Coordinating care to improve overall health, for the mind and body
By focusing on the root causes of health issues in our social and physical environments, the Health Partnership aims to improve overall health and well-being in the region
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All referrals to the Health Partnership get an intake assessment, which helps care coordinators prioritize what type of care is needed.
Once that happens, care coordinators can:
- Address transportation issues to medical or mental health appointments
- Provide education and connection to community resources (food banks, housing, senior resources, etc).
- Assist with paperwork regarding resources, medical or mental health services
- Coordinate Medicaid providers and services (dental, eye care, hearing screens, appointments, specialty referrals, etc.)
- Facilitate communication across systems such as behavioral health, long-term care and specialists
- Promote client self-efficacy
- Locate necessities (hearing aids, canes, dentures, etc.)
- Develop care plans with the patient, family/caregivers, providers, and RCCO organizations
- Identify family and client’s strengths, cultures and values.
If you know someone who needs support, make a referral to the Health Partnership’s Community Based Care Coordination team.
If you’re interested in joining the task force to reduce stigma, contact Jane Davis at firstname.lastname@example.org. The first task force meeting is Sept. 25.
We often visit the doctor when something physically ails us, or for preventative screenings such as an annual exam, but mental health is too often overlooked as a part of overall well-being
The Health Partnership wants to change that because it recognizes that mental health is physical health, and vice versa.
”Our goal is to encourage people to put forth the same intention and effort toward mental health that they put toward their physical health,” said Stephanie Monahan, executive director of the Health Partnership. “We want mental health to be part of the culture of our community — just like brushing your teeth. … What activities do we do on a routine basis to ensure positive mental well-being?”
From promoting better communication about the importance of mental well-being to providing community-based care coordinators that help people navigate health care systems, the Health Partnership wants to improve care for the mind and body.
“As people have mental health needs or illnesses, our care coordinators are here to help them,” Monahan said.
Social determinants of health
The conditions people experience where they live, work, learn and play affect their health risks and outcomes, according to the Centers for Disease Control and Prevention.
These conditions — which include economic stability, education, social and community context, health and health care, neighborhood and environment — are known as the social determinants of health. Research shows that our environmental and social situations — such as housing instability, poverty and access to healthy foods — directly impact our overall health.
Improving the social and physical environments that promote good health is also one of the four primary goals of “Healthy People 2020,” the federal government’s prevention agenda for building a healthier nation.
The Health Partnership is acutely aware of these social determinants of health in the counties it serves: Routt, Grand, Jackson, Moffat and Rio Blanco. There are large disparities of these determinants across the region, Monahan said.
“Social supports help our mental well-being and help us live healthier, longer lives,” Monahan said. “Our agency is working to ensure the structural supports are in place in these communities, so when the storm rolls in — such as illness, loss of a loved one, unemployment, etc. — people have the tools and supports to be resilient, healthy and living their lives to their fullest potential.”
When people self-identify as having a social determinants of health needs, they are connected to the Health Partnership’s community-based care coordination team, which then helps connect them to the services and programs to support their needs, Monahan said.
Annual screenings — which the Health Partnership has collected from more than 700 people so far in 2019 — asks patients about things like housing, transportation, hunger, whether they’re experiencing any interpersonal violence and other questions.
“The no. 1 need in our region is food,” Monahan said. “Social isolation is a close second — and there’s a strong correlation between social isolation and mental health.”
Rocky Mountain Health Plans, the state-sponsored health insurance in Colorado, along with the Health Partnership, is part of The Accountable Health Communities Model, a five-year study happening across the country.
The Accountable Health Communities Model (AHCM) is trying to determine whether addressing health-related social needs — housing, food, utilities, safety, transportation — can reduce healthcare costs and improve healthcare quality and delivery.
Rocky Mountain Health Plans views the program as a “meaningful opportunity to provide policy direction and feedback to federal and state policy leaders and to move the entire healthcare system in a positive direction.”
No more stigma
Reducing the stigma surrounding mental health is another major focus of the Health Partnership.
“The evidence is out there, when you say ‘mental health,’ people automatically jump to ‘mental illness,’” Monahan said. “And everyone has mental health — it’s what allows you to get up in the morning, eat breakfast and get to work or school. I think stigma is an underlying issue in most places. We see this present itself in data points like suicide rates, substance use rates, and eligible but not enrolled rates for programs like food assistance, etc.”
The Health Partnership launched a task force, led by its new Stigma Reduction Coordinator, Jane Davis, to build a playbook for how to talk about mental health and human services in more positive and productive ways.
“I believe in the importance of having a common language regarding topics that can be so polarizing. Words matter,” Davis said. “We aim to maximize individuals’ potential by focusing on the positive.”
“Our goal is to ensure people feel comfortable asking for the support they need, whether that is seeking a therapist or food assistance or help with affordable housing,” Monahan said. “And we want to move public will — including resource investment — and policy to ensure the needed programs and services exist in our community.”
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The Routt County Board of Commissioners is back in the hearing room it vacated when the pandemic sent the world home in March 2020 — and the public is welcome to attend, too.