HOSPITAL TRANSFORMATION PROGRAM …...Hospital Name: UCHealth Grandview Hospital Hospital Medicaid...

The Colorado Healthcare Affordability and Sustainability Enterprise (CHASE) is a government-owned business within the Department of Health Care Policy and Financing.

www.colorado.gov/hcpf

HOSPITAL TRANSFORMATION PROGRAM COMMUNITY AND HEALTH NEIGHBORHOOD ENGAGEMENT

MIDPOINT REPORT

Table of Contents

I. Instructions and Timeline .................................................................................. 2

II. Contact Information .......................................................................................... 3

III. Engagement Update .......................................................................................... 4

IV. Environmental Scan Findings ..........................................................................15

V. Planned Future Engagement Activities ............................................................48

VI. Additional Information (Optional) ...................................................................49

Appendix I: Community Inventory Tool .................................................................50

Appendix II: Hospital Care Transitions Activities Inventory Tool ............................57

CO HTP CHNE Midpoint Report of 59



Instructions and Timeline

Via the Midpoint Report, program participants will report on Community and Health Neighborhood Engagement (CHNE) work over the first half of the pre-waiver process. Specifically, hospitals will use this report to update the State regarding efforts to engage community partners in completing an evidence-based environmental scan to identify community needs and resources and the hospital’s plans going forward.

The State will be reviewing Midpoint Reports to ensure:

• The process has been adequately inclusive of organizations that serve and represent the broad interests of the community and that no key stakeholders are excluded;

• A diverse and regular enough range of venues, locations, times and manners for engagement are being provided to allow for a meaningful opportunity for participation;

• Needed adjustments were made to the Action Plan and any divergence from the Action Plan is justified;

• The environmental scan assessment is complete, sufficiently detailed, and evidence-based, and was informed by community input; and

• Over the remainder of the pre-waiver CHNE process, community organizations will have meaningful opportunities to inform the hospital’s planning of its Hospital Transformation Program (HTP) participation.

Please note that the word limits included are guidelines. You may exceed them as necessary to fully respond to the question or information request.

Midpoint Reports must be submitted in .pdf form with all supporting documentation included in one document via e-mail by April 19, 2019 at 5pm to the Colorado HTP email address [email protected]. Reports received after this deadline will not be considered.

Following the submission date, the State will review the reports. The reports will not be scored; however, the State will work collaboratively with participants to seek clarifications as needed and to ensure that there is agreement between the hospital and the State as to the plan for the remainder of the process, including plans to address any needed changes to the hospital’s CHNE process based on the review of the Midpoint Report.

mailto:[email protected]




Contact Information

Please provide the legal name and Medicaid ID for the hospital for which this Midpoint Report is being submitted.

Hospital Name: UCHealth Grandview Hospital

Hospital Medicaid ID Number:

Please provide any updates to the hospital address as well as to the names, titles, addresses and contact information for the hospital executive with signatory authority to whom official correspondence should be addressed and for the primary and secondary points of contact if that information has changed since submitting your CHNE Action Plan. If this information has not changed, this section can be left blank.

Hospital Address: 5623 Pulpit Peak View, Colorado Springs, CO 80918-3954

Hospital Executive Name: Doreen Hartmann

Hospital Executive Title: Chief Financial Officer

Hospital Executive Address: 1400 E Boulder St, Colorado Springs CO 80909-5533

Hospital Executive Phone number: 719-365-2062

Hospital Executive Email Address: [email protected]

Primary Contact Name: Roberta Capp

Primary Contact Title: Medical Director Care Transitions

Primary Contact Address: 12401 E 17 th Ave, Aurora CO 80045

Primary Contact Phone Number: 720-848-4398

Primary Contact Email Address: [email protected]

Secondary Contact Name: Kellee Beckworth

Secondary Contact Title: Sr. Project Manager

Secondary Contact Address: 12401 E 17 th Ave, Aurora CO 80045

Secondary Contact Phone Number: 720-848-6525

Secondary Contact Email Address: [email protected]




Engagement Update

III.a. Please respond to the following questions to provide us with an update of the hospital’s engagement activities. Please note that the word limits are guidelines. You may exceed them as necessary to fully respond to the question or information request.

Please use the following grid to provide a list of external organizations that the hospital has engaged, including the organizational contact, the type of organization, and the organization-specific engagement activities undertaken with this organization. Please also note any specific connection of the organization to HTP priority populations and / or project topics.

Organization Name Organizational Contact Organization Type Engagement

Activity

Connection to any specific HTP priority populations and / or project topics, as applicable

Vivage Heather Terhark

LTSS Partnership All

Union Printers Jill Hess-Campbell

LTSS Partnership Vulnerable Populations/Behavioral Health

Peak Vista Louie Larimer FQHC Partnership All AspenPointe Tyler Carpenter Mental Health

Center Partnership Behavioral Health

El Paso County Public Health

Mina Liebert LPHA Partnership All

RISE Southeast Colorado Springs

Joyce Salazar Health Alliance Involvement Social Determinants of Health

Silver Key Dayton Romero LTSS Partnership Vulnerable Populations Pikes Peak CHP Aimee Cox Consumer

Advocates/Advocacy Organizations

Involvement Vulnerable Populations (Homeless)

Mission Medical Kate Sweeney PCMP Partnership Vulnerable Populations CHA Opioid Summit Ashley Baker Consumer

Advocates/Advocacy Organizations

Involvement Behavioral Health

Child Fatality Meeting

Coroner's Office-Child Fatality

Mental Health Center


El Paso County HCC Mina Liebert LPHA Consultation SUD/Vulnerable Populations/High Utilizers

Senior Ethics Chair LTSS Involvement High Utilizers/Vulnerable Populations Interagency Coalition

Chair Community organization addressing social determinants of health


Peak View Behavioral Health

CEO Mental Health Center


Crossroads Detox Manager Mental Health Center






Activity


Community Justice Center (CJC) - County Jail

Director of Behavioral Health

Community organization addressing social determinants of health


Behavioral Health Criminal Justice Community Committee

County Department of Public Health

LPHA Involvement Behavioral Health

Colorado Zero Suicide Learning Collaborative

State Department of Public Health


NAMI Colorado Springs

Executive Director

Health Alliance Involvement Behavioral Health

Colorado Springs Firearm Think Tank

Assistant Dean Community organization addressing social determinants of health


El Paso County Youth Suicide Prevention Committee Data Committee



El Paso County Youth Suicide Prevention Committee



Behavioral Health Control Committee

Fire Department Lt.



El Paso County Sheriff's Office Co-Responder Meeting

Co-Responder Program Manager


Partnership Behavioral Health

CCHA

Amy Yutzy RAE Partnership All

Opioid Coalition (CPAR)

Community Health Partnership



Colorado Prevention Alliance

Lauren Ambrozic

Health Alliance Involvement Vulnerable Populations (Social Determinants of Health)

CAREs Fire Department


Involvement High Utilizers





Activity


CU Medicine- Colorado Springs

Erik Wallace Community organization addressing social determinants of health

Partnership Behavioral Health/High Utilizers/Vulnerable Populations

CCHA/Regional Program Improvement Advisory committee

Cara Herbert/Amy Yutzy

LPHA Partnership Vulnerable Populations

Pikes Peak YMCA Gloria Winters Consumer Advocates/Advocacy Organizations

Involvement All

The Resource Exchange

Camille Blakely Consumer Advocates/Advocacy Organizations

Involvement All

Colorado Health Literacy Coalition

Dana Abbey, Angela Brega


Partnership Social Determinants of Health

Colorado Health & Human Services, Refugee Department

Carol Tumaylle Community organization addressing social determinants of health

Partnership Refugee Population

Agency/Organization Acronyms: Regional Accountable Entity (RAE); Local Public Health Agency (LPHA); Primary Care Medical Home (PCMH); Community Mental Health Center (CMHC); Social Determinants of Health (SDOH); Emergency Services Transport (EMT); Deparment of Health and Human Services (DHHS); Colorado Department of Public Health Environment (CDPHE); Regional Health Connector (RHC); Office of Behavioral Health (OBH); Colorado Hospital Association (CHA); Area Agency on Aging (AAA); Adult Protective Services (APS); Long Term Supportive Services (LTSS); Colorado Health Partnership (CHP); Federally Qualified Health Center (FQHC); National Alliance on Mental Illness (NAMI); Health Care Collaborative (HCC); Resilient, Inspire, Strong, Engaged (RISE).

Please use the following grid to provide a list of engagement activities, (e.g. workgroups, committees, meetings, discussion groups, public forums, etc.) that the hospital has undertaken, including the locations and manners for participation (e.g. in-person, by phone, in writing, etc; please also indicate if the participants facilitated or provided data analysis), frequency of the activity, the partners included, how notice was provided, and the key deliverables for each activity (e.g. action items, high-level decisions, documents drafted / finalized, data reports, etc).

Engagement Activity

Location and Manners for Participation

Frequency of Activity

Partners Included

How Activity Was Noticed Key Deliverables

Partnership UCHealth/in-person

X1 Hospital (UCHealth), Vivage (LTSS)

email Discussed challenges related to care transitions and LTSS for Medicaid clients




Partnership Union Printers, CO/In person

x1 Union Printers (LTSS), hospital (UCHA)

E-mail Discussed challenges related to care transitions and LTSS for Medicaid clients

Partnership Peak Vista/UCHealth

Monthly (x3)

Peak Vista (FQHC) and UCHealth (hospital)

E-mail Discuss HTP mid-term report, data needs and ongoing common interests

Partnership In-person/Aspen Pointe

X1 Aspen Pointe (CMHC) and UCHealth (hospital)


Partnership In person Monthly (x3)

Hospitals: UCHealth, Centura; El Paso County Public Health Department (LPHA), Aspen Pointe (CMHC), Peak Vista (FQHC)


Involvement In person x1 Hospitals: UCHealth, Centura, El Paso County Public Health Dept (LPHA)

E-mail Discussed HTP, CHNA, and overview of RISE and their goals and action plans in the community.

