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. 
 

Workers collaborate on project

 

AHC Workgroup Update (July, 2020)

The Denver Regional Accountable Health Community’s community-level quality improvement plan operates through health-related social need (HRSN) workgroups. DRCOG coordinates each workgroup to prioritize a specific accessibility gap in community-based services to then develop a targeted, timely and scalable project to make services easier to access. Workgroups launched in March 2020 and will sunset a year after that. See an update of their progress:

Food Security Workgroup: The workgroup is connecting with a local clinic to pilot a co-location service model. People coming to the clinic for medical care who have food security needs can access food resources from a local food bank. This service model reduces transportation barriers for people in need, supporting their nutrition and overall health.

Housing Security and Quality Workgroup: Focused on increasing awareness of tenant rights and resources on housing habitability this workgroup will develop a guide for navigators explaining Colorado’s 2019 Residential Tenant Health and Safety Act and resources to refer to for help when individuals and families experience health and habitability concerns such as mold.

Safety Workgroup: Comprised of clinical, community-based and advocacy professionals with experience in the state's domestic violence medical reporting options and trauma-informed care, the workgroup will create an enhanced training program educating licensed providers and navigators on medical reporting options for domestic violence survivors and champion trauma-informed care so people are better equipped to address domestic violence and safety-related issues.

Utilities Workgroup: The Utilities Workgroup aims to improve access to the Low-Income Energy and Assistance Program (LEAP) and Energy Outreach Colorado (EOC) utility bill payment assistance program by creating a tool to better outline how to qualify and apply to each of these programs. The tool is meant to lessen confusion, reduce administrative follow-up due to incomplete applications, increase correctly completed applications, and ultimately increase delivery of the much-needed assistance.

AHC Success Story: Rita*

When Rita met her AHC navigator in December, she and her daughter had just gotten a Section 8 housing voucher after having lived in transitional housing the last three years. Because of an outstanding bill, Rita was worried she'd run into challenges getting electricity at her new apartment, but with help from her navigator, she was able to secure assistance from Energy Outreach Colorado to cover the balance. Rita's navigator also contacted the Assistance League of Denver to set up Rita with the free wheelchair she needed to help her manage the symptoms of a chronic lung condition. 

Woman holds older adult's hand

AHC Success Story: Laura*

While Laura, a single woman living alone who was just diagnosed with breast cancer, waited for an update on her Social Security Disability Income application, her AHC navigator suggested she talk to Benefits in Action. They told her about the Aid to the Needy and Disabled cash benefit, and her navigator gave her a direct referral to Hunger Free Colorado for information on SNAP. Now Laura feels much more hopeful for the future as she begins her radiation treatments.

* 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.