Small Health Care Provider Quality Improvement - Tri-County Health Network, doing business as Thrive Community Health Network, is requesting funding to launch the Critical Time Intervention (CTI) project in Montrose and Delta counties in rural Colorado. Our proposed clinical service area is Care Coordination. Through CTI, Thrive will replicate the evidence-based Critical Time Intervention model. The project will address the need for intensive, targeted, care coordination support services for people navigating a crisis who are high utilizers of medical care. Many community members in our region struggle with chronic disease, mental health disorder, and substance use disorder self-management due to a lack of providers, disparate community resources that are challenging to navigate, limited transportation options, and a rural culture of self-reliance. While some care coordination services are available in our region, they are all designed for people with a baseline level of stability. CTI will allow us to support 100 high-risk clients across the three core CTI phases: Transition, Try-out, and Transfer of Care. At the end of the provision of services, we anticipate improved mental health disorder management, reduced severity of substance use, improved chronic disease self-management, reduced reliance on the emergency room, and improved quality of life for participants. With CTI, we will serve patients accessing care with two of our Network members (Montrose Regional Health and River Valley Family Health Center). These clinical partners will screen patients for chronic disease, mental health disorder, and substance use disorder; social driver of health needs; and 2 or more emergency room or urgent care facility visits in the previous 12 months or 2 of more missed appointments in the previous 6 months. We will implement three quality improvement strategies with the CTI project. Thrive will convene a multidisciplinary quality improvement (QI) team with partner clinic, community-based organization, and Thrive staff to conduct rapid-cycle Plan-Do-Study-Act tests using the evidence-based Model for Improvement (MFI). QI team members will be trained on MFI and act as accountability partners so we can build a shared regional QI culture and streamline referral workflows. Thrive and our partners will also strengthen data collection using health information technology (HIT). During the first 6 months of the project, Thrive will select and implement a HIT platform with artificial intelligence predictive functionality. This tool will standardize monthly data integration with clinical electronic medical records and the regional Health Information Exchange, monitor quality measures (such as HbA1c, blood pressure, and emergency room utilization), maintain a digital map of community resources, and support our efforts to bill Medicaid and Medicare for services. To support the sustainability of services beyond the 4-year grant period, Thrive will operationalize Medicaid and Medicare billing for CTI client services. Systems and training will be implemented to leverage Colorado's Medicaid State Plan Amendment for Health System Navigation and Medicare Principal Illness Navigation (and Community Health Integration codes. During the final year of the CTI project, we will conduct a formal revenue optimization analysis to ensure we can maximize Medicaid and Medicare billing and that services will sustain after the grant ends. The quality improvement components of CTI will allow us to address the following needs: no current HIT resource used by clinics or community-based organizations that can support needed for project management, evaluation, quality improvement, and billing; a lack of knowledge and systems in place to bill Medicaid and Medicare for CHW services; and no multidisciplinary quality improvement efforts in our region.