Partnership In person X2 UCHealth, APS, AAA

E-mail meals on wheels, case management, housing for seniors/homeless seniors, elder abuse emergency housing, advocating

Involvement Phone X2 UCHealth and Pikes Peak CHP (SDOH CBO)


Partnership In person Quarterly UCHealth & Mission Medical

E-mail Provide PCP for underinsured working poor, advocate

Involvement In person x1 Hospitals, OBH, CMHC, PCMH, FQHC, RAE, CDPHE, CHA, advocates

Public Announcement

Discuss ED MAT program, discussed HTP, made connections with community organizations and obtained key contacts from OBH.

Involvement In person Monthly (x3)

Reviews mortality cases, members of the community school district, DHS, law enforcement, local public agency

E-mail Discuss cases - the youth suicide prevention committee workgroup because several cases were 2/2 suicide.




Consultation In person X2 Over 60 community representatives. Introduction of HTP.

E-mail Discussed HTP and introduced interview questions. Organization needed feedback from colleagues to fully answer all questions. Returned completed questionnaire.

Involvement In person Monthly UCHealth, Penrose, Long Term Care Facilities, Peak View Behavioral, Coached by county ombudsman and state ombudsman comes down from Denver, law enforcement (Detective in charge of elder abuse), Teller county representative, criminal justice system (SW)

E-mail Meeting to have community collaboration of care of geriatric patients and geriatric patients with behavioral health issues. How to utilize hospitals correctly


Memorial, Psych hospitals, Air force representative, Aspen Pointe, Ft. Carson Behavioral Health Chief and staff

E-mail BH meeting to discuss how the community works with the military. Ensuring that hospitals follow protocols.

Involvement In person Quarterly (x2)

Memorial Hospital and Peak View Behavioral Health

E-mail and direct phone conversation

Memorial has a contract with Peak View to provide care by case rate to unfunded patients at Memorial who meet criteria for M-1 holds and need acute psychiatric care. The meeting is to collaborate on care of BH patients between both facilities

Involvement In person Variable Memorial, Psych hospitals, CSPD, EPSO, CARES Program, CCHA, Aspen Pointe, Fire Department

e-mail Community Detox was closed to relocate and meeting was to review admission criteria and how community stakeholders will work with Crossroads.




Involvement In person Variable Memorial Hospital, Cedar Springs, CJC

E-mail and direct phone conversation

Memorial working to partner with CJC behavioral health regarding high utilizers of service in the community, ED, psych hospitals and reoffending back to CJC.


Aspen Pointe, Memorial, law enforcement, county representatives, county jail.

E-mail Discuss correspondent model. Committee doing a behavioral health summit on March 20th. Correspondent data. Review data for Co-Responder Program

Involvement By Skype Business Solutions

Monthly (x3)

State Department of Public Health, Memorial Hospital, and state wide agencies working in the field of behavioral health

E-mail Meeting to review what different agencies are doing related to use of the Zero Suicide Model for prevention of suicide. Review state data on suicide rates.


Memorial, Penrose, Aspen Pointe, Peak View Behavioral Health, Community Attorney's, and other community members

E-Mail Board Meeting, organization which provides free educational programs and support to families and patients experiencing mental illness.

Involvement In person Monthly (X3)

Memorial, Penrose, Children's Hospital, Psych Hospitals, Community citizens, School of Medicine students, law enforcement

E-mail Collaborate with community stakeholders and partners coming together to discuss statistics and problem solve ideas for community action change.




Involvement In person Every other month (x2)

Memorial, El Paso County Public Health, representatives from most agencies providing behavioral health services in the county, Teller County agencies, suicide prevention organizations, schools, faith based organizations, parents, and community members.

E-mail The subcommittee meets to review community partnership to improve sharing of data between organizations and find a solution for development of a system to capture accurate data related to behavioral health, suicide attempts and suicidal ideation.


Memorial, El Paso County Public Health, representatives from most agencies providing behavioral health services in the county, Teller County agencies, suicide prevention organizations, schools, faith based organizations, parents, and community members.

E-mail Discuss interventions to prevent suicide. Minutes from this meeting.


Memorial, Psych hospitals, CSPD, EPSO, CARES Program, CCHA, Aspen Pointe, Fire Department, CRT, Crossroads Detox

E-mail Advisory board of community stakeholders who oversee the CRT and Co-responder Programs providing input of improvement needed for services, review data and trends, as well as keep agencies updated on any community changes of services.





Memorial, Psych hospitals, CSPD, EPSO, CARES Program, CCHA, Aspen Pointe, Fire Department, CRT, Crossroads Detox

E-mail Advisory board of community stakeholders who oversee the CRT and Co-responder Programs providing input of improvement needed for services, review data and trends, as well as keep agencies updated on any community changes of services.

Partnership In person x1 Introduction to RAE- behavioral health programs, ways to improve BH care transitions

E-mail Share care coordination call, develop next steps, case reviews for UM denials, understand BHO metric related to ED follow up and how we can collaborate on next steps.

Involvement In person Bimonthly (x2)

Fire department, hospitals, Aspen Pointe, Psych hospital, Peak Vista, Law Enforcement

E-mail Review cases for high utilizer patients

Involvement CIVHC Board Room/In person

x1 Health Systems, Payers, CDPHE, CCMU

E-mail SDOH white paper put together by CPA; RWJ work on community capacity was presented: https://www.rwjf.org/en/our-focus-areas.html. The group will no longer be meeting again.

Consultation In person x1 CU Medicine (SOM); UCHealth

E-mail Discussed HTP and student involvement

Involvement Phone x1 CCHA, UCHA, DentaQuest,

E-mail PIAC meeting: discussed prioritization of RAE community funds processes. Discussed voting member guidelines.

Consultation In person x1 YMCA, Centura, UCHealth

E-mail Discussed HTP and collaborations. Completed questionnaire for HTP mid-term report.

Consultation In person x1 Resource Exchange, Centura, UCHealth

E-mail Discussed HTP and collaborations. Completed questionnaire for HTP mid-term report.

Partnership Phone x1 Colorado Health Literacy Coalition and UCHealth

E-mail Capture the health literacy rates by county and discussed partnership opportunities.




Partnership Phone x1 Colorado Health & Human Services, Refugee Department and UCHealth

E-mail Discuss refugee populations and needs




III.b. Please respond to the following questions to tell us about your experiences of executing your Action Plan, including the challenges you have faced and how, if at all, you have had to adjust in light of those challenges.

1. Please use the space below to describe:

• Any organizations that you expected to engage but were unable to or that are no longer engaged and your understanding of why; and

• How you have attempted to address these gaps in engagement

Response (Please seek to limit your response to 500 words or less)

The application stated hospitals needed to contact the RETAC. We met with people from the RETAC. But we found that working with the fire department or local EMS agencies was the best approach. They were actively working on high utilizers or providing community paramedicine service. This helped us gather details we needed for the mid-term report. It will also help us work with them in the future.

The El Paso Public Health Department set up meetings with the 10 groups that hospitals needed to work with as stated in the Action Plan. While all hospitals in the area worked together to gather facts for the mid-term report, UCHealth also used other ongoing meetings to add to the mid-term report.

2. Please use the space below to describe any challenges you faced in implementing planned activities as described in the Action Plan and the cause of the challenges.


The biggest challenge with carrying out the action plan activities was linked to the amount of time between Action Plans and Midpoint Reports. The state stressed using ongoing meetings as a way to have talks about gathering data and information needed for this report.

But, since many community groups meet each quarter and hospitals were given 3 months to do the Midpoint report activities, this was a challenge. Also, hospitals did not want these groups to become tired of answering questions and coming to meetings that were all very much the same. Working with hospitals in one area to gather the same group of stakeholders was challenging.

3. Please use the space below to describe any divergences from your final Action Plan made in order to successfully conduct your Community and Health Neighborhood Engagement, including those made to address the challenges described above.


1. We met with all stakeholders listed in our Action Plan. We went to larger community meetings to get feedback from many stakeholders when we could. We were part of meetings and partnerships that are in place right now between UCHealth and community groups.

This scan includes insights from community partners and stakeholders representing all HTP priority populations and identified in the community health needs engagement guidebook. Most




of the challenges we had were linked to getting details needed for the Midpoint report and turning talks towards doing the needs assessment and environmental scan. This was the case in the El Paso community because many groups have done a needs assessment and have been working on an implementation plan.

The Midpoint report phase was an information gathering stage, and the Hospital Transformation Program does not have more money to pay for this phase. In spite of this, community groups often gave solutions but still asked hospitals to help pay for issues that were found.




Environmental Scan Findings

Please see Appendices I and II for checklists that may be useful in responding to these questions.

Please note that the word limits are guidelines. You may exceed them as necessary to fully respond to the question or information request.

IV.a. Please use the space below to describe how the hospital has defined the community (based on input received).


The hospital defined the community based on its setting and the zip code of citizens that use the hospital system. For UCHealth Grandview Hospital, most of its hospital users lived in El Paso County.

IV.b. Please use the space below to identify the sources and information used to identify community health needs and service levels available including specific to the HTP priority populations and project topics.


We did many surveys and interviews with community groups. By being part of ongoing community meetings we could ask for needed facts. We also reviewed public records that contained points about the broad population of the area. We want to thank all of our partners for setting up groups of community stakeholders and sharing data with us.

Also, we developed an internal UCHealth data workgroup to review our internal electronic health record data. We teamed up with the Regional Accountable Entity (RAE) and got data linked to the Medicaid population. The Health Policy and Finance (HCPF) Center also gave hospitals data on Medicaid members that used the hospital identified in this application. All data had any proof of who the members were taken off.

