Together Colorado “Bridges to Care” Fact Sheet
SUMMARY
The Bridges to Care project in Aurora, Colorado follows an initiative developed in Camden, New Jersey by Dr.
Jeffrey Brenner called “Hotspotters” that focuses on getting patients and resources out of overcrowded
emergency rooms and into quality primary care. In the “hot spot” model care teams visit patients in high-need,
high-cost neighborhoods to improve their access to health care and manage their chronic conditions.
Together Colorado will build relationships with patients and bring everyday voices to the public square on
affordable and quality health care.
Together Colorado Mission Statement
Together Colorado is a non-partisan, multi-racial, multi-faith community organization that unlocks the power of
people to transform their communities through community organizing. Comprised of 120 congregations, schools
and faith leaders from Pueblo to Fort Collins we are building a moral and democratic voice for human dignity in
Colorado through a racial and economic lens.
History
What is the history of Together Colorado and affordable healthcare?

Began working on Health Care in 2005

40% of membership did not have access to care

First issue cut was on extension of SCHIP, CHP+ in Colorado, children’s Medicaid

In 2009-2010 worked with PICO on protecting affordability in Affordable Care Act (ACA)
Who is Dr. Jeffrey Brenner?

Family physician
o
Lives and works in Camden, New Jersey
o
Member of PICO
o
Developed the hotspot project in Camden
o
Director of Camden Coalition of Healthcare Providers
History of Hotspotting in Camden, Jersey

Dr. Jeff Brenner learned community organizing from Camden Churches Organized for People (CCOP), a
PICO affiliate and applied the skills and principles of PICO’s community organizing model to re-organize the
health care system in Camden. In 2007 he began by asking the hospital to share claims data for city
residents. He was able to see that a small number of patients were over-using the hospital and relying on the
emergency room. The data also showed that the patients came from similar zip codes in the city, he called
them hot spots. Brenner used the data to create a team of health care providers that would wrap better
coordinated care around these patients. The group of providers was called the Camden Coalition of Health
Care Providers (CCHP).
Grants received (list types of grants and amount)

The Bridges to Care Project is funded primarily by the Center for Medicare and Medicaid Innovation (CMMI)
through a program called "The Healthcare Innovation Challenge". In June 2012, MCPN, along with 4 other
sites received funding to implement a clinical model based on the Camden Coalition of Healthcare Providers
partnership with Camden Churches Organized for People. The overall Innovation Award was for $14.3
Million for three years. Aurora will receive $3.3 over the three years of the project.

The community-organizing portion of Bridges to Care is being funded by Atlantic Philanthropies, which is
funding the same three years for the PICO national network affiliates working at each site. Together Colorado
will receive $50,000/year from this work. Additionally, Together Colorado's healthcare work is funded by The
Colorado Health Foundation, which has and will continue to support this project in Aurora as well as work
across the Metro Area. And the Colorado Trust supports Together Colorado’s work in building the public will
for people to receive the care they need, when they need it, at a price they can afford.
What is hotspotting?

Hotspots are areas of the community where the most amount of money is being used at the hospital, where
high utilizers of the hospital live

Lowering the cost of health care by wrapping high quality coordinated care around the highest utilizers of the
hospitals

Located in:
o
Aurora, Colorado
o
Camden, New Jersey
o
San Diego, California
o
Kansas City, Missouri
o
Allentown, Pennsylvania
Who is involved in the Bridges to Care project?

Together Colorado

Aurora Health Access

Metro Community Provider Network

Aurora Mental Health

Doctors of the University of Colorado Hospital
Who is Aurora Health Access?

Through community engagement and research, Aurora Health Access formulates solutions for a healthcare
system in Aurora that meets the needs of all residents

Aurora Health Access brings together a unique combination of residents, professionals and public officials
who are invested in creating a healthier Aurora for all residents
How did Aurora Health Access (AHA) form?

Began in 2009 at a public meeting hosted by St. Therese Catholic Church as the brainchild of their social
justice ministry FAMILY – a member of Together Colorado

In 2012, the AHA taskforce chose to formalize as a Colorado Non Profit and seated its first Board of Directors
in January 2013

Took action on a number of health fronts in Aurora
o
Lending their name and time to the "Yes on Recreation Campaign”
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Providing information about coverage options to Employers, Employees and customers of ethnic
restaurants
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Catalyzing several exciting projects, which will increase access to care for adults and children in Aurora
Who is MCPN? What is their role in Bridges to Care?

Metro Community Provider Network
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The only federally qualified health center in Aurora
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Care team
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Coordinating care between hospital and primary care to specialty care
o
Hiring the community health workers, social workers, nurse practitioners involved in the project
o
Care team has first contact with patients in the hospital and asks patients to be involved in the project
When did the initiative begin?

January 2013
What will the initiative look like? Timeline?

The Bridges to Care project is funded for the 3 years

In the first year MCPN will enroll 150 patients in the project
o
900 patients will be enrolled in the project after 3 years
o
Patients will enroll in project and participate in high-quality coordinated care from the home for the 60 days

End goal is that patients have their first appointment with their physician at MCPN after the 60 days

In the 60 day period Together Colorado leaders will make 2 houses visits to the patient’s home for
relational conversations with the patient, to hear their story and understand their barriers to
care. Additionally, Together Colorado leaders will explain the larger vision and goals of the Bridges to
Care Program.

After the 2 house visits Together Colorado leaders will invite patients to a meeting with other patients to
share stories and talk about the barriers to health care access in Aurora

Upon graduating from the program the patients will be invited to join the Together Colorado Health Care
committee
What are the goals?
Big goal:

Create better and more cost-effective care for frail older adults and people with disabilities nationwide
supported by Medicare and Medicaid policy.
Three-year goal 2013-15:

Improvements in the delivery of care, based off the Camden hot spot model, supported by evidence of cost
savings measures in accordance with standards set by Medicare and Medicaid actuaries, and the
reinvestment of a partition of savings in each local community to support addition service improvements.
What does success look like?

Generate savings between all five sites (Camden, San Diego, Aurora, Kansas City, and Allentown) of 67.7
million in Medicaid over three years

Develop health care transformation coalitions of providers, patients and community residents

Established data systems capturing base-line costs and quality to assess real-time impact

Develop formal mechanism to capture and re-invest Medicaid savings

Develop a national advisory board of respected health care experts who have provided strategic guidance to
the project and promoted it in articles and conference presentations