Accountable Health Communities

Group of people, diverse ages and ethnicities

The Denver Regional Council of Governments received a five-year award from the Centers for Medicare and Medicaid in the amount of $4.51 million in May  2017 to implement the Accountable Health Communities (AHC) model. The model seeks data to show connecting people with community-based services improves health outcomes and decreases health care costs.  The AHC will work with Medicare and Medicaid beneficiaries in Denver, Arapahoe, Adams, Douglas, Jefferson, and Broomfield counties.
The AHC program collaborated with five clinical partners who assessed their clients’ health-related social needs in the areas of living situation, transportation, food, utilities, and safety. Clients were eligible for navigation services through the DRCOG AHC if they had at least one of those needs and had at least two emergency room visits in the past 12 months. If they had needs in four or more areas they were referred to the DRCOG’s community resource navigators for more extensive assistance. Resource navigators connected people with community based-services to address their needs in the manner they prefer.
Over the course of the grant, DRCOG collected data and engaged in a quality improvement plan to streamline and improve the process for screening and referring people from clinical settings to community settings, integrate and align clinical and community health providers, and improved understanding of the value and impact of community services on healthcare costs and health outcomes. This data was used to identify areas where gaps existed creating barriers to efficient access to community-based services. The AHC will continue its work beyond the initial grant period to increase funding for community-based services and foster healthy communities in the Denver region. 


People holding hands


AHC e-Campaign

In Nov. 2020, the Denver Regional AHC launched an e-campaign project in partnership with Denver Health that sought to reach Medicare and Medicaid beneficiaries through email. Patients receive the AHC social determinants of health screening virtually, then the AHC team reviews the responses and reaches out to those with needs.

The e-campaign allowed the Denver Regional AHC to access a larger and more diverse population of patients. At of the end of March, the e-campaign had screened over 1,400 individuals. Of those who completed the online questionnaire, approximately 75% reported at least one need, and around 15% are eligible for navigation services, compared to 10% consortium-wide. Additionally, the e-campaign is beginning to reach out to Arabic speakers, as well as individuals who speak Amharic, Kunama and Tigrinya.

AHC Workgroups

In the fourth year, the Denver Regional AHC’s community-level quality improvement plan operated through health-related social needs (HRSN) workgroups. The four workgroups wrapped up their year-long efforts at the end of March 2021.

  • The Safety Workgroup developed a Domestic Violence and Medical Reporting Options Training and a Trauma-Informed Care (TIC) Training curriculum for navigators and licensed providers. Access these valuable free domestic violence training resources here.
  • The Food Security Workgroup conducted an environmental scan to begin developing plans to pilot a co-location service model in the form of an on-site food pantry. The project is still being developed.
  • The Utilities Workgroup authored a “Low Income Energy Assistance Program (LEAP) and Energy Outreach Colorado (EOC) Quick Guide” to assist community-facing staff help clients apply for utility assistance programs. Access the quick guide here.
  • The Housing Security and Quality Workgroup created a “Quick Guide to Colorado’s 2019 Implied Warranty of Habitability Law” to assist navigation staff when working with clients experiencing housing quality issues. It can be viewed here.

The Denver Regional AHC team would like to thank Margaret Franckhauser, Megan Hiltner, and Panos Smyrnios of John Snow, Inc. (JSI) for their tremendous work over the last year through facilitation of the workgroups.

AHC Success Story: Sandra *

When she was diagnosed with COVID-19, Sandra, who has auditory issues, didn’t know where to turn for help. She completed the AHC screening tool online and was contacted by her e-campaign navigator. Sandra told her navigator that she was unable to leave the house to get food and was short on funds to pay for rent. The e-campaign navigator sent a referral to Brothers Redevelopment where she was added to a waitlist, and in fewer than three weeks, Sandra was able to obtain rent assistance. While Sandra was quarantining, her navigator had food boxes delivered to her door through Benefits in Action and also helped Sandra obtain an e-gift card to King Soopers through Amp the Cause. These were all delivered to her home. Thanks to her e-campaign navigator, Sandra is now fully recovered from COVID-19 and her food and housing needs have been met.

* The names and personal identifying information of these individuals were changed to protect privacy.

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