As executive director of the Health Partnership, Stephanie Monahan is known for her expertise in cross-sector partnership building, program development, and comprehensive health and wellness systems work. Prior to taking her current position in June, she served as the regional health connector for NCCHP, working to improve the efficiency of navigation supports throughout Grant, Jackson, Routt, Moffett and Rio Blanco counties. She spearheaded the regional community health needs assessment on behalf of clinical and community partners to align efforts and strengthen the collective impact on issues like behavioral health and food insecurity.
Ascent: You began your service with NCCHP as the regional health connector. That’s not a job title that's commonly understood. What does a regional health connector do?
Monahan: The role of the regional health connector (RHC) was to serve as a critical linkage point between clinical teams and community organizations to support better patient outcomes. RHCs operated in Colorado as a unique workforce; we could take the time to understand community needs—what the priority areas were and the opportunity gaps to fill—via environmental scans and one-on-one conversations with community stakeholders.
Sustainability was important, so we put in place initiatives that will continue to improve the system beyond the regional health connector role and timeline.
One of the first priorities was starting care navigation networks—one in each of the five counties. because each is unique with its own dynamics and opportunities. The navigation networks are for anyone providing care coordination to come together and understand the roles of those in a clinical space and what’s happening at the community level. The idea is to create a no-wrong-door approach, making the system more efficient and connecting people to what they need in a much faster timeframe.
Another big initiative we’re launching is around stigma reduction. We recognize that we have a lot of compassionate, caring people working to help others make a change, but so many times we run into stigma as a barrier--whether it’s trying to raise funding for a program or getting people in the community to access various programs. We want to make resources like substance use disorder treatment, housing and food resources feel more friendly, and have people feel comfortable accessing resources. We really want to shift the culture in Northwest Colorado to one of health seeking, whether it’s around parenting advice, annual exams or supplemental nutrition assistance programs.
A third project is supporting regional hospitals in the hospital transformation project. We performed a regional community health needs assessment, involving the hospitals, health agencies and federally qualified health centers. We analyzed the data to identify community needs and how we can prioritize them, working together. It’s a powerful experience to embed those needs into the hospitals’ strategic plans as well as our own.
Ascent: How does connecting organizations--and their leadership—through the work of NCCHP improve health for the residents in your region?
Monahan: The predominant work we do as an organization is changing our care environment and system. For example, if your doctor prescribes weight loss for your health, but there’s no walking paths, or the only nearby food choices are fast food, the environment needs improvement. We’re looking at systemic issues and asking how we can we make healthy choices easier. What factors get in the way of our mental and physical health? What are the barriers to people accessing good nutrition? How can we work to pull those opportunities together to help people live longer, happier, healthier lives?
In addition to shifting the system, our health alliance supports people in a one-to-one capacity through care coordination. We see people move across the self-sufficiency spectrum when they enter care coordination. Care coordinators educate them on services and resources available and really coach them to advocate for themselves. That’s a huge role that we play.
Ascent: Looking at the big picture, what are three things The Health Partnership is doing to improve access to resources that contribute to health (housing, food, mental health services, etc.)?
Monahan: We participate in a federally-funded project called the Accountable Health Communities Model, which encourages screening for social determinants of health needs in the clinical setting and then connecting patients with care navigation and resources at the community level. That’s where systemic issues come into the picture. For example, transportation is a huge issue in our region. What are the policy levers we can pull to address transportation? How can we address food insecurity, working together to be innovative above and beyond the supplemental nutrition assistance program? We support the navigation network because there’s nothing more important than helping the boots-on-the-ground people who are connecting with people on a daily basis. How can we elevate those experiences to drive change?
We’re also embarking on a shared data dashboard that will elevate social health needs and allow community partners to see where they can plug in, which I hope will drive interest and public policy development around the social determinants of health.
Rural access to clinical and social health resources is one of the policy and advocacy areas we want to continue to address; how to care for people living in our rural communities is very different from business models we see in urban centers. It requires a different funding formula. That’s a barrier we have to address from a policy standpoint.