Navigator - Provider Newsletter from Colorado Access

Welcome to the first edition of our quarterly Navigator newsletter. The quarterly Navigator is an expanded version of the previously monthly Navigator newsletter. This quarterly Navigator features community and provider partnership stories that will have themes related to diversity, equity, and inclusion, telehealth, behavioral health, social determinants of health, and highlights from our executive team. Our topics and stories will go more in-depth on important issues in health care and will be applicable to our provider network.

In the past, we have sent out a monthly Navigator newsletter in addition to a weekly COVID-19 update. We are excited to introduce a new format where we can share relevant information about not only COVID-19, but also important Colorado Access operational information and Colorado Department of Health Care Policy & Financing updates monthly as a Provider Update. If you do not currently receive the Provider Update each month, please email our team at providercommuncation@coaccess.com.

In good health,

Marissa Kaesemeyer
Director of Provider Affairs
Colorado Access

What to expect when you’re expecting: there are countless books out there, countless myths, countless theories, and countless differences among those experiencing a pregnancy. It can be confusing and daunting for anyone. Every expectant parent can use a little help but some need more guidance and oversight. Colorado Access has a program that is looking to identify those people, contact them, and make sure their pregnancy goes as smoothly as possible.

Colorado Access members alone made up approximately 15% of births in Colorado, according to the organization’s data from 2019. Their Healthy Mom, Healthy Baby (HMHB) program is addressing their needs and focusing on the complete care of those who are expecting, with the goal of healthy pregnancies, regular prenatal visits, access to the right resources, and proper care after birth. It covers all aspects of what makes for a healthy pregnancy - from doctor visits to emotional needs. The program now extends from first learning of a pregnancy to celebrating a child’s first birthday.

“It is important to make sure members are receiving prenatal care and taking other steps to ensure a healthy pregnancy such as taking prenatal vitamins and following a healthy diet,” says Karen Fowler Smith, a Colorado Access care manager who works with the Child Health Plan Plus (CHP+) side of Healthy Mom, Healthy Baby, “It is also important to assess members’ emotional health and screen for postpartum depression. Many times members need resources and referrals such as the Women, Infants, and Children program (WIC) but oftentimes members just need support. Members also frequently have coverage questions.“

Enrollment can begin when a member has their first doctor’s appointment, and the provider marks the patient as pregnant. It can also stem from claims data indicating a member is pregnant, then Colorado Access jumps in to get the member enrolled.

The member is assessed for their risk level. A variety of factors are considered, including a history of past complications, age, medical conditions, history of substance use, and behavioral health needs. According to the Colorado Access 2021 Pregnancy Registry, more than 1,300 pregnant members had up to three risk factors. If the pregnant person is given a higher risk score, a care manager will outreach that member first. If the member accepts care management, the care manager will give trimester-specific assessments. The assessments help to identify gaps, barriers, or other needs the member may have. The care manager also helps to create care plan goals to make sure needs are addressed. Even if a member is not deemed a high-risk priority, the member receives information from the Healthy Mom, Healthy Baby program with resources for each stage of their pregnancy. This includes everything from information on medical care and when to see providers, to postnatal topics like safe sleeping and postpartum depression.

One aspect of the program that Colorado Access is particularly proud of is the recently enhanced digital engagement component. It allows those who are expecting to receive text messages that send everything they need right to their phones. The enrolled participants get texts about three times a week, depending on the stage of pregnancy they are in. The most recent enhancements include an increased frequency of messages, bidirectional messages (including appointment reminders), and an extension of the program providing postpartum support for up to one year.

“Digital engagement reaches members with their preferred communication channel and ensures we are reaching as many members as possible,” Kate Myers, a Colorado Access health programs specialist, explains. “It allows us to access a large volume of members and we have seen a large reach and a large amount of messages sent.” She goes on to say, “We hope to see increased well visit rates as well as lowered adverse outcomes like premature birth and low birth weight.”

This makes it so that all the participants in the program, but especially the ones deemed higher risk, do not have to seek out information or timelines for care; it comes to them directly in an easily accessible way.

Colorado Access is continuing to work on digital engagement by sending surveys to those in the program through their text alerts. The information from the survey results will allow the organization to improve things and amend things as needed.

Caring for those who give birth is a topic that has been top of mind in Colorado recently. At the beginning of July, new legislation went into effect that extends postpartum coverage for Health First Colorado (Colorado’s Medicaid program) members and CHP+ members in Colorado from 60 days to a full year after they give birth, in addition to the care they receive while they are pregnant. Previously, when the coverage ended after 60 days, Colorado Access found that a significant portion of Medicaid members ended up with a gap in coverage, putting them at a higher risk for poor outcomes and higher costs. Now Colorado Access is adjusting the program and digital engagement so that it accommodates the extended coverage. And they are excited to add additional resources for their parents.

