Organizing Tools & Resources

Bridges to Care

Together Colorado“Bridges to Care”Fact Sheet

SUMMARY

The Bridges to Care project in Aurora, Colorado follows an initiative developed in Camden, New Jersey by Dr. Jeffrey Brenner called “Hotspotters” that focuses on getting patients and resources out of overcrowded emergency rooms and into quality primary care.  In the “hot spot” model care teams visit patients in high-need, high-cost neighborhoods to improve their access to health care and manage their chronic conditions.

Together Colorado will build relationships with patients and bring everyday voices to the public square on affordable and quality health care.

Together Colorado Mission Statement

Together Colorado is a non-partisan, multi-racial, multi-faith community organization that unlocks the power of people to transform their communities through community organizing.  Comprised of 60+ congregations, schools and youth committees from Pueblo to Fort Collins and a growing statewide clergy network, we are building a moral and democratic voice in Colorado through a racial and economic lens. 

History

What is the history of Together Colorado and affordable healthcare?

  • Began working on Health Care in 2005
  • 40% of membership did not have access to care
  • First issue cut was on extension of SCHIP, CHP+ in Colorado, children’s Medicaid
  • In 2009-2010 worked with PICO on protecting affordability in Affordable Care Act (ACA)

Who is Dr. Jeffrey Brenner?

  • Family physician
    • Lives and works in Camden, New Jersey
    • Member of PICO
    •  Developed the hotspot project in Camden
    • Director of Camden Coalition of Healthcare Providers

History of Hotspotting in Camden, Jersey

  • Dr. Jeff Brenner learned community organizing from Camden Churches Organized for People (CCOP), a PICO affiliate and applied the skills and principles of PICO’s community organizing model to re-organize the health care system in Camden. In 2007 he began by asking the hospital to share claims data for city residents. He was able to see that a small number of patients were over-using the hospital and relying on the emergency room. The data also showed that the patients came from similar zip codes in the city, he called them hot spots. Brenner used the data to create a team of health care providers that would wrap better coordinated care around these patients. The group of providers was called the Camden Coalition of Health Care Providers (CCHP).

Grants received (list types of grants and amount)

  • The Bridges to Care Project is funded primarily by the Center for Medicare and Medicaid Innovation (CMMI) through a program called "The Healthcare Innovation Challenge". In June 2012, MCPN, along with 4 other sites received funding to implement a clinical model based on the Camden Coalition of Healthcare Providers partnership with Camden Churches Organized for People.  The overall Innovation Award was for $14.3 Million for three years. Aurora will receive $3.3 over the three years of the project.
  • The community-organizing portion of Bridges to Care is being funded by Atlantic Philanthropies, which is funding the same three years for the PICO national network affiliates working at each site. Together Colorado will receive $50,000/year from this work. Additionally, Together Colorado's healthcare work is funded by The Colorado Health Foundation, which has and will continue to support this project in Aurora as well as work across the Metro Area.  And the Colorado Trust supports Together Colorado’s work in building the public will for people to receive the care they need, when they need it, at a price they can afford.

What is hotspotting?

  • Hotspots are areas of the community where the most amount of money is being used at the hospital, where high utilizers of the hospital live
  • Lowering the cost of health care by wrapping high quality coordinated care around the highest utilizers of the hospitals
  • Located in:
    • Aurora, Colorado
    • Camden, New Jersey
    • San Diego, California
    • Kansas City, Missouri
    • Allentown, Pennsylvania

Who is involved in the Bridges to Care project?

  • Together Colorado
  • Aurora Health Access
  • Metro Community Provider Network
  • Aurora Mental Health
  • Doctor’s of the University of Colorado Hospital

Who is Aurora Health Access?

  • Through community engagement and research, Aurora Health Access formulates solutions for a healthcare system in Aurora that meets the needs of all residents
  • Aurora Health Access brings together a unique combination of residents, professionals and public officials who are invested in creating a healthier Aurora for all residents

How did Aurora Health Access (AHA) form?

  • Began in 2009 at a public meeting hosted by St. Therese Catholic Church as the brainchild of their social justice ministry FAMILY – a member of Together Colorado
  • In 2012, the AHA taskforce chose to formalize as a Colorado Non Profit and seated its first Board of Directors in January 2013
  • Took action on a number of health fronts in Aurora
    • Lending their name and time to the "Yes on Recreation Campaign”
    • Providing information about coverage options to Employers, Employees and customers of ethnic restaurants
    • Catalyzing several exciting projects, which will increase access to care for adults and children in Aurora

Who is MCPN? What is their role in Bridges to Care?

  • Metro Community Provider Network
    • The only federally qualified health center in Aurora
    • Care team
    • Coordinating care between hospital and primary care to specialty care
    • Hiring the community health workers, social workers, nurse practitioners involved in the project
    • Care team has first contact with patients in the hospital and asks patients to be involved in the project

When will the initiative begin?

  • January 2013

What will the initiative look like? Timeline?

  • The Bridges to Care project is funded for the next 3 years
  • In the first year MCPN will enroll 150 patients in the project
    • 900 patients will be enrolled in the project after 3 years
    • Patients will enroll in project and participate in high-quality coordinated care from the home for the 60 days
      • End goal is that patients have their first appointment with their physician at MCPN after the 60 days
      • In the 60 day period Together Colorado leaders will make 2 houses visits to the patients home for relational conversations with the patient, to hear their story and understand their barriers to care.  Additionally, Together Colorado leaders will explain the larger vision and goals of the Bridges to Care Program.
      • After the 2 house visits Together Colorado leaders will invite patients to a meeting with other patients to share stories and talk about the barriers to health care access in Aurora
      • Upon graduating from the program the patients will be invited to join the Together Colorado Health Care committee

What are the goals?

Big goal:

  • Create better and more cost-effective care for frail older adults and people with disabilities nationwide supported by Medicare and Medicaid policy.

Three-year goal 2013-15:

  • Improvements in the delivery of care, based off the Camden hot spot model, supported by evidence of cost savings measures in accordance with standards set by Medicare and Medicaid actuaries, and the reinvestment of a partition of savings in each local community to support addition service improvements.

What does success look like?

  • Generate savings between all five sites (Camden, San Diego, Aurora, Kansas City, and Allentown) of 67.7 million in Medicaid over three years
  • Develop health care transformation coalitions of providers, patients and community residents
  • Established data systems capturing base-line costs and quality to assess real-time impact
  • Develop formal mechanism to capture and re-invest Medicaid savings
  • Develop a national advisory board of respected health care experts who have provided strategic guidance to the project and promoted it in articles and conference presentations