Neighbors Leading Change: Creating Something Out of Nothing: South Metro Transitions

By: Stephanie Spriggs, Grant Writer and Report Specialist, CIVHC

“Alone we can do so little, together we can do so much”

–          Helen Keller

The word “vulnerable” can describe many different types of populations – from those with limited access to care or lack of insurance, to those with a language barrier or new to the United States. The South Metro Health Alliance(SMHA) evolved as the health and wellness arm of the Littleton Immigrant Integration Initiative, an organization dedicated to making a new country feel like home to recently relocated individuals.

SMHA struck out on its own in 2010, with the mission to unite the community for better access tohealth care for all and to organize and advocate for improved health outcomes for the vulnerable patient population. Membership includes providers, educators, community–based organizations, and non-profits, all committed to work together to serve those who need it most.

In 2013, the SMHA was invited to a meeting at Swedish Medical Center to discuss community concerns about ambulance and emergency department utilization in lieu of urgent and primary care.  The goal of the meeting was to find a way to increase patient education regarding accessing care, reduce costs for taxpayers, and increase health equity for vulnerable patients.

SMHA agreed to convene a committee of necessary stakeholders to develop a pilot program to address the concerns of the community. Once prepared to begin work, the planning committee submitted an application for funding to get the initiative off of the ground. Unfortunately, the application was denied due to changes in funding strategy and the committee disbanded.

Months later, at the urging of a primary care physician and member of SMHA, a smaller group gathered with the intention of moving forward with the pilot despite the lack of operational funding. Each stakeholder at the table would provide what resources they could with their existing funding and through determination, creativity, and collaboration, South Metro Transitions (SMT) was established in late 2014.

Stakeholders of SMT:

At participating hospitals, SMT serves a population which includes the highest users of emergency room facilities, the uninsured, those on Medicaid, or those with high care management needs. Patients are enrolled in the program during an initial emergency room visit which then activates the rest of the SMT network.

The patient’s application for the program is sent to the Tri-County Health Department (TCHD) where the home-visit team schedules an in-home assessment and notifies both the behavioral health specialist at the Arapahoe/Douglas Mental Health Network (ADMHN) and the volunteer patient navigator at SMHA of the new participant. The patient navigator then contacts the patient and assists them with any additional community support required such as making clinic appointments and child-care, employment, or food assistance.

Valerie Purser, Executive Director of SMHA, stresses the importance of this final portion, “We often take for granted things like contacting a workforce center if we have lost employment or registering at the county human services department for food assistance to eat, but those tasks can become monumental to someone dealing with a serious illness either physical or mental.”

All stakeholders of SMT share responsibilities associated with the pilot program. TCHD manages the data and patient records as well as the home visit team. Boomers Leading Change in Health trains the volunteer patient navigators and SMHA coordinates them while at the same time providing technical assistance to TCHD.

Though the pilot is still quite new, and data is not yet available,  Ms. Purser notices “positive movement with people showing up for their medical appointments, and we have identified specific team members at ADMHN to work with our patient navigator in helping the SMT clients secure job opportunities and access employment programs that will set them up for success.”

It is not often that so many disparate stakeholders will rally together, much less without financial incentive. SMT and its participating members should be proud of what they have accomplished. Few would disagree with Ms. Purser when she says, “I believe that starting with no dedicated money and creating the infrastructure and showing our community that we can make a program like this work for very little investment is a success.  Demonstrating improved health outcomes, reducing ED visits, helping the person and their family become stabilized and able to contribute as active healthy citizens in their community again is a success.  And finally providing our evidence that we can work together even though we have our own missions and goals for each of our respective organization to fulfill is a success.”

South Metro Health Alliance is a Community Partner of Healthy Transitions Colorado.