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. 
 

People holding hands

 

AHC on CBS Denver

Christine Manikowski, an AHC navigator working in the Denver Health Emergency Department, was interviewed this summer about the AHC’s work with Denver Health. Watch the segment to find out more about how the partnership between clinical and community partners and navigators, like Christine, assist individuals across the Denver region.

AHC on No Copay Radio

Ruth Ellen Tubbs, an AHC navigator working in the Denver Health Emergency Department, joined No Copay Radio in September for a segment discussing what it means to be a health navigator. Hear what she had to say here.

Woman holds older adult's hand

Update on Via Mobility

In July, Seniors’ Resource Center transferred its role as the region’s older adult transportation provider to Via Mobility. Via Mobility is working hard to meet the transportation needs of our region’s older adults. For more information on Via and other transportation resources in the Denver metro area, call the DRCOG Area Agency on Aging Information & Assistance line at 303-480-6700.

AHC Success Story: Mary *

As a single mother to four children and a baby on the way, Mary needed assistance with a high utility bill. Her household Xcel bill was over $1,000, and Mary was only able to save $400 and needed assistance with the remainder. She was able to turn to her navigator who helped get her in contact with the Salvation Army’s Energy Outreach Colorado (EOC) bill payment assistance program. Within a few days, the Salvation Army helped her pay off the bill just in time for her to give birth to her baby. Now Mary can focus on caring for her newborn and will not have to worry about how her family will keep the electricity on.

* 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.