Health Care Innovation Awards: Project Profile


Project Title: "Integrated model of individualized ambulatory care for low income children and adults"
Geographic Reach: Colorado
Funding Amount: $19,789,999
Estimated 3-Year Savings: $12,792,256


The goal of the project is for Denver Health to transform its primary care delivery system to provide individualized care to more effectively meet its patients' medical, behavioral and social needs. This model provides team-based care, coordinates care across health settings and offers self-care support between visits enabled by health information technology (HIT) and team-based patient navigators who reach out to patients in a variety of ways. It also integrates physical and behavioral health services in collaboration with the Mental Health Center of Denver (MHCD) in existing primary care settings and in newly created high-risk clinics for the most complex patients. Over the three-year grant period, Denver Health's 21st Century Care program will ensure increased access to care by 15,000 people, improve overall population health for Denver Health patients by 5 percent, improve patient satisfaction with care delivered between visits by 5 percent without decreasing satisfaction with visit-based care, and decrease total cost of care by 2.5 percent relative to trend.

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