References:

[1] http://www.countyhealthrankings.org/app/colorado/2019/rankings/el-paso/county/outcomes/overall/snapshot

[2]https://datacdphe.opendata.arcgis.com/datasets/5878e60d6a714c5395fd934ec7f864e9_2

[3] https://www.migrationpolicy.org/programs/data-hub/charts/us-immigrant-population-state-and-county

[4]https://www.elpasocountyhealth.org/sites/default/files/CHA%20Report%202017.pdf

[5] http://healthliteracymap.unc.edu/




[6]https://www.colorado.gov/pacific/sites/default/files/El%20Paso%20County%20Fact%20Sheet_0.pdf

[7] Health Care Policy and Finance, Hospital Transformation Program Data Source

[8] https://www.macpac.gov/wp-content/uploads/2018/11/Pregnant-Women-and-Medicaid.pdf

[9] https://www.macpac.gov/wp-content/uploads/2015/06/Behavioral-Health-in-the-Medicaid-Program%E2%80%94People-Use-and-Expenditures.pdf

[10] https://www.cdc.gov/ncbddd/disabilityandhealth/impacts/colorado.html

[11] https://www.cdc.gov/nchs/pressroom/states/colorado/colorado.htm

[12] http://www.rmpbs.org/blogs/news/cliff-effect-rachel-contizano/

[13] https://www.coloradohealthinstitute.org/research/suicides-colorado-reach-all-time-high

[14]https://www.samhsa.gov/data/sites/default/files/2015_Colorado_BHBarometer.pdf[15] https://www.worldlifeexpectancy.com/usa/colorado-chronic-lung-disease

[16] https://drive.google.com/file/d/1yAFojMgrxRlAfTbNNrI5Mfv3AxUhTHSS/view

[17] https://public.tableau.com/profile/omni#!/vizhome/RXConsortiumdashboard/Readmefirst

[18] https://www.colorado.gov/pacific/cdphe/colorado-health-indicators

[19] Peak Vista CHNA

[20] https://coloradosprings.gov/fire-department/page/community-and-public-health-cares#cares

[21] https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator

[22] https://www.coloradohealthinstitute.org/data

IV.c. Please use the space below to describe any data gaps encountered while conducting the environmental scan, and how these were accounted for.


We did many surveys and interviews with community groups. By being part of ongoing community meetings we could ask for needed information. We also reviewed public records that contained details about the broad population of the area.

What we learned from this data has some limits linked to it and how it was done. This includes:




• Data telling us about Medicaid enrollees that use the hospital services may not be the same as to the Medicaid population as a whole in that area.

• Knowing how much a person uses the hospital can’t be known for sure since data about a person was only used once, not for each time they used the hospital for care.

• The data we have may not show the true amount that people on Medicaid use a service at the hospital. Because people may have Medicaid only for part of year, we miss the details of what services they need and use when not on Medicaid.

We were not able to study many data points by county and payer (Medicaid/public) because there was no data to be found. County values are for the whole population unless stated.

Quantitative data (things that can be counted) telling the unique health needs of the groups of people that are our main concern are limited. These groups of people include:

• prenatal or pregnant women

• those with behavioral health and substance use concerns

• non-English speakers

• refugees

• people with developmental disabilities

We addressed any gaps by doing many surveys and interviews with community groups. We used ongoing community meetings to ask for valid information and reviewed public documents that contained general population information.

IV.d.i. Please use the space below to provide an overview of the hospital’s service area, including providing basic information about the demographics of the general population and the Medicaid population, including related to:

• Race; • Ethnicity; • Age; • Income and employment status; • Disability status; • Immigration status; • Housing status; • Education and health literary levels; • Primary languages spoken; and • Other unique characteristics of the community that contribute to health status.





General Population:

According to the Robert Wood Johnson County Health Rankings 2019 Dataset:

El Paso County

• 699,232 residents

o making up 12.47% of overall Colorado's population [1]

• 55,595 rural residents (8.9%) in El Paso County [1]

• 49.5% female

• 50.5% male [1]

Population

• Non-Hispanic White (69.3%)

• African Americans (6.1%)

• Hispanic (17.1%)

• Asian (3.0%)

• Native Hawaiian/Other Pacific Island Native (0.4%) [1]

Age

• 169,913 (24.3%) below 18 years of age

• 442,614 (63.3%) between ages 18 and 64 years of age

• 86,705 (12.4%) were 65 years of age and older [1]

Income and Employment Status

State of Colorado

• state of Colorado at 12.7% [4] at FPL

• (2.8%) unemployment rate

El Paso County

• 9.9% individuals living at or below the Federal Poverty Level




• unemployment rate (3.3%)

• median household income $65,300

• homeownership rates (63%) [2]

Disability Status

• Eastern El Paso County and an isolated area around Colorado Springs had higher rates of individuals with a disability (11.7%-45.8%) when compared to northwestern El Paso County (0.0% to 9.3%) [2].

According to the Migration Policy Institute:

Immigration Status

• 12,000 foreign-born immigrants were living in El Paso County

• 200 refugees arrived in El Paso County in 2017 [4]

• refugee settlement areas included:

o Colorado Springs (7%) [4]

o Greeley (13%)

o Denver Metro (80%)

Education and Health Literacy Status

State of Colorado

• High school graduation rates in the state of Colorado (79%).

El Paso County

• High school graduation rates (76%)

According to the Health Literacy Data Map:

• The East El Paso County health literacy rate was within the second lowest state quartile, while the West El Paso County was within the top 2 state quartiles 3 and 4.

Primary Languages Spoken

• In 2019, there were 2% of residents with an English proficiency deficiency [1].

Unique characteristics that impact the health of El Paso County residents:




o large with varying geographic characteristics

o embracing the spirit of the west

o a mix of urban, suburban, and rural communities

The city of Colorado Springs is known as the Olympic City, USA.

o attracts elite athletes and also families and retirees

There are 5 military installations in the city. The military is a strong presence, but also creates a transient nature for the hospital’s service area. About, 70% of the population lives within the city of Colorado Springs. The community faces trials due to the large size of the city. This includes:

• limited transportation options

• employment opportunities

Community needs named by the local public health agency include:

• housing that can be afforded

• not enough people to support businesses and public services

In El Paso County, there is a 16.1-year difference in life expectancy across census tracts.

This is as low as 69.3 years in some neighborhoods and as high as 85.4 years in other neighborhoods.

The average life expectancy in Colorado is 80.2 years [4].

The top two leading causes of death among people between the ages of 1 and 44 years are [4]:

o suicide

o accidents

1 out of every 2 adults in El Paso County is either overweight or obese. 1 out of 5 adults is obese [4].

Medicaid Population:

According to HCPF's El Paso County Fact Sheet, in 2017:

• 188,493 Health First Colorado Members

o 64,249 (34.1%) were Affordable Care Act (ACA) expansion adults




o 76,966 (40.8%) were children [6]

During the state fiscal year of 2018:

Treatments at UCHealth Grandview Hospital

• 696 unique Medicaid citizens who used the hospital over a period of 12 months [7].

Age

• 130 (18.7%) were below 18 years of age

• 559 (80.3%) were between 18 to 64 years of age

• 7 (1.0%) were 65 years of age and older [7]

Gender

• 61.1% Female

• 38.9% Male

Race & Ethnicity

• 299 (43.0%) Non-Hispanic Whites

• 294 (42.2%) Multiple Races

• 34 (4.9%) African American

• 28 (4.0%) Latino/Hispanic

• 2 (0.3%) Native Hawaiian/Other Pacific Island Native [7]

Disabilities

• 90 (13.0%) had permanent disabilities

Immigration Status

• 9 (1.2%) Legal permanent residents [7]




• 1 (0.1%) refugee

Housing

• 21 people with no home

Primary Language Spoken

• less than 0.3% Spoke languages other than English

o The secondary language field had 17.7% missing responses. So, we may not have all of the facts [7].

We were not able to get details from the state or the RAE on these items:

• income

• employment status

• education

• health literacy levels

IV.d.ii. Please also provide information about the HTP populations of focus within the hospital’s service area, including:

• Individuals with significant health issues, co-occurring conditions, and / or high health care utilizers;

• Vulnerable populations including related to maternal health, perinatal, and improved birth outcomes as well as end of life care;

• Individuals with behavioral health and substance use disorders; and • Other populations of need as identified by your landscape assessment. Please consider

those at-risk of being high utilizers to whom interventions could be targeted. This should include populations that may not currently receive care in the hospital but are known to community organizations and reflected in the response to IV.d.i.


Individuals with significant health issues, co-occurring conditions, and high health care utilizers:

UCHealth Grandview Hospital evaluated 154 unique Medicaid high utilizers citizens [7].

Age

• 15 (9.7%) below 18 years of age

• 139 (90.3%) were between 18 to 64 years old




• 0 (0.0%) were 65 years of age and older [7]

Gender

• 66.2% female

• 33.8% male

Race & Ethnicity

• 61 (39.6%) Non-Hispanic Whites

• 69 (44.8%) Multiple Races

• 9 (5.8%) African American

• 4 (2.6%) Latino/Hispanic

• 0 (0.0%) Native Hawaiian/Other Pacific Islander [7]

Disabilities

• 21 (13.6%) Medicaid enrollees had permanent disabilities

Immigration

• 2 (1.3%) Medicaid enrollees were legal permanent residents

• 0 (0.0%) were refugees [7]

Housing

• 12 (7.8%) Medicaid enrollees who used the hospital and had no home

Primary Language

• less than 0.6% Medicaid enrollees who spoke languages other than English

In talks with our local stakeholders, in particular, people that are part of the Community Assistance Referral and Education Services (CARES), we found that those who use services more than others (high utilizers) are:

• 61% are females

• 39% are males

• 67% are White

• middle age or 30 to 50 years of age




Of those who are Medicaid high utilizers of the 911 system:

• over 90% have at least one chronic disease

• The average number of reported medical complaints per patient was 9.

