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. 

AJ at a conference


The Center for Medicare and Medicaid Innovation convened the 2nd national summit of Accountable Health Communities on November 12-13, 2019. Bridge organizations representing their local AHC’s came together with the theme of “Partnering for Impact”. AJ Diamontopoulos and Kirsti Klaverkamp attended on behalf of DRCOG. Attendees discussed quality improvement strategy and activities, focusing on how to better engage and address community members’ health-related social needs, how to enhance clinical and community partnerships and address gaps and barriers to community-based resources. Public health leaders from across the country moderated sessions and encouraged the future work and sustainability of the Accountable Health Communities. In this photo, AJ Diamontopoulos speaks with Katherine Verlander and Natalia Barolin from the Centers for Medicare and Medcaid Services, and Ben Miladin from United Way of Greater Cleveland.

Young hands holding older person's hands

DRCOG’s Accountable Health Community (AHC) is excited to begin 2020 with the addition of several new partners. Two Denver Health Emergency Department Navigators joined the team in the fall, and staff from Tri-County Health Department are going through program orientation in January. Hunger Free Colorado will also be participating in the AHC as a community partner providing food resources to individuals and families.

Child embraces her mother outdoors

There are a lot of myths surrounding safety net programs for people experiencing food insecurity. In the video “Food Stamps, Hunger, and How Nutrition Assistance Works,” Healthcare Triage examines how the Supplemental Nutrition Assistance Program (SNAP or “food stamps”) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) work and how they affect overall health and well-being for millions of American adults and children. Learn more by watching this video.

Affectionate young woman holds older woman around shoulders

Jana* was visiting the Denver Health Pediatric Emergency Department after an accident when she and her mother met with two AHC navigators who referred them to Jewish Family Services. Through this community partner, Jana and her mom not only received enough food for their household, but they also obtained help with their electric bill and were even given holiday presents for Jana’s two younger siblings. According to Jana’s navigators, “by identifying Jana’s family’s needs when she were seen in the emergency department, Jana and her family are in a more secure situation with better food security and lower utility costs to better support their overall health.”

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

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