Stage 1

by mid-2013, more than 1,000 new providers joining with the HIE, and 93,000 lives in the newly

established population health registry – all indicators of sustainable infrastructure development.17

The Board has continued to meet as the Western Colorado Executive Committee. Its function is

to advise community-based efforts to improve care, including identifying, prioritizing and filling

gaps in community services to improve health in the region.

Currently, RMHP is a Colorado Medicaid Regional Care Coordination Organization

(RCCO) serving 22 urban and rural counties on the western slope and northern Colorado.

RMHPs care coordination model is community driven with regional oversight committees

comprised of medical and behavioral health providers as well as local public health departments

and community based organizations. The model supports members’ medical and non-medical

needs with an assessment that is inclusive of medical, behavioral health and social needs as well

as assessing barriers to care, including transportation, food instability and housing. Community

based care coordination teams provide care coordination to support individuals in accessing

community based services as well as health and behavioral health care. RMHP consistently has

the lowest Emergency Room utilization rates among the seven Medicaid ACC regions. For the

period of 12/2014-11/2015, RMHP is also ranked with the lowest, rates of 30-day readmissions,

and the total cost of care.

17 Colorado Beacon Consortium Final Report 2010-2013.

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