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1 Click to edit Master title style Click to edit Master title style The Denver Regional Accountable Health Community Presented by: AJ Diamontopoulos Nov. 3, 2017

2 Click Welcome to edit Master title style Click to edit to Master the consortium! title style The Denver Regional Accountable Health Community $4.51 million over five years DRCOG is the bridge organization Designed to: Identify and address the health-related social needs of Medicare and Medicare beneficiaries to improve quality of care and reduce health care costs Position DRCOG in the role of integrator to further improve health care quality and reduce costs by engaging partners to identify and address community-level gaps.

3 Click Accountable to edit Master title style Click to edit Health Master Community title style goals Primary: Integrate and align the screening and referral of Medicare and Medicaid beneficiaries from clinical care to community care. Secondary: Reduce total health care costs and improve outcomes for communitydwelling beneficiaries by addressing unmet health-related social needs through April 30, 2022.

4 Click The consortium to edit Master title style Click to edit Master title style Community health providers Colorado Visiting Nurse Association Seniors Resource Center Brothers Redevelopment Volunteers of America Colorado Coalition Against Domestic Violence Energy Outreach Colorado Jewish Family Services City and County of Denver Adult Protective Services Clinical health partners Centura Health Metro Community Provider Network Denver Health Behavioral health partners Aurora Mental Health Center Jefferson Center for Mental Health

5 Click Core health-related to edit Master title style Click to edit Master social title style needs housing instability and quality food insecurity utility needs interpersonal violence (elder abuse, child abuse, domestic violence) transportation

6 Click Schedule to edit Master title style Click to edit and Master core functions title style Year one: Start-up activities Years two through five: Screen 75,000 people for health-related social needs in a clinical setting each year. Provide navigation services to 3,000 people each year. Track data and provide reports. Develop a care plan for each enrollee. Make referrals to community services consistent with care plans. Deliver community services. Conduct an annual gap analysis of community needs and resources. Create and update a resource directory. Implement a quality improvement plan.

7 Click Accountable to edit Master title style Click to edit Health Master Community title style boundary

8 Click Relationship to edit Master title style Click to edit of Master consortium title style activities Clinical process Community process screening and community referral summary accept referral data reporting enrollment and action plan data reporting assessment and enrollment navigation and referral service delivery

9 Click Guiding to edit Master title style Click to systems edit Master title style gap analysis data analysis and ecosystem health resource equity statement quality improvement plan policies and procedures data system

10 Click Data to edit Master title style Click flow to edit Master title style community partners clinical sites cost and use data use data process and outcome data navigators evaluation data claims data Medicaid and Medicare Centers for Medicare and Medicaid Services

11 Click to edit Master title style Click to edit Master title style Data collection and analysis A PREVIEW: REFER TO HANDOUT

12 Click to edit Master title style Click to edit Master title style Thank you! QUESTIONS? AJ Diamontopoulos Area Agency on Aging EO-PP-LEADAGE V04