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Social Determinants of Health


Health cannot be confined to the walls of medical practices and hospitals. For many patients, achieving health goals requires more than just medical treatment. It requires connection to and coordination with the culturally appropriate community resources and social health needs they need to improve their health status.

Likewise, practice transformation requires active leadership and consistent collaboration. Each provider in each RMHP practice transformation program comes with unique needs and challenges. But all are committed to this goal: Improve each patient’s experience of care while being accountable for the health of the population as a whole.  

Our Solutions: 

Practice Transformation staff work closely with practice leadership to provide the skills and tools to effectively drive quality improvement projects. RMHP’s practice transformation Learning Collaboratives bring together local leaders to share best practices and mutual resources. 

The RMHP team helps practices tap into their local resources to identify and meet their community’s needs. These include skilled nursing facilities, school districts, recreation centers, other wellness organizations, state organizations, health departments, other PCPs, hospitals, advocacy agencies, gyms and specialists.  

By connecting local leadership, providing organizational-development courses and fostering collaboration, these programs create momentum beyond the practice walls and help ensure transformation is sustainable. 

The practice transformation team at Rocky Mountain Health Plans (RMHP) has been selected to work with practices in the CPC + Western Colorado region.  RMHP is part of a larger CPC+ Regional Practice Network that is led by the Lewin Group in direct partnership with TMF Health Quality Institute and HealthTeamWorks.

RMHP Prime emerged as a concrete result of nearly three years of engagement between RMHP, physician, hospital and community mental health center leaders. Additional partners include the Mesa County Department of Public Health, federally qualified health centers, independent primary care practices, Quality Health Network, an Aspen Valley employer initiative and the University of Colorado Department of Family Medicine. Working together, RMHP Prime is a model for how Medicaid services should be provided and funded for the most vulnerable members.

Colorado’s Medicaid Accountable Care Collaborative (ACC) is a central part of Medicaid reform, and Rocky Mountain Health Plans serves as the Regional Accountability Entity (RAE) for Region 1.

RMHP’s efforts are built entirely upon a foundation of local leadership and community engagement. RMHP works with each community to establish the structures, communication processes, expertise and leadership to create medical “neighborhoods.” In many communities throughout Region 1, provider and community leaders have elected to pool their efforts and resources to improve care coordination for vulnerable populations. 

Across our region, we work closely with community partners such as independent living centers, case management agencies and community health care coalitions to seek feedback from patients—consumers--about their experiences. We work to engage members in meaningful discussion about the ongoing challenges Medicaid clients face, and areas for improvement.

In each community, a committee provides guidance, strategy and oversight to the teams, as well as setting strategy to provide them with local support. Members of these committees include hospitals, primary care providers, community mental health centers, public health departments, area health education councils and other community partners and agencies. RMHP funds these teams through the money we receive from the state for serving as an RAE. Other community partners also provide financial support for these teams, bolstering the idea that they are truly a community resource.  

The Accountable Health Communities Model (AHCM) is an opportunity to test, over five years, if systemically identifying and attempting to address the health-related social needs (housing, food, utilities, safety, transportation) through referral and community navigation can reduce healthcare costs, inpatient and outpatient utilization, and improve healthcare quality and delivery. This PowerPoint presentation provides a brief overview of the project.

Western Colorado was selected as one of 32 sites across the country to participate in this Center for Medicare and Medicaid Innovation initiative from May 1, 2017 to April 30, 2022. Learn more about the AHCM.