Food for Thought: It Takes A Village

Health experts have long recognized the importance of factors outside the clinic that impact a person’s health and well-being. Food security, opportunities to exercise, and good jobs are all part of the social determinants of health. And even small communities usually have groups that work to improve these areas.

But connecting patients of medical care providers with community social resources isn’t always easy.

The July SNAC Lab looked at two relatively new Colorado workforces that seek to make these connections: Opportunity Liaisons and Regional Health Connectors.

Opportunity Liaisons: Picking the Right Program

Several state agencies are members of the Colorado Opportunity Project, an effort to identify and remove barriers to well-being at every stage of life.

Kathy Orr, the Opportunity Liaison for El Paso, Teller, Park and Elbert counties, discussed the work.

Members of the project’s steering committee began by looking at each life stage, from birth through old age, to identify indicators that matter most and the interventions most likely to make a positive change. For example, indicators of health during the family formation life stage include unintended pregnancies, low birth weight, maternal depression and family income. Opportunity Liaisons can connect families with evidence-based interventions, such as the Women Infant Children program, the Colorado Family Planning Initiative, Temporary Assistance for Needy Families and various family resource centers.

Regional Care Collaborative Organizations (RCCOs) will take over the Opportunity Project, Orr said, and local projects will take different approaches. Although the RCCOs are part of Medicaid’s Accountable Care Collaborative, several state agencies participate in the Opportunity Project, including the Colorado departments of Human Services, Labor and Employment, and Public Health and Environment.

The project aims to get agency workers to think differently about the value of the state’s many resources. Several programs work toward the same goals, but different ones might work best for different families.

The initiative holds promise, yet it’s hard to find data to measure its effectiveness, Orr said.

“What we learned is it’s super complicated,” Orr said.

Regional Health Connectors: Filling Various Needs

Two Regional Health Connectors from neighboring regions shared their work at the SNAC Lab: Darlyn Miller from Community Health Partnership in El Paso and Teller counties and Ashley Hill from Central Colorado AHEC in Park, Clear Creek and Gilpin counties.

Regional Health Connectors are hired by community-based health organizations throughout the state. Their aim is to build and strengthen networks of primary care, public health, human services, and community organizations working to improve health.

Miller said alcohol abuse is a big issue in her region. El Paso County leads the state in alcohol-related traffic deaths, she said. So she is working to connect health care providers with resources like Screening, Brief Intervention and Referral to Treatment (SBIRT), an evidence-based practice used to identify, reduce and prevent substance use problems.

Just over the mountains from Colorado Springs, Hill performs her Regional Health Connector work from her hometown of Hartsel.

“I have a special region. We don’t have any health care access,” Hill said. There are no clinics, no pharmacies, no dentists.

She is working with the South Park Health Service District Steering Committee to create a health service district in Park County, funded by a one percent sales tax on non-food items. It will be a tough goal to achieve. Clear Creek County tried a similar idea, but voters soundly defeated it.

Hill has also connected Easter Seals with people in Park and Clear Creek counties. As a local resident, she is well suited to make such introductions.

“Anybody who tries to work in Park County who isn’t from there, good luck. They’re not going to show up. They’re not going to trust the flatlanders,” Hill said.

The Regional Health Connectors are financially supported by Colorado’s State Innovation Model (SIM) and EvidenceNOW Southwest programs. The Colorado Health Institute hosts the SIM component of the project.

 Regional Health Connectors are in 21 regions that cover all of Colorado. They have just two years to work under current the funding set up.

Conclusion

The idea of connecting clinical care to community social resources isn’t new, but it’s gaining traction in Colorado. Community workers from two programs told SNAC Lab attendees about their successes and challenges. Data to show systemic improvements are hard to come by, and long-term sustainable funding is a challenge for these workforces. But one early lesson is that Colorado communities vary widely in their needs and priorities, and workers in the health connections field need local knowledge and local trust to be effective.