“I have really enjoyed being a HMHB care manager for CHP+ the last four years. It is the work I love to do! It is very rewarding to follow a member throughout her pregnancy,” Smith says of her work with the program, “I think it is beneficial for members to have a point person who can answer questions and fill in the gaps. It is a wonderful position.”

Now that the coverage is extended, there’s no time like the present to make sure that any Colorado Access member who is pregnant is taking part in the program.

The great thing about Healthy Mom, Healthy Baby is the partnerships and other aspects that extend far past the regular program. For example, the program can connect those who are expecting with Supplemental Nutrition Assistance Programs (SNAP), childbirth classes, and family planning. They can also call on the AccessCare Virtual Care Collaboration and Integration (VCCI) Program to get members help if they are experiencing things like depression or other mental health issues. It’s as simple as referring a member to the program and getting them signed up.

To get a member who is high-risk and in need of care management enrolled in the program, call 866-833-5717 or complete this form to make a referral.

Being a teenager is tough. In addition to worrying about grades, sports, clubs, rules, parents, friends, and the future, the pressures of being an adult are already seeping into everyday life. That means dealing with things like stress, anxiety, and sometimes even depression. A recent survey by the Colorado Department of Health and Environment showed that 40% of Colorado youth surveyed experienced feelings of depression in the past year. Still, prioritizing weekly visits with a therapist is probably not at the forefront of the minds of most Colorado teenagers. It might be that they are too busy, or that they are embarrassed to tell their parents about what they are dealing with. The AccessCare partnership with Kids First Health Care (Kids First) addresses those concerns head-on.

AccessCare is a subsidiary of Colorado Access that provides telehealth services. In 2017, it implemented the Virtual Care Collaboration and Integration (VCCI) Program, which offers virtual behavioral health care support to participating Colorado Access network primary care providers. In partnership with Kids First (a nonprofit organization and school-based health center providing primary and preventative health services to children and youth), the VCCI Program connects students that have behavioral health needs with virtual counseling and psychiatry, as well as coordinating the care with Kids First as the primary care medical home. Students have the option to participate in telehealth services in their home or directly within the schools now that the VCCI Programs works with all Kids First clinics, which include 6 school-based health centers and 2 community clinics.

The benefits of this type of integrated care are numerous for these students, but the biggest, if you ask AccessCare Director of Telehealth George Roupas, is the improved access to behavioral health care. It can eliminate the involvement of their parents, surpass any internet access issues, and avoid adding one more thing to their already busy schedule. “Behavioral telehealth can connect students with care that they may not be able to receive otherwise, allowing for more equitable access to services regardless of physical, social, or transportation barriers,” says Roupas.

It also means that more youth get the behavioral health care they need, in part because counselors who see students face-to-face are able to recognize the signs and get almost immediate help. Instead of waiting weeks or months to see a therapist in person, with the VCCI program, they are often seen in just one week. That’s because when virtual appointments during the day are an option for students, more appointments are available.

In addition, it allows the school-based health centers to coordinate physical care with behavioral health care, something that can be extremely important in cases where a student may be dealing with something such as an eating disorder, which needs to be treated both physically and mentally. And it gives students a place to discuss things they may not feel comfortable discussing at home.

“The program has provided a safe space for students to discuss and receive treatment for depression and anxiety, PTSD, gender identity exploration, family-related issues, and much more,” says Roupas. “Preliminary reporting also reflects a potential for a reduction in truancy and visits to the ER.”

Possibly the most important benefit is the change in mindset. “This program helps patients recognize the importance of mental health care and aids in reducing the stigma around seeking mental health services,” says Emily Human, clinical initiatives manager for Kids First Health Care.

Since the program began in July 2017, there have been more than 5,100 encounters, with more than 1,300 in 2021 alone. From 2019 through 2021, the VCCI Program experienced a 47% uptick in the utilization of its virtual behavioral health services. This increase reflects the growing need for these services since the pandemic began and hit Colorado’s youth especially hard. In May 2021, Children’s Hospital Colorado declared a state of emergency for pediatric mental health. In May 2022, Children’s Hospital said the situation had worsened during the past year.

Of course, the pandemic stressed just about everyone out. But for youth, it meant missed milestones, isolation during lockdowns, stretches of remote learning, the fear of losing a loved one to illness, and watching parents struggle with uncertainty and stress at home.

Staff working with the VCCI program say that most of the youth using the program are between the of ages 13 to 19 years old, and they are often seeking services for depression or anxiety. These age groups missed things like school dances, graduations, driver’s education courses, getting their licenses on their sweet sixteen, college campus visits, and parties with their friends.

It is possibly more important than ever for students to receive timely therapy and have issues addressed. And learn how to address those issues, before they become more prevalent.

“Having a program like Kids First counseling at school has really helped me take control of my own mental health,” wrote a student who was part of the program and submitted a quote to Kids First, “Prior, it was very difficult for someone my age to find some place that would help put me on the right path for counseling and psychiatry. Kids First has opened so many doors for me to finally understand what I need and finally start to feel better. Since having the telehealth program at school, it has become way more accessible and way more simple to get help when I need it, and for that I am forever grateful.”

