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 collaborates with five clinical partners who assess their clients’ health-related social needs in the areas of living situation, transportation, food, utilities, and safety. Clients are eligible for navigation services through the DRCOG AHC if they have at least one of these needs and have had at least two emergency room visits in the past 12 months. If they have needs in four or more areas they are referred to the DRCOG’s community resource navigators for more extensive assistance.  Resource navigators connect people with community based-services to address their needs in the manner they prefer.
 
Over the course of the grant, DRCOG will collect data and engage 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 improve understanding of the value and impact of community services on healthcare costs and health outcomes.  This data will also be used to identify areas where gaps exist that create 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. 
 

Food fair participants choose food to take home

 

Food Resource Fair

After an initial successful event in August, the Denver Regional AHC Food Security Workgroup held its second food resource fair in February, 2020, hosted by STRIDE Community Health Center in Wheat Ridge. Critical support was provided by Volunteers of America, Hunger Free Colorado, Food Bank of the Rockies, Jefferson County WIC/Jefferson County Food Policy Council, PASCO and DRCOG. Like the first food resource fair, attendees were invited to take home a variety of fresh and shelf-stable goods. They also learned how to access the region's health and nutrition resources.

Despite the chilly weather, many people attended the event. Over 107 households and more than 440 individuals (including 177 children) were served!

Woman typing on laptop

COVID-19 and Food Insecurity

Since mid-March, when Colorado's stay-at-home order went into effect, the DRCOG Accountable Health Communities team has been teleworking. We're supporting our clinical and community partners on the front lines by developing workflows to continue performing health-related social needs screenings remotely. COVID-19 has increased the need of food-insecure individuals and their families and we're working hard to come up with strategies to connect these populations with navigators who serve the region. 

Despite daily capacity challenges, navigators are finding ways to connect people with resources, even going the extra mile to find food for pets- sometimes someone's only companion during stay-at-home orders. The DRCOG AHC project team is working with other AHC bridge organizations across the country to learn from and support each other during the COVID-19 public health crisis.

Chairs in hospital waiting room

AHC Success Story: Leslie *

When Leslie and her mother visited the emergency department at Denver Health, the navigator who met them was concerned about Leslie's declining physical abilities. 

"I directed them to speak with the social worker at Leslie's primary doctor's office, who helped her arrange home health. I also got Leslie on the waiting list for Project Angel Heart due to her poor diet and physical difficulties preparing food," the navigator said.

A few weeks later, when threatened with eviction, Leslie's navigator connected her with Brothers Redevelopment to obtain information on low-income housing. Leslie's mother recently reached out to the navigator, reporting she is grateful for the services provided by AHC, and that she feels renewed hope for her daughters' future.

Shelf-stable foods on a table at food fair

AHC Success Story: Bob*

Bob, who is in his 50s, lives alone and has minimal family support. He was approved for social security disability benefits when he first met with an AHC navigator at the emergency department at Denver Health, but needed a hand from his navigator.

"His health was poor due to [his] being unable to afford food that would help him control his diabetes," his navigator explained. "I provided Bob with contact information for Hunger Free Colorado, which helped him apply for SNAP."

Bob was also connected with Project Angel Heart, and with the help of his navigator, his application was expedited so that he received his first meal delivery within two weeks.

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

Please email us at AHC@drcog.org with any questions or feedback.