For the past decade, our health system has taken bold steps toward whole-person health through the integration of behavioral health care. The next frontier is social health integration, and we’ve made exciting progress on that front starting with social needs screening and now progressing that vision with the Community Resource Network (CRN).

The Centers for Medicare and Medicaid Services Innovation Center (CMS) launched the Accountable Health Communities Model (AHCM) to test whether addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.

To support the AHCM initiative, Rocky Mountain Health Plans and Quality Health Network (QHN) launched a social needs screening platform for use by primary care, behavioral health, and hospital partners in 2018. Clinical partners implemented social needs screening and provided resources to patients as a first, and critical, step towards addressing whole-person health.

Social needs screening has the potential to not just assist individual Members in addressing their needs but also can inform community priorities and programs.

A few of our findings as of March 2021:

Needs decline as income increases but even in individuals and households with incomes above $50,000 we are seeing food insecurity rates of roughly 7%.

The top three needs in western CO as identified by the screener are food, housing, and transportation.

There are clear racial and ethnic social need disparities in our Western Colorado population. Especially amongst individuals who are Native American.

Screening is an important step to ensure clinical care plans are realistic and effective and to change the culture around health, however, screening and resource identification doesn’t always lead to connection to services. We know that as much as forty percent of low-income Western Coloradans are experiencing shortages in food, housing, transportation, utilities, social isolation, and interpersonal violence. Community Members with these needs have significant strains on their emotional, time, and financial resources and just knowing about a resource does not mean that a person has the capacity to connect with the resource.

To improve health, we have to do more than just provide information about resources. We need to remove the barriers our patients face when trying to get help and take steps to connect them, knowing they may not have the time, energy, or resources to make the connection for themselves. This is why we are working hard to implement CRN in all of western Colorado, as quickly as possible. We believe that our platform, along with careful community organization and mobilization, will change lives in Western Colorado.


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