Almost 80% also had chronic mental health or substance use disorder.

Vulnerable Populations including related to maternal health, perinatal, and including outcomes of birth and end of life care:

The El Paso Public Health Department evaluated 36,339 Women, Infants and Children clients in 2018. In the state of Colorado, 16.7% of all new mothers with Medicaid had insurance a month before pregnancy [8].

Compared to women covered by private insurance, Medicaid covered pregnant women tend to:

• be between ages 20 to 34 years

• be adolescents

• be single mothers

• have fewer years of education

• be obese

• have a diagnosis of:

o diabetes

o mental health

o substance use disorder

Individuals with behavioral health disorders:

• single largest payer in the U.S. for behavioral health disorders including:

o mental health

o substance use disorders [10]

• most common mental health disorder is major depressive disorder

• females are more likely to have a mental health disorder than male enrollees

• African Americans and Latino/Hispanics with Medicaid are more likely to have a mental health disorder, compared to Whites.




• Members with disabilities are more likely to also have a mental health disorder or substance use disorder.

• About 1 in 4 Medicaid members diagnosed with a mental health disorder also have some other issues such as substance use disorder.

• More likely to be divorced or separated compared to people with mental health disorders that have private insurance.

• Less likely to work full time compared to a person with behavioral health disorders that have private insurance.

• are mostly young, between ages 18 and 55 years of age

• Chronic physical health and behavioral health issues in this group is like the broad population.

o But the costs linked with a Medicaid member having another physical and behavioral health problem is 3 times more than a Medicaid member with only a physical chronic disease.

Other populations of need:

Refugee groups:

• have complex social situations

• often have faced early life trauma

o many have mental health diagnosis

• less likely to look for mental health care or take medicines due to contrasts of culture

• language barriers and health care system navigation add to the challenge of caring for this group

People with disabilities

• have complex health care and social needs

• In Colorado, there were 16.9 % of people who lived with some disability

o compared to the U.S. with 22.5% [10]

As stated by Medicaid claims, a large part of Medicaid health care costs came from people with disabilities.

About 32.7% of adults in Colorado with disabilities were more likely to be inactive compared to 16.3% of those without disabilities [10].




Compared with those without disabilities, adults in Colorado with disabilities were also more likely to:

• have high blood pressure

• smoke

• be obese [10]

IV.e.i. Please use the space below to describe the prevalence of significant behavioral and physical health needs generally in your service area, specifically citing the service area’s top behavioral health, substance use, and chronic disease burdens for both the Medicaid and the general population. Include rates for:

• Serious Behavioral Health Disorders; • Substance Use Disorders including alcohol, tobacco and opiate abuse; and • Significant physical chronic conditions.


Serious Mental Health Disorders for General and Medicaid Populations:

Deaths

Firearms

• 13.4% of deaths by firearms in the state of Colorado

• 12.0% of deaths by firearms in the U.S. rate [11]

Drug overdose

• 17.6% of deaths by drug overdose in Colorado

• 21.7% of deaths by drug overdose in the United States [8].

El Paso County saw the most residents die from guns in the years between the Columbine High School and the Aurora Theater shooting [12].

Behavioral Health

El Paso County

• 19.6% rate of depression

• 19.3% rate of anxiety

State of Colorado

• 18.4% rate of depression




• 16.4% rate of anxiety [10]

Suicide

The age-adjusted death rate due to suicide in:

El Paso County:

• 22.8 for each 100,000 people

o Of all suicides in El Paso County, 74% were gun deaths [12].

State of Colorado

• 20.2 for each 100,0000 people [13]

According to the state dataset, there were no ED visits to UCHealth Grandview Hospital for serious mental health disorders for those who are ED high utilizers [7].

When reviewing the statewide Medicaid dataset, there were no ED visits for primary serious mental health diagnosis [7]. However, the state dataset may be limited to only physical health claims. It might not account for behavioral health claims.

According to SAMHSA, 4.2% of adults in Colorado live with serious mental health conditions such as:

• schizophrenia

• bipolar disorder

• major depression [14]

Only 0.2% of all hospital visits for people with one or more mental health issues was for a serious mental health condition, such as:

• schizophrenia

• psychotic disorders

Of all patients who utilized UCHealth Grandview Hospital, those with Medicaid insurance were 4.7 times more likely to use the hospital for schizophrenia and psychotic disorder treatment, when compared to patients that have commercial insurance.

In total, 0.9% of all visits for people with 1 or more mental health disorders were for suicide ideation or attempt. Of all patients who came to UCHealth Grandview Hospital, those with Medicaid were 2.2 times more likely to use the hospital for suicidal ideation or attempt when compared to patients with commercial insurance.




Top Substance Use Disorders for General and Medicaid Populations:

Alcohol Abuse

The alcohol abuse and dependence diagnosis was the leading cause of being admitted to the hospital for many Medicaid members with chronic conditions [7].

El Paso County

o 42% alcohol-impaired driving deaths [1]

o 18% excessive drinking rates

State of Colorado

o 34% alcohol-impaired driving deaths [1]

o 21% alcohol-impaired driving deaths

RAE 7

o Number 1 potentially avoidable cost was being admitted the hospital for an alcohol related use disorder.

Substance Abuse

El Paso County

In 2016, there were 476,242 opioid prescriptions dispensed to 130,541 El Paso County residents [16].

Most opioid prescriptions were covered by commercial insurance, followed by Medicaid and Medicare.

El Paso County has one of the highest rates of prescription opioid-related issues such as:

o emergency department visits of 20.2 for each 100,000 people

o being admitted to the hospital for prescription opioid-related issues of 15.3 for each 100,000 people

o opioid-related deaths of 5.8 for each 100,000 people in the state of Colorado [17]

Heroin

o 101 substance use treatment admissions for those with heroin addiction in 2017

o substance use treatment admissions for those with heroin addiction in 2017 in the state of Colorado was 134.3 admissions for each 100,000 people [17]




Smoking rates

El Paso County

o 14% of people smoke

State of Colorado [1]

o 16% of people smoke

Chronic Disease Burden for General and Medicaid Populations:

The leading causes of death in El Paso County were:

o cancer (malignant neoplasms) 134.1 for each 100,000 people

o heart disease 128.5 for each 100,000 people

o unintentional injuries 48.0 for each 100,000 people

o chronic lower respiratory disease 49.1 for each 100,000 people

o stroke (cerebrovascular diseases) 37.0 for each 100,000 people) [18]

These diseases are found more often in El Paso County than in the State of Colorado:

• cancer 153.84 for each 100,000 people

• heart disease 130.9 for each 100,000 people

• lung disease 51.3 for each 100,000 people [15]

Of the adults living in the region:

• 35% had a diagnosis of high cholesterol

• 25% had a diagnosis of high blood pressure [19]

• 9.2% had a diagnosis of asthma, and

• 7.5% had a diagnosis of diabetes [19]

The most common mental health conditions along with the physical illnesses:

• depression

• anxiety




During the state fiscal year 2018, there were no Medicaid members who had a diagnosis of cancer and came to the UCHealth Grandview Hospital.

During the same time-frame, Medicaid members who had a diagnosis of asthma were most often admitted to UCHealth Grandview Hospital for diabetes. This shows how common other issues are present with the main diagnosis [7].

Medicaid members who had a diagnosis of COPD were most commonly admitted to the hospital for:

• heart failure

• COPD flare

• alcohol dependence [7]

IV.e.ii. Please also specifically address other significant behavioral and physical health needs in your service area that align with the populations and project topics of focus within the HTP, such as:

• Top chronic conditions accounting for most utilization (include both physical and behavioral health chronic diseases);

• Physical health conditions that commonly co-occur with mental health diagnoses; • Related to maternal health, perinatal, and improved birth outcomes; and • Related to end of life care.


High utilizers & Physical Health Conditions that commonly co-occur with mental health diagnosis:

According to the state record set showing people that use services more often than others (high utilizer dataset), 142 people came to the emergency department (ED) 206 times. High users come to the ED at least 4 or more times in a year. The average number of times this group of people came to UCHealth Grandview Hospital is 1.5 ED visits a year. This is a much lower ED visits by Medicaid high users as compared to 6.3 ED visits a year in the state of Colorado [7].

When reviewing the UCHealth electronic health record data, over 88% of all UCHealth Grandview Hospital patients lived in El Paso County. In total, 92% of all Medicaid Grandview Hospital high utilizers lived in El Paso County.

The most common chronic diseases of high users at UCHealth Grandview Hospital are:

o COPD

o asthma

Still, most emergency department visits are for non-chronic disease-related causes such as an upper respiratory infection.




Being seen by a provider after leaving the hospital is linked with lower return rates to the hospital. Region 7’s 30-day post inpatient follow up rates were 53.3%, which is similar to Colorado’s Medicaid baseline rates (53.4%).

o The top reason for ED use by Medicaid high utilizers of UCHealth Grandview Hospital was an upper respiratory infection.

o Medicaid members get care at UCHealth Grandview Hospital less than 1% for mental health or substance use related issues.

o In total, 19.9% of Medicaid ED high utilizers and 7.9% of Medicaid non-high utilizers had a chronic mental health disorder.

o Medicaid ED high utilizers most commonly go to the ED for non-mental health-related conditions such as an upper respiratory infection.

