CORHIO Partners With Mile High United Way and 2-1-1 Colorado on Care Coordination Project

With funding from Colorado’s Office of eHealth Innovation, CORHIO and Mile High United Way, on behalf of 2-1-1 Colorado, are partnering on a project to improve care coordination between health and human services for Coloradoans. This collaborative team is currently reaching out to healthcare providers, social service providers and community-based organizations to explore key partner and stakeholder needs.

This important effort builds on Social Determinants of Health (SDoH) research, which has shown that health outcomes are largely determined by social factors, and how coordinating health and social care could positively affect individual and population health outcomes, lower costs, and improve services.

The 2-1-1 Colorado database holds information for more than 8,000 services across the state of Colorado. These services are supported by more than 2,800 agencies. Offering a wide range of assistance, 2-1-1- Colorado connects individuals and families to resources including but not limited to: food resources, childcare, emergency shelter and housing, rent and utility assistance, and more.

CORHIO manages the health information exchange (HIE) for Colorado’s metro metropolitan areas, the eastern plains and some mountain towns. With more than 19,000 community healthcare users and all of the state’s large hospitals and health systems, imaging centers and laboratories sending data to the HIE, CORHIO’s infrastructure is in place to enable a successful referral program.

Three key elements of the proposed model CORHIO and 2-1-1 Colorado are exploring shows great potential that could help support a sustainable care coordination infrastructure for Colorado, including:

A statewide community resource inventory (CRI) provided by 2-1-1 Colorado 

• Standardizes community resources for all licensed and public users in Colorado; available to license by any healthcare, government, or partner entity
• Incorporates into an organization’s EHR, or case management system, or used as a standalone digital CRI resource
• Combines/aggregates other community resources and curates all resources to create a statewide CRI

Simplifies Community Based Organizations (CBOs) information updates (resource capacity, services, hours of operation, etc.) in one CRI rather than having to update information in several CRIs 

A closed-loop referral system provided by CORHIO

• Simplifies digital referrals of patients to social service agencies to meet their needs (food insecurity, mental health services, diabetes prevention programming, or rent/utility assistance) 
• Enables communication whereby CBOs pass information (status, service results, etc.) back to the healthcare provider 
• Completes a patient’s total picture of health/human service by adding information to the patient’s record
• Utilizes CORHIO’s established health information exchange (HIE) infrastructure, including data sharing agreements and technology capabilities
• Makes aggregate data available for analysis to understand efficacy, trends, etc.

A model that provides financial sustainability of the statewide CRI

• Focuses on the long-term sustainability of a statewide system with the ability to scale as appropriate and provide critical services to Colorado

Stay tuned for more details about this exciting project and please contact us if you’d like to participate in initial conversations about community needs.