Collaborise Helps Communities Navigate SDoH Challenges

Jan. 18, 2024
Cathy Story discusses new convener service Collaborise by QHN

Cathy Story is the director of Community Collaboration and Collaborise for Quality Health Network (QHN). She recently spoke with Healthcare Innovation about the new initiative Collaborise, which launched last month. Collaborise is, per a news release by QHN, “a convener service helping communities and organizations understand and navigate complicated issues, processes and technology surrounding whole-person health and social determinants of health (SDoH).”

Per the statement, “Collaborise is helping communities in Colorado’s West Mountain area identify resources and solutions to improve a mom’s access to behavioral health services through a grant-funded project started earlier in 2023.”

 

Could you speak to the structure of Collaborise?

Collaborise is one of the four offerings through QHN. QHN started in 2004 as Colorado’s rural communities’ Health Information Exchange (HIE). We evolved and built through 100 percent hospital participation. Clinicians and physicians are all part of that HIE. We moved into gathering behavioral health data, not just medical health data. As we evolved in 2020, at the height of the pandemic, we released our new Community Resource Network (CRN) platform, which is building the SDoH software so that the medical community and physicians could match up with community-based organizations to improve health outcomes. We piloted it here in western Colorado, and we have begun to see and feel the difference when a system talks to the medical community and talks to the behavioral community. Now, it talks with the social entities serving the same clients who need housing, food resources, and transportation to improve health outcomes. Then, circle the wagons around that person holistically and ask how we get the right data at the right time to inform the best services possible. There's less duplication of effort. There's less time that a client has to tell their story because we have shared platforms. Then we get the data out of it to say, are we making a difference? QHN evolved to create data and analytics for our partners in a much more robust way.

This year, we have built out Collaborise. As we put the CRN platform in, we realized that the communities often needed much more support because it wasn't around the software they struggled with. It was around determining how to communicate and move in a direction they could all agree on. Collaborise came out, and it's a way for us to go in now.

It might be a hospital looking to reduce emergency department (ED) access by patients with chronic diabetes. The hospital may see homeless people entering the ED because they can't manage their diabetes. When they dig in, they find out they're on insulin but can’t refrigerate it. They have no mechanism to keep it safe so that they can continue to use it. So, let's figure out how we can help them manage keeping their insulin.

If a care coordinator at a primary care physician's office finds out somebody doesn't have transportation, they have to know how to connect to the community and find that out. A community needs to circle around. The ED may want to impact the chronic use or overutilization of the ED and need patients to get to their primary doctor. If we can reduce the amount of time spent in an ED, we can reduce the cost of health care for everybody involved.

They bring me in and ask, who needs to be at the table to help us navigate the resources for the social or the behavioral part? And, who can we get to the table so we stay on top of what's happening in the village? Or, we want to improve this outcome, and we can't do it ourselves.

Hospitals are already stretched. They don’t have the capacity or staff to seek out those services.

My role as the convener for Collaborise is to pull together the different groups. Now, I have a methodology that will say, let's start here. Let's figure out what you want to do. You need to formalize this group, and let's move you through the steps of planning, discovery, implementation, strategies, and solutions. Then we're going to ask, how are you going to track it with data? How are we going to prove that you're making a difference? Because they want to see that they're making a difference for their funders and everyone else.

That's my job to come in and convene and offer facilitation assessment.

Does Collaborise work on a consulting basis?

It is partially consulting. It's multifaceted and depends on the project. I have two projects in Western Colorado, one in Mesa County and one in the resort mountain counties. Vail and Aspen are where our big ski resorts are and where the cost of living is extraordinarily high. I am being paid to build a group around perinatal behavioral health access because, in the mountain towns, we have probably 30 percent of the population in the service industry. They are struggling with access to behavioral health for a variety of reasons. There have been some difficult birth outcomes for that population compared to the Caucasian population because they're not seeking health services in behavioral health, postpartum depression, and postpartum anxiety. I am working in all four counties, a huge geographical region over mountain passes, trying to pull those rural communities together to maximize access and build access around behavioral health services specifically for pregnant women. I did a gap analysis, but now I'm convening groups that care about perinatal health, specifically behavioral health. I'm talking to those in behavioral health, and I'm having them talk to those people who actually deliver babies and treat pregnant women. I am pulling together those groups and formulating a plan to help them navigate how to improve outcomes: What needs to shift and change, and can we have a group that continues to meet even after I exit? I'm not in there very long. I come in and guide them in organizing and teaching them to facilitate effectively. I don't think of it as consulting, as I teach facilitation. I am coaching. I might meditate again.

My project in Mesa County is building a systemic approach to improve the quality of services for those unhoused or at risk of becoming unhoused. We have a large, unhoused population in Mesa County. They want to build a group that's active in a systemic way, not providing direct service, but supporting the providers that provide that service with either funding advocacy and policy change. With that group, I have moved them from meeting to formalizing their governance. So, help them create bylaws and conflict of interest documents. I help them work through navigating the difficult conversations to say, how do we think as a system and not as our own entity.  That's part of the collaboration, but we have gone through iterations to build that systems team there so that they can take the stage, offer improved services and client experience, and then prove our outcomes through data. It comes back to; we need to make sure that we can track and utilize the data to say that what we're doing is making a difference. In Mesa County, that's part of their big picture, to say, we got to pull together the numbers because there's not one number that you can just look up to see how many homeless people are living in Mesa County and how many people are at risk. That's the work of this group that I am helping them navigate through.