Maternal Health, perinatal and improved birth outcomes:

In 2019, there were 45,399 total live births in El Paso County.

o 10% of those births were low birth weight babies [3,1]

In RAE region 7:

o 60.6% of pregnant women with Medicaid received adequate prenatal care

o 26.9% of pregnant women with Medicaid received adequate postpartum care

In Colorado:

o 53.4% of pregnant women with Medicaid received adequate prenatal care

o 30.6% of pregnant women with Medicaid received adequate postpartum care

There were no Medicaid covered inpatient admissions at UCHealth Grandview Hospital for pregnant women. There were few visits to the emergency departments at UCHealth Grandview Hospital for pregnant women with Medicaid.

o most were not related to pregnancy such as an ear infection (otitis media)

End of life care:

A little over a third of El Paso County residents (36.0%) have an advance care directive. This is slightly higher compared to 35.7% in the state as a whole [22].

The state found 2 Medicaid covered visits for those on hospice care and using UCHealth Grandview Hospital. These visits were the second highest reimbursements made by Medicaid to




UCHealth Grandview Hospital for patients who have hospice care. These two hospital admissions were for chronic diseases:

o chronic obstructive pulmonary disease (COPD)

o congestive heart failure (CHF)

IV.f.i. Please use the following response space to describe the delivery system’s service capacity within the region and any identified gaps in direct or supporting care services. Assessments should address the state of capacity generally in the community, including community-based social services beyond medical services (i.e. housing and legal assistance, nutrition programs, employment services), as well as information specific to the HTP priority populations and project topics (including services for high utilizers, maternal health and end-of-life services and services for other vulnerable populations, those with behavioral health and substance use disorders, and population health interventions), and should specifically address:

(a) Service availability, access, and perceived gaps generally as well as related to HTP priority populations and project topics, including related to:

i. Primary care; ii. Specialty care; iii. Long term care; iv. Complex care management; v. Care coordination via primary care or other providers; vi. Maternal health, perinatal, and improved birth outcomes; vii. End of life care; viii. Behavioral health; ix. Other outpatient services; x. Population screenings, outreach, and other population health supports and

services; and xi. Any other areas of significant capacity gaps.

(b) Qualified staff recruitment and retention concerns, particularly related to the services listed in (a).

(c) Resources and gaps related to care transitions among specific populations or across major service delivery systems, including:

• Available resources and partners that can be leveraged; and • Perceived gaps.

(d) Social supports related to social factors impacting health outcomes specific to HTP priority populations:

• Available resources and partners that can be leveraged; and • Perceived gaps.

Take into consideration the following community-based social services-resources:

i. Housing;




ii. Homelessness; iii. Legal, medical-legal, financial; iv. Nutrition; v. Employment and job training; and vi. Transportation.

Response (Please seek to limit your response to 2,000 words or less)

Primary Care:

There is a shortage of primary care providers in El Paso County.

o For every primary care provider, there are 1,650 residents.

o In the state of Colorado for every primary care provider there are 1,230 people [1].

There are 188,493 Health First Colorado Members enrolled each month in El Paso County. It is unclear how many providers are contracted and see new Medicaid members in this county.

The main clinic for Medicaid members coming to UCHealth Hospitals is Peak Vista, the local Federally Qualified Health Center. The next highest use clinic is Sunrise Health Care and Center Pointe Family Medicine.

Being seen by a provider within 30 days of leaving the hospital is linked with lower return rates to the hospital.

o UCHealth Grandview Hospital, 30-day return visit rated after leaving the hospital is 57.9%.

o The Colorado’s Medicaid baseline rate is 53.4%.

Having Medicaid members work with a primary care provider or medical home is vital to avoid the need to be admitted to the hospital.

o Medicaid’s region 7 ambulatory well-visit rates were 26.5%.

o The Medicaid state of Colorado ambulatory well-visit rates were 29.2%.

Getting Medicaid members seen within 7 days after a change in the level of care such as leaving the hospital (transitions of care or TOC) is often hard. Most often visits in primary care clinics are open between 15 and 30 days from the time of the request to the visit date.

Specialty Care Services:

During our community interviews, local primary care providers said that there were challenges with getting Medicaid members to see a specialist. One of the interviewees said “Patients in need of referrals to physician specialists often have significant waits and have to travel to other communities for care. This barrier can result in [unmet] care needs leading to an avoidable emergency department visit.” It was also noted that the lack of coordination and high no show




rates for Medicaid members remain a barrier for specialists’ willingness to accept new Medicaid members.

Over-all, the most needed specialties to provide care for Medicaid members are:

o orthopedic surgery

o neurology (epilepsy)

o endocrinology

Long Term Care:

The UCHealth Hospital care managers will work with the RAE care managers to start a single entry point (SEP) form for members who need to be discharged from the hospital with community-based home services.

In our interviews with home health agency partners, many mentioned home health agencies being unable to get orders signed by the Medicaid member’s primary care provider. This leads to 1 post-hospital visit by the home health agency. But no future visits can be made until orders are signed. This is often the reason for return visits and re-admissions in this patient population.

The home health agencies were not aware that the RAE could provide care coordination and facilitate primary care provider to home health agency communications. There are only a few home health agencies and nursing homes that accept Medicaid. Many of the agencies mentioned low reimbursements as the main reason for this.

Medicaid members discharged to a post-acute care facility had a 20.3% 30-day hospital re-admission rate. The all payers group had a 14.9% 30-day hospital re-admission rate.

Several post-acute care facilities also commented on limiting or not accepting patients who have severe social determinants of health such as having nowhere to live. There is not a safe place for these patients to go to, even a temporary house.

Many Medicaid members who have a traumatic brain injury or dementia have behavioral health disorders also. The latter diagnosis makes it almost impossible to have these patients placed in a long-term care facility.

Most long-term care facilities do not have trained behavioral health staff. They feel there is a high cost linked to these types of patients. This cost is to cover:

o constant behavioral management

o classes

o counseling




These behavioral health services are not reimbursed by Medicaid. This causes these patients often stay in the hospital for months to years.

Complex Care Management and Care Coordination via Primary Care or Other Providers:

The RAE is the main contractor for care management services to all Medicaid members. The RAE subcontracts this care management agreement with Peak Vista.

Both groups provide basic and complex care management for Medicaid members. UCHealth Grandview hospital has access to contacts at CCHA and Peak Vista. This helps to connect patients with these agencies as they move from the hospital back into the community.

Colorado Springs has a program called Community Assistance, Referral and Education Services (CARES) that target high utilizers of the 911 call system. The program finds high utilizers and provides them with:

o chronic disease management education

o non urgent medical needs

o help to find their way through the medical system

o follow up with hospital and ED discharge plans [20]

Maternal Health, perinatal and improved outcomes:

There are several OB providers in the Colorado Springs area. The local public health department has a family planning clinic that is open to the public. They also connect women with Women Infants and Children (WIC) services.

The El Paso Public Health Department manages the Nurse-Family Partnership Program. This is a national program that has produced measurable positive results. The program is a nurse-based program that provides home visits to all women who have Medicaid or are eligible for WIC.

Rates of substance use mental health disorders for mothers in Colorado Springs is high. There is a shortage of mental health and substance use providers. Getting a visit after leaving the hospital in a timely way for those who suffer from the conditions mentioned above is challenging.

End of Life Care:

There are a few hospice agencies in the local area:

• Compassus Hospice and Palliative Care

• Pikes Peak Hospice and Palliative Care

• Centura Health-Saint Anthony Hospice




• New Century Hospice

• Prospect Hospice and Palliative Care

• Sangre de Cristo Hospice

• Abode Hospice

• Interim Hospice

• Kindred Hospice at Home

Of all agencies, only 4 of the 9 used by UCHealth Grandview Hospital accept Medicaid members. Re-admissions for members who use any of the hospice agencies above are very low for non-Medicaid members but high for Medicaid members.

Medicaid members are less likely than others to have an advance care directive in place. This is often best done in the primary care setting.

Behavioral Health:

There is a shortage of mental health providers in El Paso County. For every 1 mental health provider in El Paso County, there are 340 people. In the state of Colorado where for every 1 mental health provider there are 300 people [1].

Aspen Pointe:

o the main community mental health center in the Colorado Springs area

o the main Medicaid provider for substance use disorder treatment

Peak Vista

o can provide medication-assisted treatment

Colorado Springs has a peer services agency. They can provide patient-centered peer services to help those with substance use disorder navigate through the ambulatory substance use disorder system.

Colorado Springs has a program called the Community Response Team (CRT) which was created in response to community mental health needs [20]. The program is funded by a grant from the Colorado Governor’s office to AspenPointe. The team responds to calls from the Colorado State Crisis Hotline and 911 with a:

o CSPD officer trained in crisis intervention

o CSFD paramedic




o behavioral health clinician

There are two main local inpatient psychiatric hospitals, and both accept patients with Medicaid insurance. One of the inpatient psychiatric hospitals also provides medical detoxification, but this is not a Medicaid covered benefit.

Medicaid members with a sudden change in their mental illness who need an inpatient psychiatric stay, are often evaluated by the local hospital’s behavioral health providers in partnership with AspenPointe behavioral health providers.

Medicaid members wanting to get sober and seeking detox services have limited choices in Colorado Springs. Crossroads, a new private company, has taken over the detoxification center that was run by the sheriff’s office in the past.

According to the SAMSHA buprenorphine provider locator, there are 59 medical providers able to prescribe buprenorphine. This is a medicine used to treat opioid use disorder [21]. It is not clear how many of those providers take new Medicaid patients. It is also not clear what the wait times are for seeing new patients with substance use disorder.

Suicide rates in El Paso County are higher than in Colorado. There is a local suicide task force that is led by the Department of Public Health in El Paso County. This group is being pulled together to review suicide cases and find areas to improve.

Other Outpatient Services:

El Paso County has a range of other outpatient services, such as dialysis and cancer centers.

The Local Public Health Agency

The Local Public Health Agency provides many services to the community. It is a group that sets up meetings with other groups to talk about health and social issues in the area. Also, they give direct health and social services. They provide services to all residents, but are mostly focused on mothers and children.

