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Resources for Clinical Sites

We invite all primary care clinics, behavioral health clinics and hospitals in Western Colorado to participate by administering the Accountable Health Communities Model Screening.

 Why should practices participate in AHCM?

  • Improved Patient Care
  • Efficiency in identifying community resources
  • Preparation for value-based purchasing 
  • Connection to community navigation
  • Support evidence-based community investments
  • Be a leader in a national conversation

What does it mean to participate?

Primary care practices and clinics will do three simple things to participate:

  1. Screen for Social Determinants of Health. Use the AHCM screening tool to identify your patients who have acute social needs and patients who are at high risk.
    1. AHCM Social Needs Screener - Note: the screener has been translated into a number of different languages, including Spanish. Please contact Kathryn Jantz to request a translated version.
    2. National Academy of Medicine Discussion Paper: Standardized Screening for Health-Related Social Needs in Clinical Settings
  2. Provide your patients with a print-out of the list of resources. When you submit patient screening information electronically, we will automatically send you a list of community services appropriate for that patient.  We are partnering with 211 to develop the right list of resources for your patients based on their needs, age, gender, income level, and where they live.
  3. Refer high-risk patients to a community navigator. For patients who have two or more ER visits and a social need, we are committed to ensuring that they receive community navigation. This might mean that we are providing support to your in-house community navigators so that they can continue to be the primary point of contact for your patients or it could mean that we are connecting your patient to a navigator in the community.

Read our Frequently Asked Questions for more information about what it means to participate as a practice.

This is a good idea, but how can we fit this in to our already busy schedule?

We understand your workflow challenges and are committed to helping you find the smoothest way to integrate this into your work. We have created a toolkit to assist you in the implementation of the screener.

How do I get started?

Contact Kathryn Jantz at 303-638-9897 or Sally Henry at 970-640-7722 if you are interested in participating.

Resources for Participating Practices 

The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

The project described was supported by Funding Opportunity Number 1P1CMS331575-01-00 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.

AHCM Newsletter


Stay informed with latest AHCM updates


AHCM Western Slope Community Meetings

Rocky Mountain Health Plans is facilitating a series of meetings to gather input and share information on the model and proposal.

Upcoming Meetings                                      

Regional meetings are being held by each Community Leader in July. These meetings gather participating and prospective providers, community partners and other local agencies to come together and discuss issues relevant to the specific region as well as get updated on how screenings are going, hurdles being faced, needs being identified, and how the Community Lead is working to address one or more gaps that have been identified. Please mark your calendar with the dates below and see the Community Calendar for specific dates, times and locations.

West Mountain Regional Health Alliance, 7/15/19, 9:30am-11am
Tri-County Health Network, 7/25/19, 1-2pm
Mesa County Public Health, 7/26/19, 8-9:30am
Northwest Colorado Community Partnership, 7/30/19, 11:30am-1pm

Please view the Community Calendar for all upcoming events and deadlines.

Past Meetings

Please view the Advisory Board page for meeting details

Meeting Materials

Annual AHCM Day-Long Symposium 5/7/19

AHCM Community Partners Quarterly Meeting 2/22/19

AHCM Consortium Meeting 6/9/16

AHCM Western Slope Proposal - Update & Discussion 3/4/16

AHCM Meeting for Community Based Organizations 2/23/16

AHCM Kick-Off Meeting 2/4/16