Seeing the impact this partnership has had on the kids who utilize it, the hope is to expand. “Kids First Health Care hopes to continue to grow our mental health program for our patients,” says Human, “We hope we can continue to offer this program to support the mental health needs of our patients. This program is an incredible resource for patients in need of short-term therapy.”

A study indicates that 46% of Americans will meet the criteria for a diagnosable mental health condition sometime in their life and half of those people are estimated to develop conditions by the age of 14.

If you ask Perla Duran what the biggest strength of the Latinx community is, she will immediately tell you, “I think resilience, most of us are immigrants so we have survived a transition in culture and we can survive mental health issues.”

But Duran also knows, that her community is currently in need of a little bit of help.
“Mental health is an issue right now” she says, “because people don’t have the knowledge of what mental health is and what mental health is not. So, I think, the resiliency is being able to learn and be open and seek help.”

Duran works at El Consultorio, a practice in Denver that specializes in working with Latinx and multicultural clients in the area of mental health. She gathered in a room of her peers and community members in June near Metropolitan State University (MSU) Denver. The sounds of conversation, spoken in native Spanish, filled the room as partners and providers talked about the challenges they face in offering behavioral health services to the Latinx community. The providers gathered to share stories and solutions, to form a cohesive group that is banding together on this important issue.

In Colorado, more than 22% of the population is considered Latinx and 37% of Colorado Access members identify as Latinx. The numbers make it clear that more thinking and action are needed to make sure the cultural, linguistic, religious, and financial needs of this community are represented in the providers they seek. And right now, that is still a work in progress. Work that this group, along with Colorado Access, is ready and willing to roll up their sleeves and do.

The participants gathered at the June Colorado Access Sombremesa (a term in Spanish for a conversation held over the dinner table). The attendees mainly hailed from smaller practices, ones that have a significant impact in addressing these issues. It’s been proven that members of the Latinx community seek out these smaller practices, partially because going to a smaller practice makes them more comfortable, but also because they may be more likely to accommodate the culture and the language. The attendees hope that this is something that can change. For them, it can sometimes be about the smaller details; the issues that are often overlooked.

The language barrier has long been at the forefront of the issues surrounding Latinx providers, along with finding and retaining the right staff to offer services to the community. As members of the June discussion pointed out, it isn’t just about finding people who speak Spanish, it’s about finding people who are proficient enough in Spanish to give counseling. It’s also about retaining those staff members.

Just because someone says they speak Spanish, the participants pointed out, doesn’t mean they are able to give feasible and clear therapy in Spanish. That may require an entirely different level of proficiency. Similarly, a client may need to be engaged with the nuance that is sensitive to their personality and life experience; fostering trust is critical, and that aspect may also need to be considered when providing the right staff member. One of the biggest barriers the group spoke about came with paperwork. Although members may not speak any English at all, they are required to sign regulatory paperwork that is provided in English. It would probably be hard for most native English speakers in the United States to even fathom how daunting and possibly frightening it would be to sign medical documents in a language they don’t understand.

It isn’t just finding fluent Spanish-speaking clinicians, or translating paperwork; cultural aspects exist in the Latinx community that keep members from seeking help when they need it most. Of course, there is stigma. It’s an issue that exists in many other communities as well, the pervasive thought that seeking therapy or other services means there’s something wrong with you; that you could and should be able to figure this out on your own. But then the issues only continue when community members finally work past these ingrained thoughts, only to find that providers are not taking their culture into account.

One discussion group member shared that her religion was a big part of her wellness, but that it was hard to find a provider who would blend her therapy with her faith - something that was extremely important not only to her culture, but to her recovery. It was her thought that understanding the language is not the only thing one must understand to offer care, they need to understand other cultural needs.

It was also pointed out that providers get paid more for the treatment of individuals than for couples or family counseling. But in this community, family is everything and including the entire unit in treatment can be extremely beneficial. “We stay close to our families longer,” explained Russell Urrutia of Forward Families Denver/Adelante Familias, “So, if you work with us without our families, you estrange us from our families and make us different from our families.”

Urrutia, who has been passionate about working with the Latinx community and was instrumental in the creation of the Sobremesa event, admits that he was not previously offering family services himself because of the difference in pay. Duran echoes this sentiment, as she puts it, “Latinos are family-oriented so the adults may not seek treatment for themselves, but they will do it for their kids and their family. That’s how they get involved in this type of help.”

The event was not just held for discussion, solutions are a big part of what makes this event so important. Groups pointed out various ideas for increased support. That’s where Colorado Access truly enters the picture. There needs to be a change. And as Bobby King, Colorado Access vice president of diversity, equity, and inclusion said at the event, “This is the first time that we are meeting as a community, but it won’t be our last.”

As Duran puts it, her greatest wish is just more attention for her community. “We are just hoping that they know we are here, and they know that we can help them.”