Many of their grant-funded initiatives are focused on young children and teens including:

• decreasing childhood obesity

• anti-bullying

• substance use prevention

• teen suicide prevention

They also provide services for:

• vaccines

• TB treatment




• hepatitis A vaccinations

• family planning services

Finally, they house the Healthy Children and Families Program. This gives care coordination for people regardless of diagnosis or income.

The Local Public Health Agency notes that there are limited health and social service resources in the area. But this is mostly true for those who live South of Colorado Springs.

Population screenings, outreach, and other population health supports and services:

The UCHealth medical group participates in providing population health services and supports. The Colorado Community Health Alliance also has population health programs and plans that were given to the state. All Federally Qualified Health Centers are involved with CCMCN and work on population health efforts.

The local fire department does community outreach with public health partners. They give basic prevention resources and help people understand their health and available health care services [20].

Current Medicaid Program and Opportunities for Alignment:

HTP Priority Area: High Utilizers & Vulnerable Populations

Data shows that getting high users of services to use them less is a multi-faceted approach. This includes addressing social determinants of health such as:

• housing

• improving access to primary care and care coordination

• addressing behavioral health needs

We have found ways to work with key partners to look into 2 of the 3 areas locally. The RAE has a team of care coordinators. They are responsible for providing Medicaid member care coordination services that could improve knowledge from hospital providers. They can also start projects that could help partnerships and communication as Medicaid members move from the hospital back to their communities.

Also, the largest local Medicaid provider, Peak Vista, has its team of care coordinators and poses other possible partnership opportunities. This may help line up services for people as they move from the hospital to the community.

HTP Priority Area: Behavioral Health

Both Aspen Pointe and the RAE have interests in working together to improve care for patients with behavioral health challenges and helping connect patients within the ambulatory care




setting. However, ambulatory medication-assisted treatment and behavioral health counseling services are limited in the area.

HTP Priority Area: Social Determinants of Health

Many agencies speak to the social determinants of health, but their resources are limited. There is a wish to know how large the issue of the social determinants of health in a community is and share referral data across different settings.

Perceived gaps:

In talks with the community, nursing homes and housing for the aging populations was brought up as an observed gap. There is a high number of people with no home in El Paso County, yet services are lacking. There is a local medical homeless respite program for residents, but these services are not a Medicaid covered service. There are limited detoxification options for patients to get care for substance use disorder withdrawal.

Ambulatory care centers that treat maternal substance use disorders are also limited in the community. Community partners mentioned transportation as a challenge for patients and that it is not a covered Medicaid service for El Paso County. While programs are being started to treat opioid use disorder, there is little emphasis on the treatment of alcohol use disorders with medication-assisted therapy.

Most long-term care facilities do not accept Medicaid patients with behavioral health conditions or aggressive behavior. These patients find themselves staying in the hospital for weeks to months before finding long-term placement because there are no options nearby.

Many groups serve and help the community, but many have limited resources. There is a higher need for social services than the community can provide for its residents.

Employment and job training:

The service area’s behavioral health team directors note that it is hard to recruit behavioral health specialists and psychiatrists to work in El Paso County. This is also true for getting medical providers to work in the area.

Transportation:

Transportation is a primary barrier to getting to health and social service resources in El Paso County. Many groups mentioned that no local cab company takes Medicaid payments. So the transportation benefit is not used in El Paso.




IV.f.ii. Please use the table below to identify the hospital’s facilities and services available in the community as the hospital has defined them.

Facility Type Facility Name Facility Address Services Offered Hospital UCHealth Grandview

Hospital 5623 Pulpit Peak View, Colorado Springs, CO 80918

Hospital – Inpatient hospital which services include but are not limited to: adolescent medicine, cardiovascular disease, child & adolescent psychiatry, critical care medicine, dermatology, emergency medicine, family medicine, foot & ankle orthopedic surgery, gastroenterology, general practice, general surgery, hand surgery, hematology/ oncology, infectious disease, internal medicine, medical oncology, neonatal-perinatal medicine, nephrology, neurological surgery, neurology, obstetrics & gynecology, orthopedic surgery, otolaryngology, pediatric hematology-oncology, pediatrics, physical medicine & rehabilitation, plastic surgery, podiatric medicine, psychiatry, psychology, pulmonary disease, rheumatology, sleep medicine, sports medicine, thoracic surgery, vascular surgery.

Outpatient Clinic UCHealth Physical Therapy and Rehabilitation Clinic - Powers

2999 New Center Point, Colorado Springs, CO 80922

Occupational Therapy, Physical Therapy, Rehabilitation, Speech Therapy




Facility Type Facility Name Facility Address Services Offered Outpatient Clinic UCHealth Physical

Therapy and Rehabilitation Clinic - Rockrimmon

415 West Rockrimmon Boulevard, Colorado Springs, CO 80919


Outpatient Clinic UCHealth Breast Surgical Clinic - Printers Park

175 S. Union Boulevard, Printers Park Medical Plaza, Suite 345, Colorado Springs, CO 80910

Surgery

Outpatient Clinic UCHealth Mary Lou Beshears Breast Care Clinic - Printers Park


Cancer Treatment, Imaging, Mammography, Oncology, Radiology, Surgery, Women’s Health

Outpatient Clinic UCHealth Brain and Spine Clinic - Colorado Springs

1725 E. Boulder Street, Boulder Medical Building, Suite 101, Colorado Springs, CO 80909

Neurology, Surgery

Outpatient Clinic UCHealth Physical Therapy and Rehabilitation Clinic - Printers Park



Outpatient Clinic UCHealth Primary Care Clinic - Briargate

8890 N. Union Boulevard, Suite 170, Colorado Spring, CO 80920

Family Medicine, Flu Shot, Pediatrics, Primary Care

Outpatient Clinic UCHealth Primary Care Clinic - Rockrimmon

6615 Delmonico Drive, Colorado Springs, CO 80919


Urgent Care UCHealth Urgent Care - Circle Square

2767 Janitell Road, Colorado Springs, CO 80906

Urgent Care

Outpatient Clinic UCHealth Wound Care Clinic - Colorado Springs


Wound Care

Laboratory UCHealth Laboratory - Briargate

8890 N. Union Boulevard, Briargate Medical Campus, Colorado Springs, CO 80920

Laboratory, Pathology

Laboratory UCHealth Laboratory - Printers Park

175 S. Union Boulevard, Printers





Facility Type Facility Name Facility Address Services Offered Park Medical Plaza, Colorado Springs, CO 80910

Radiology UCHealth Radiology - Briargate

8890 N. Union Boulevard, Suite 100, Colorado Springs, CO 80920

Imaging, Radiology

Radiology UCHealth Radiology - Printers Park

175 S. Union Boulevard, Printers Park Medical Plaza, Colorado Springs, CO 80910

Imaging, Radiology

Outpatient Clinic UCHealth Printers Park Surgery Center


Surgery

Outpatient Clinic UCHealth Occupational Medicine Clinic - Printers Park


Occupational Medicine

Outpatient Clinic UCHealth Diabetes and Medical Nutrition Therapy - Printers Park


Diabetes, Endocrinology

Radiology UCHealth Radiology - Woodmen

4190 Woodmen Road, Colorado Springs, CO 80920

Imaging, Radiology

Outpatient Clinic UCHealth Primary Care Clinic - Monument

15854 Jackson Creek Parkway, Suite 120, Monument, CO 80132

Family Medicine, Flu Shot, Primary Care, Rehabilitation

Outpatient Clinic UCHealth Primary Care Clinic - Scarborough

8540 Scarborough Drive, Suite 100, Colorado Springs, CO 80920

Family Medicine, Flu Shot, Primary Care

Outpatient Clinic UCHealth Mary Lou Beshears Breast Care Clinic - Briargate


Cancer Treatment, Imaging, Mammography, Oncology, Radiology, Surgery, Women’s Health

Outpatient Clinic UCHealth High-Risk Breast Cancer Clinic - Printers Park

175 S. Union Boulevard, Printers Park Medical Plaza,

Cancer Treatment, Oncology, Women’s Health




Facility Type Facility Name Facility Address Services Offered Suite 345, Colorado Springs, CO 80910

Outpatient Clinic UCHealth Primary Care Clinic - Academy

5265 N. Academy Boulevard, Suite 1800, Colorado Springs, CO 80918

Family Medicine, Primary Care, Women’s Health

Outpatient Clinic UCHealth Physical Therapy and Rehabilitation Clinic - Scarborough

8540 Scarborough Drive, Colorado Springs, CO 80920

Physical Therapy, Rehabilitation, Speech Therapy

Laboratory UCHealth Laboratory - Cascade

2920 N. Cascade Avenue, Colorado Springs, CO 80907


Urgent Care UCHealth Urgent Care - Powers

4323 Integrity Center Point, Colorado Springs, CO 80917

Occupational Medicine, Urgent Care

Urgent Care UCHealth Urgent Care - Voyager Parkway

13445 Voyager Parkway, Colorado Springs, CO 80921


Urgent Care UCHealth Urgent Care - Garden of the Gods

1035 W. Garden of the Gods Road, Suite 120, Colorado Springs, CO 80907


Outpatient Clinic UCHealth Orthopedics Clinic - Briargate


Orthopedics, Sports Medicine, Surgery

Outpatient Clinic UCHealth Physical Therapy and Rehabilitation Clinic - Monument

15854 Jackson Creek Parkway, Monument, CO 80132

Physical Therapy, Rehabilitation

Outpatient Clinic UCHealth Orthopedics Clinic - Printers Park


Orthopedics

Outpatient Clinic UCHealth Women’s Care Clinic - Printers Park


Obstetrics/ Gynecology, Pregnancy Care, Reproductive Health, Women’s Health

Outpatient Clinic UCHealth Falcon Medical Center

11605 Meridian Market View, Suite, 184, Falcon, CO 80831

Primary Care, Urgent Care, Occupational Medicine




Facility Type Facility Name Facility Address Services Offered Emergency Room – Free Standing