Collaborise is a way for communities to say, we have an issue or a problem, and we have to bring teams together to either brainstorm, build some strategies, or, in the long term, teach us how to collaborate.

Are there membership fees involved?

No, but they will pay for the services based on what they want me to do. So, if my team comes in and we say, alright, you want us to help you figure out how to track two medical outcomes from the emergency department and our largest hospital. I'm going to help bring this team together to say, what outcomes do you care most about? How are we going to gather the data and track it? It is the work of getting the community to what I would call rowing in the same direction, trying to solve an issue they can then parse through in a very efficient amount of time so that people’s day jobs are less impacted.

How are you collecting, organizing, and analyzing data?

Fortunately, in Colorado, and most states are going to this, HIEs and SDoH, the social information exchanges, are starting to blend. It’s becoming more common where they're shared. They may not be the same platform, but they are like QHN. I have the hospital data already through our HIE. With whatever HIE and whatever state I may work in, there's a health information exchange and they typically will have behavioral data. If they don't, we will help them figure out how to get behavioral data.

We're cutting edge. We are statewide doing some initiatives where other states are just piecemealing it by a variety of different platforms, but we are coalescing, at least in the state of Colorado and soon the state of Arizona. Then, we figure out how to teach people to combine all those for the best health outcome. If we need to feed data back to entities that are part of our HIE, then that's where our data analytics come into play. All the data is coming through there, whether through our CRN or HIE right now; we have databases for that.

Our CRN is a platform that is a closed-loop referral system. It has resource mapping. If you need access to food, we can send a referral electronically to the food bank and send them your information. This is with the right consent. It's shared referrals and case management reports.

Was there a model you based this program on?

No, it came out of this need. We’ve always been a convener at QHN. When we started in 2004 as QHN, they brought an advisory group of key community people, whether they were physicians, hospitals, community-based organizations, little nonprofits and asked, in a perfect world, what would our health information exchange look like?

One of the things we do that is probably the cornerstone of our data is admins' discharge and transfers from the hospital. Many of our partners need to know that their client was admitted to the hospital, discharged, or transferred to a higher or lower level of service. They get a notification from our HIE. This is so important to the well-being of the patient. Let’s say a senior at the hospital showed up at the ED because of a fall; their primary physician can do a wellness check. Then, when they are discharged, are they safe to go home, or do they need to go to a rehab center? That’s just a little bit about HIE and CRN and how it came to be that Collaborise came out of that. There’s constant convening to have these conversations about what’s necessary to improve services and outcomes and to help a community or an organization make an impact they couldn’t have made themselves.

How many patient care organizations are involved, and in which ways?

In Western Colorado, we deal with rural hospitals and communities. We have in our database only 16 hospitals. We are looking to affiliate with Contexture, which is the HIE for the Denver Metro area. We’re building out the CRN and piloting that in four different communities in the eastern plains to get them on board because they're very rural. One small town might have mental health services but not a hospital. Our job is to help them by getting on the pilots that we're going to do out there to get them in the SOdH so that they can share across these rural communities. We're trying to coalesce the eastern plains to get them as connected to each other as possible to maximize their efficiency in providing services.

What is the size of your team?

We have four people right now on my team. I have the whole team of QHN behind me as far as the data is concerned.

What are some of the outcomes you’re hoping for?

In Mesa County, we want to sustain existing emergency safety net providers for people experiencing homelessness. We want to make sure that we don't lose shelter beds, transportation, and food services because they're all nonprofits that struggle to stay afloat financially. They're constantly looking for grants and funding. It's hard work, so our job is to ensure those providers stay afloat and are supported. Because they spend so much time grant writing, it takes them away from doing the actual service to clients. We want to keep those people in place and improve the referral mechanism through our CRN. We want to synthesize how we take referrals. We will train care coordinators, navigators, and whatever you want to call them to be highly efficient in doing a standard referral and an assessment. We want them to create a care plan that will improve outcomes.

We're looking at the workforce; we're looking at advocacy. We're looking at funding and synthesizing data. We have to train those entities to gather that data, so it doesn't impact them very much. Then, that proves our outcomes.

We're going to try to emulate the best practices that we find. In Grand Junction, our homeless population has had encampment evacuations. This group wants to look at temporary housing because there’s not enough transitional housing.

We're beginning to make a difference for the service providers. We're looking at how we can then offer that support to keep them viable out of the gate. We're getting good feedback about that in Mesa County.

Collaborise wants to help communities more efficiently and more effectively solve whole health issues around the human that is person-centered and strength-based.

Check back with me in probably three months, and I'll bet I'll have some data outcomes for you.

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