Aging, Elderly, Senior Citizens
People/Families of People with Health Conditions
Poor, Economically Disadvantaged, Indigent
The Healthy Grand County 202 plan, created by healthcare providers in collaboration with community partners, is a blueprint to create a healthier community within 10 years. This plan focuses on access to care by assuring everyone has a primary care provider or a medical home, and on health education and literacy with an emphasis on patient responsibility and empowerment. Initiatives that focus on systemic changes, such as the Meeting Milestones Initiative, fall under this program. The Network is also the administrator of the Healthcare Professionals Society, an all-inclusive society of healthcare professionals from all sectors who collaborate to "put the patient first", and the Health and Human Services Coalition, an all-inclusive coalition of nonprofit and government agencies in the human services field working to create long-term sustainable solutions and implement community-wide programs.
The Network facilitates, or ensures the facilitation of multi-organizations minimally quarterly meetings for community nonprofits, providers and partners, to create ongoing trust and build relationships across organizations.
Young Adults (20-25 years)
Our Health Coverage Guide program provides individual and family education and assistance in enrolling in the Connect for Health Colorado insurance marketplace for Grand and Jackson Counties. This program is made possible through a partnership with the Northwest Colorado Community Health Partnership.
GCRHN employs 1 full-time certified health coverage guide who travels throughout Grand and Jackson Counties to meet individuals where convenient for them. The health coverage guide educates individuals and families on health insurance options, assists them in enrolling in Medicaid, CHP+, and Connect for Health CO, and refers those that don't qualify for tax credits to a certified broker.
Due to the nature of the program, it is extremely difficult to track the number of people the Health Coverage Guides helped enroll. Therefore, we review the trend of enrollment in both Connect for Health CO and Medicaid, knowing that our Health Coverage Guides assisted only a portion of the people enrolled.
Grand County had 589 covered lives through Connect for Health Colorado in 2013 and 855 in 2017; Jackson County had 37 covered lives through Connect for Health Colorado in 2013 and 80 in 2017.
Mental Health, Substance Abuse
Children and Youth (infants - 19 years)
Substance Abusers (Drug/Alcohol Abusers)
People/Families of People with Health Conditions
The Mental Health Navigator Program is a collaboration between the Grand County Rural Health Network, Middle Park Medical Center, Grand County, and Mind Springs Health, as well as an informal collaboration with all other local medical and mental health providers.
The Mental Health Navigator program, modeled after the Patient Navigator Program, launched in March 2017. This purpose is to provide brief intervention for a patient with an acute mental health need in a primary care or community setting. The Mental Health Navigator also removes barriers to mental health care, coordinates care across primary and mental health care, and empowers the patient to do the same once their acute need has been addressed.
The program has two 0.75 full-time employees at Mind Springs Health, both of whom are master's level clinicians. One employee works at Middle Park Medical Center for their primary care clinic and one employee works at the private providers and general community sites.
The pilot program was funded through the Colorado Health Access Fund, a fund of The Denver Foundation. The Colorado Health Access Fund then transferred the funding responsibility to the main employer of the Mental Health Navigators, Mind Springs Health, due to that organization having most of the administrative responsibility. GCRHN remains a partner with Mind Springs Health ensuring neutral convening of collaborative partners, as well as continuity in program marketing and system evaluation.
In 2017, hitting our benchmarks such as hiring and training navigators, are evidence of success. However, we also will gather baseline data on the number of patients in Grand County with diabetes, cardiovascular disease, and coronary artery disease. We will then compare that data with the number of those patients that received a primary care visit during the first year AND received an anxiety and depression screening. Of those patient, we will then track program data on the number that were referred to a mental health navigator, received brief intervention, and any referrals and follow-ups that occurred.
We will also track the number of patients transported in an emergency as well as track the entire process from the time the patient is discharged from a mental health hospital until they formally re-enter the community.
Children and Youth (infants - 19 years)
A.C.H.E.S. is our Advocacy for Children's Health and Education Services program. P.A.I.N.S. is our Partners for Adults in Need of Services program. In the absence of a centralized community care clinic, the Grand County Rural Health Network developed these programs to help meet the healthcare needs of low-income, uninsured residents of Grand County.
Through the A.C.H.E.S. program we provide vouchers for acute and preventative medical, dental, and mental health services for qualifying uninsured children. Through the P.A.I.N.S. program we provide vouchers for acute medical care and mental health services to qualifying uninsured adults.
The A.C.H.E.S. and P.A.I.N.S. Programs provided timely access to healthcare to 30 children and 44
adults in 2017. We have already served 8 children and 28 adults from January-May 2018.
Our follow-up surveys provide additional community impact information and allow us to accurately measure our objectives. The A.C.H.E.S. and P.A.I.N.S. programs provide timely healthcare intervention, thus improving the health and well-being of our Grand community. In 2017:
• 69% of clients spent $10 or less on their or their child's healthcare issue.
• 56% of clients were able to see a provider either the same or next day upon receiving the voucher.
• 91% of clients missed one day or less of work due to their or their child's illness.
• 17% of children missed less than one day of school due to their illness, illustrating the A.C.H.E.S. program positively affects the child's quality of life and ability to learn, while allowing more household dollars to be spent on basic necessities. Therefore, low-income children and adults receive timely medical intervention through the A.C.H.E.S. and P.A.I.N.S. Programs, resulting in less impact on their current financial situation and promoting health and well-being in their family and community.
Children and Youth (infants - 19 years.)
The Network implemented the Patient Navigator Program in early 2011 to guide patients through the healthcare system and community resources to assure patients get the care they need when they need it. The program also helps reduce barriers to care, such as language and financial and insurance status, by linking the patient with existing human services. In 2017, navigators served 235 clients, plus helped clients receive over $22,873 in direct funding for healthcare needs such as prescription assistance.
What the Patient Navigator Program Does:
Assists Grand County residents with barriers to healthcare.
Coordinates care and works with you to guide you through the healthcare system and to community resources to help you get the care you need when you need it.
Coordinates care in cases where there are several different specialists and healthcare providers. This is designed to reduce confusion and frustration for consumers.
Educates, clarifies, and reinforces diagnosed conditions to help you understand what is going on with you.
Assists you with what to do, how to do it, and planning for your best health.
Follows-up with you and your healthcare providers to be sure that the plan is on track and you are getting what you need.
Current program results indicate patients had better understanding of their chronic disease, feel better equipped to manage their disease, and illustrate improved clinical outcomes. Further, all patients exhibit higher scores; patients' average increase in scores from the first to last survey is seven points of 100 over the average case-open time span of 13 months―significantly higher than other similar programs. Further, current results illustrate a link between higher PAM scores and improved clinical outcomes. We will continue to improve PAM scores through navigation services. We will also work with Insignia Health to identify best practices for a long-term follow-up PAM score (example, one year after close of service) to determine retention of PAM scores. Therefore, we will increase immediate and long-term patient engagement levels.