UCHealth Emergency Room - Fountain (Freestanding)

7890 Fountain Mesa Road, Fountain, CO 80817

Emergency Room

Emergency Room – Free Standing

UCHealth Emergency Room - Woodmen (Freestanding)

3790 E. Woodmen Road, Colorado Spring, CO 80920

Emergency Room


UCHealth Emergency Room - Powers (Freestanding)

2770 N. Powers Boulevard, Colorado Spring, CO 80922

Emergency Room


UCHealth Emergency Room - Meadowgrass (Freestanding)

13510 Meadowgrass Drive, Colorado Springs, CO 80921

Emergency Room

Outpatient Clinic UCHealth Allergy and Immunology Clinic - Printers Park


Allergy, Respiratory

Urgent Care UCHealth Urgent Care - Falcon


Urgent Care

Outpatient Clinic UCHealth Primary Care Clinic - Falcon



Outpatient Clinic UCHealth Podiatry Clinic - Printers Park


Podiatry

Outpatient Clinic UCHealth Occupational Medicine Clinic - Powers

4323 Integrity Center Point, Colorado Springs, CO 80917


Outpatient Clinic UCHealth Internal Medicine Clinic - Printers Park


Flu Shot, Primary Care

Outpatient Clinic UCHealth Primary Care Clinic - Chapel Hills

595 Chapel Hills Drive, Suite 325, Colorado Springs, CO 80920

Flu Shot, Primary Care

Outpatient Clinic UCHealth Occupational Medicine Clinic - Falcon






Facility Type Facility Name Facility Address Services Offered Outpatient Clinic UCHealth Occupational

Medicine Clinic - Garden of the Gods

1035 W. Garden of the Gods Road, Colorado Springs, CO 80907


Outpatient Clinic UCHealth Occupational Medicine Clinic - Voyager

13445 Voyager Parkway, Colorado Springs, CO 80921


Outpatient Clinic UCHealth Aspen Creek Medical Center

9480 Briar Village Point, Suite 200, Colorado Springs, CO 80920

Family Medicine, Primary Care

Outpatient Clinic UCHealth Plastic and Reconstructive Surgery Clinic - Colorado Springs

1625 Medical Center Point, Suite 220, Colorado Springs, CO 80907

Plastic and Reconstructive Surgery

Outpatient Clinic UCHealth Pain Management Clinic - Colorado Springs

1625 Medical Center Point, Suite 215, Colorado Spring, CO 80907

Pain Management

Outpatient Clinic UCHealth Colorado Springs OB/GYN Clinic - Rangewood

6705 Rangewood Drive, Colorado Springs, CO 80918

Obstetrics/ Gynecology, Women’s Health

Outpatient Clinic UCHealth Physical Therapy and Rehabilitation Clinic - Woodmen

4150 E. Woodmen Road, Colorado Springs, CO 80920

Physical Therapy, Rehabilitation

Outpatient Clinic UCHealth Women's Care Clinic - Pikes Peak

1015 E. Pikes Peak Avenue, Suite 100, Colorado Springs, CO 80903


Outpatient Clinic UCHealth Primary Care Clinic - Fontanero

320 E. Fontanero Street, Suite 100, Colorado Springs, CO 80907

Family Medicine, Flu Shot, Primary Care

Outpatient Clinic UCHealth Endocrinology Clinic - Printers Park


Diabetes, Endocrinology

Outpatient Clinic UCHealth Front Range OB/GYN - Colorado Springs

4105 Briargate Parkway, Suite 200, Colorado Springs, CO 80920


Outpatient Clinic UCHealth Ear, Nose and Throat Clinic - Colorado Springs

595 Chapel Hills Drive, Suite 240, Colorado Springs, CO 80920

Ear Nose and Throat




IV.g. Please use the space below to describe the current state of protected health data exchange infrastructure and use inside the defined service area (available RHIOs, participation level amongst area providers, primary data exchange capabilities) as well as an assessment of the hospital’s current capabilities regarding data exchanges across network providers, external partners and with RHIOs or regional data exchanges. Please speak specifically to how this impacts care, including care transitions and complex care management.


UCHealth uses EPIC© as its electronic health record platform across all hospitals and ambulatory clinics. Patient’s records are available through Care-Everywhere.

UCHealth is also part of the CORHIO (Colorado Regional Health Information Organization) by sending in electronic health record information. CORHIO has been collecting and storing data since 2009. There are more than 16,000 health information exchange (HIE) users and nearly 5.6 million unique patients in the HIE. The RAE and select primary care practices also get data from CORHIO.

UCHealth hospitals can share data with CORHIO, RAE, and primary care providers. However, CORHIO data cannot be seen in EPIC©. To see data clinicians must log in to the CORHIO website: Once on the site they can see details related to:

• admissions

• discharges

• transfers

• lab results

Current gaps include not being able to:

• see the plan of care that is in use at the current time

• quickly find high utilizers without reviewing all visits in the electronic health record, and

• find if patients followed up on recommended social services or health care agency referrals if it was with an external health system.

• see primary care notes that are not in Care-Everywhere

• share data on people with substance use disorder secondary to 42 CFR regulations

Lastly, the RAE has access to the patient's risk scores and complex care plans for COUP patients (Client Overutilization Program). Still, at this time there is no way to share such care plans and risk stratification scores. Also, it is a challenge to find Medicaid members who get home-based community services (HCBS) as they use the hospital. This is because the care management staff does not have access to such information in a timely fashion.




IV.h. Please use the space below to provide information about any other major topics discussed with community stakeholders and input received.


Community stakeholders talked about the bias around behavioral health as a disease area. For example, members of the El Paso community mentioned some people find it embarrassing to look for counseling services. And providers are often not certified to order substance use medicines.

Also, while most suicides occur by firearm, there is concern and fear from certain community groups to talk about this topic with patients as they get care for serious mental illness. Men are 4 times more likely than women to die from suicide. The local community started the nationally recognized “Man Therapy” campaign to target this group with the hopes of decreasing suicide completion rates.

IV.i. Please use the space below to provide preliminary thinking regarding the likely focus of HTP initiatives, in particular target populations and target community needs.


The Midpoint report shows what the needs are in the community right now. We focused on finding the resources that are in place already. Our next step is to talk about what we found with our partners. We need to find how we can work together in areas that are already in place between hospitals and community based services.

We will be talking about the HTP initiatives focus with our community partners in this next phase of the HTP pre-waiver period.

From the needs assessment and scan of the area, we found that the main items groups ask for as their most important needs are in behavioral health (including mental health and substance abuse) and care transitions.

Resources that will help the Medicaid population to have the structure needed for transitions of care are available. These are found through:

o the RAE

o local public health agencies

o other community agencies

During this process, we found that we have partnership projects now underway with many community organizations. We also found that our hospital care management team works with many of the resources in the community already.

As we set up any screening or transitions programs for this patient group, we will make sure we can find resources in the area as well.




Planned Future Engagement Activities

V.a. Please use the space below to outline planned future activities for engaging community organizations and processes that will be completed to inform and develop the hospital’s HTP application. Please describe how organizations that serve and represent the broad interests of the community will continue to be engaged in the planning and development of the hospital’s application, including:

• Prioritizing community needs; • Selection of target populations; • Selection of initiatives; and • Completion of an HTP application that reflects feedback received.

Please note that the word limit is a guideline and you may exceed it as necessary.


We will keep on working with groups so we can blend activities and make sure outcomes for people are helped. We will see these results in the data collected for the HTP. The community health needs process let us to find the areas we needed to focus on first. These will likely change and grow as we work closely with the state, RAE, and community partners over the next 5 years.

The community health needs engagement process showed the areas that people felt were the most important to work on first. We will choose groups of people to focus on and make sure our plans line up with the HTP priorities and areas to be measured. Over the next few months as we pick projects for the Hospital Transformation Program, we will think over:

• stakeholder input

• feasibility

• sustainability

• cost

Throughout the HTP pre-waiver phase, we have shared our reports for the state with stakeholders and asked for feedback from our partners. We know this record will be made public by the Health Care Policy and Financing Department. We welcome any feedback that you may feel will add value to the final HTP report. The UCHealth contact names and email address are found on the first page of this form.




Additional Information (Optional)

You may use the space below to provide any additional information about your CHNE process.

Please note that the word limit is a guideline and you may exceed it as necessary.


We do not have additional information.




Appendix I: Community Inventory Tool1

Use this tool to inventory clinical, behavioral, and social service resources in the community that could provide timely post-hospital follow-up, monitoring, and assistance. Use this inventory to identify which resources your hospital regularly uses. Also use this inventory as an implicit gap analysis to stimulate a consideration of providers or agencies you may want to more regularly use.

Clinical and Behavioral Health Providers Provider or Agency Transitional Care Services [Examples] Yes No Community health centers, federally qualified health centers

Peak Vista: • Have established warm hand off

processes; • Have access to organization's point of

contact (liaison); • Time to first appointment: 1-7 days; • Coming to complex care rounds

☒ ☐

Accountable care organization with care management or transition care

CCHA – Regions 7 • Established relationship, CoA presents

information on CoA and services provided to UCH-A care management staff.

• No established shared lists or care plans on COUP patients. No established process for CoA care manager to participate in complex discharge patient meetings.

*We have partnerships with regions 1, 2, 6, 7 as well, but most Medicaid patients in this hospital come from regions 3 & 5.

