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. 
Families attending the Accountable Health Communities Food Fair sign up for resources On Aug. 26, DRCOG’s Accountable Health Community (AHC) Food Security Workgroup held a Food Resource Fair to connect people experiencing food insecurity with the resources they need. The event was held at STRIDE North Aurora Family Health Services and brought together a diverse group of community partners including Food Bank of the Rockies, Volunteers of America, Jewish Family Services, Hunger Free Colorado, Tri-County Health Department, STRIDE and DRCOG. Attendees could take home fresh and canned food, and had a chance to talk to experts about health and nutrition education and supplemental programs like Meals on Wheels, WIC and SNAP. 
AJ Diamontopoulos presents at a roundtable discussion on population health improvement The National Academies of Sciences, Engineering and Medicine held a one-day public workshop on Sept. 19 to discuss the growing field of health care delivery in the context of outcomes for various social groups, and the ways in which health care delivery correlates with socioeconomic status. DRCOG employee, AJ Diamontopoulos, Manager for the Denver Regional Accountable Health Community, joined a panel to discuss the AHC model of integrated clinical and human service organization partnerships.
Food pantry client opens up to staff about grief and loss

Susan* had been visiting the Jewish Family Service (JFS) food pantry for a few months when she became comfortable opening up to JFS staff. According to a staff member, Susan “disclosed that her spouse had passed away within the last year and the food pantry had been a big help to her during her grief. She said that the pantry was a welcoming place for her to be in a social environment without having to discuss her pain and to be able to interact with others rather than isolate. According to Susan, the pantry helped her heal and reconnect with the world around her.” If you or someone you know is struggling with food insecurity, help is out there.

AHC navigator assists client in finding a more affordable living situation

When Charles*, a 70 year-old living the mountains, struggled to pay his high utility premiums, he turned to the AHC navigator he met in the emergency room for help. In just a few weeks, Charles was connected to Brothers Redevelopment and added to multiple waitlists for affordable housing. According to his navigator, Charles “is in a more sustainable and affordable living situation with lower utility costs, greater access to food and transportation to support his overall health.”

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