☒ ☐

Medicaid managed care organizations

• Denver Health Managed Medicaid • Rocky Mountain Managed Medicaid ☒ ☐

Program of All-inclusive Care for the Elder (PACE), Senior Care Options (SCO), Duals Demonstration providers

• PACE: None • SCO:

o Rocky Mountain Options o Long Term Supportive

• Nursing homes: o Centennial o Cordera o Sunny

• DDP o No Dual programs

☒ ☐

1 Adapted from: Designing and Delivering Whole-Person Transitional Care. Content last reviewed June 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html




Provider or Agency Transitional Care Services [Examples] Yes No Medicaid health homes UCHealth-CU medicine Primary Care Clinics:

• Refer patients to this organization without a formalized relationship;

• Aware of organization and services provided;

• Time to first apt: 7-14 days for CU attributed Medicaid members.

☒ ☐

Multiservice behavioral health centers, including beshavioral health homes

Aspen Pointe and RAE

☒ ☐

Behavioral health providers Aspen Pointe: • Refer patients to this organization without

a formalized relationship; • Aware of organizations and services; • Time to first appointment: walk in

available for Medicaid clients.

☒ ☐

Substance use disorder treatment providers

Aspen Pointe: • Refer patients to this organization with a

formalized relationship; • Aware of organization and services

provided; Peak Vista:

• Refer patients to this organization with a formalized relationship;

• Aware of organization and services provided;

☒ ☐




Heart failure, chronic obstructive pulmonary disease (COPD), HIV, dialysis, or cancer center clinics

Heart Failure Clinics • UCHMG Heart Failure-Cardiology:

o Refer patients to this organization with a formalized relationship;

o Aware of organization and services provided;

HIV Center Clinics • El Paso Public Health • ID Private Practice-Infectious Disease

Specialist COPD

• Pulmonary Associates: o Refer patients to this organization

with a formalized relationship; o Aware of organization and

services provided; Dialysis Center Clinics

• US Renal: o Refer patients to this organization

without a formalized relationship; o Aware of organization and

services provided; o Time to appointment: 3-7 days.

Pueblo • DaVita:



o Have access to organization’s point of contact (liaison);

o Time to appointment: 1-3 days and urgent appointments available.

• Fresenius: o Refer patients to this organization


services provided; o Have access to organization’s

point of contact (liaison); o Time to appointment: 1-3 days

and urgent appointments available.

Cancer Center Clinics • Memorial Cancer Center:



☒ ☐




Provider or Agency Transitional Care Services [Examples] Yes No o Infusion center and urgent

appointments available. • Rocky Mountain Cancer Center

Pain management or palliative care

• Palliative Care- Liaison • Palliative Care Pikes Peak Hospice • Compassus • Interim

☒ ☐

Physician/provider home visit service

• None ☐ ☒

Skilled nursing facilities • Terrace Gardens Health Care: o Refer patients to this organization


services provided; o Part of preferred network*

• Cedar Care Wood: o Refer patients to this organization


services provided; o Not part of preferred network*

*All preferred network providers are engaged with UCHealth to improve 30 and 90-day re-admission rates. Every quarter these SNFs receive their data from UCHealth Post-Acute Care on patient’s they have accepted from UCHealth that are re-admitted. If re-admission rates are higher than expected, then a discussion with root because analysis takes place between the UCHealth PAC representative and PAC representative.

☒ ☐

Home health agencies • Interim Home Health • Encompass Health Home Health – does

not accept Medicaid nursing ☒ ☒

Hospice • Pikes Peak • Compassus



o Have access to organization’s point of contact;

☒ ☐




Provider or Agency Transitional Care Services [Examples] Yes No Adult day health • Good Will -

• Mosaic- None *Programs that provide: daily clinical, nutritional, medication management, socialization, etc.

☒ ☐

Public health nurses • Nurse Family Partnership. • Peak Visit • First home visit program

☒ ☐

Pharmacies • Medicine Shop • Referral only

☒ ☐

Durable medical equipment • Apria Healthcare: o Refer patients to this organization


services provided; o Have access to organization’s

point of contact (liaison) o Time to DME delivery: 1-3

• Advance Medical Solutions • Major Medical

☒ ☐

Other Ascending Health ☒ ☐

Social Services Provider or Agency Transitional Care Services [Examples] Yes No Adult protective services • Adams County –APS:

o Refer patients to this organization without a formalized relationship;


o Response times between 1-3 days. • Arapahoe County –APS:



o Response times between 1-3 days. • Denver County –APS:



o Response times between 1-3 days.

☒ ☐




Provider or Agency Transitional Care Services [Examples] Yes No Area Agency on Aging (AAA) • Scott Bartley:

o Refer and do warm hand off o Attend ethics committee – mental

health challenging patients

☒ ☐

Aging and Disability Resource Centers

• All through AA • Kent Matthews- runs the program • Silver Key- senior resource center

☒ ☐

Assisted living facilities • View pointe assisted living facility • The palisades ☒ ☐

Housing with services • Ascending to Health • Partners in House • Geroccio • Silver key working on housing –homeless

senior

☒ ☐

Housing authority or agencies • City-Housing Authority • Not first referred place ☒ ☐

Legal aid • None-Senior book ☐ ☒

Faith-based organizations • Catholic Charities • Mission Medical • ESM (Eastern Medical Social Ministries)

☒ ☐

Transportation • Silver Key and Metro Mobility: o Refer patients to this organization

without a formalized relationship; o Aware of organization and services

provided. • Uber-discount (max $5):


o Aware of organization and services provided.

o Provides discounts. • Z-trip/Coach • Taxi service • Summit

☒ ☐

Community corrections system • None ☐ ☒




Provider or Agency Transitional Care Services [Examples] Yes No Other • Human Network Systems:


o Have access to organization’s point of contact (liaison);

o Aware of organization and services provided: private guardianship agency.

• Guardianship Alliance: o Refer patients to this organization

with a formalized relationship; o Have access to organization’s point

of contact (liaison); o Aware of organization and services

provided: support for families/friends filing paperwork for guardianship. Educational opportunities and classes for guardians. Legal aid.

• The Blue Bench: o Refer patients to this organization



provided: refer patients with history of sexual trauma/assault or domestic violence.

• Women’s Empowerment Program: o Refer patients to this organization



provided: criminal justice services, education, employment, housing and trauma support group, legal aid.

• Hunger Free Colorado: o Refer patients to this organization


of contact (liaison); • Tassa- Domestic Violence • Food banks • Care and Share

☒ ☐




Appendix II: Hospital Care Transitions Activities Inventory Tool2

An inventory of readmission reduction efforts will reveal the administrative, clinical, health information technology, and other organizational assets already in place. Once you know what efforts and assets already exist, you can consider whether they are optimally aligned and coordinated. The inventory will also serve as an implicit gap-analysis of activities or assets not currently in place. You may identify the need to implement new practices as part of this process.

Readmission Activities/Assets

ADMINISTRATIVE ACTIVITIES/ASSETS For Which Patients?

☒ Specified readmission reduction aim All Patients

☒ Executive/board-level support and champion All Patients

☒ Readmission data analysis (internally derived or externally provided) All Patients

☒ Monthly readmission rate tracking (internally derived or externally provided)

All Patients

☒ Periodic readmission case reviews and root cause analysis All Patients

☒ Readmission activity implementation measurement and feedback (PDSA, audits, etc.)

All Patients

☒ Provider or unit performance measurement with feedback (audit, bonus, feedback, data, etc.)

All Patients

☐ Other: N/A

HEALTH INFORMATION TECHNOLOGY ASSETS For Which Patients?

☒ Readmission flag All Patients

☒ Automated ID of patients with readmission risk factors/high risk of readmission

All Patients, CHF Patients

☐ Automated consults for patients with high-risk features (social work, palliative care, etc.)

None

☒ Automated notification of admission sent to primary care provider All Patients

☒ Electronic workflow prompts to support multistep transitional care processes over time

All Patients

☒ Automated appointment reminders (via phone, email, text, portal, or mail)

All Patients

☐ Other: N/A

2 Adapted from: Designing and Delivering Whole-Person Transitional Care. Content last reviewed June 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/index.html




TRANSITIONAL CARE DELIVERY IMPROVEMENTS For Which Patients?

☒ Assess “whole-person” or other clinical readmission risk All Patients

☐ Identify the “learner” or care plan partner to include in education and discharge planning

None

☒ Use clinical pharmacists to enhance medication optimization, education, reconciliation

All Patients

☐ Use “teach-back” to improve patient/caregiver understanding of information

None

☒ Schedule follow-up appointments prior to discharge High Risk Patients, Patients without PCP, Patients without insurance, Orthopedic patients

☒ Conduct warm handoffs to post-acute and/or community “receivers” All Patients

☐ Conduct post discharge follow-up calls (for patient satisfaction or follow-up purposes)

None

☐ Other: N/A

CARE MANAGEMENT ASSETS For Which Patients?

☒ Accountable care organization or other risk-based contract care management

All Payors

☐ Bundled payment episode management None

☐ Disease-specific enhanced navigation or care management (heart failure, cancer, HIV, etc.)

None

☒ High-risk transitional care management (30-day transitional care services)

All Patients

☐ Other: N/A

CROSS-CONTINUUM PROCESS IMPROVEMENT COLLABORATIONS WITH:

FOR WHICH PATIENTS?

☒ Skilled nursing facilities All Patients

☒ Medicaid managed care plans All Patients




CROSS-CONTINUUM PROCESS IMPROVEMENT COLLABORATIONS WITH:

FOR WHICH PATIENTS?

☒ Community support service agencies Skilled Nursing Facilities, Home Health Agencies, Homeless, Pediatrics (only memoral), Geriatrics, At Risk, Low Income, Developmentally Disabled Patients

☒ Behavioral health providers Aspen Pointe, LPHA, PD, Corresponder model

☐ Other: N/A

HOSPITAL TRANSFORMATION PROGRAM …...Hospital Name: UCHealth Grandview Hospital Hospital Medicaid...

Documents

Transcript of HOSPITAL TRANSFORMATION PROGRAM …...Hospital Name: UCHealth Grandview Hospital Hospital Medicaid...