Personalizing care coordination in Colorado

Effective care coordination is critical to supporting our members’ experiences and health outcomes. Care coordination provides connections to essential care and resources. At Rocky Mountain Health Plans, a UnitedHealthcare company, we are dedicated to delivering exceptional, personalized care coordination. Our approach includes connecting each member with a longitudinal care coordinator. For members with unique needs, including complex conditions, we have specialized care coordination to address a wide range of populations and health conditions.

With nearly a 50-year history in Colorado, we are uniquely embedded in the communities that we serve. Our innovative hybrid care coordination model draws on our deep experiences and strategic local partnerships. The hybrid model consists of RMHP-based care coordinators as well as Integrated Community Care Teams (ICCTs). ICCTs are the subject matter experts in their local area; many have decades of trust with both members and providers.

ICCTs consist of interdisciplinary teams that can include both clinical and non-clinical roles. They exist in a variety of settings throughout the area we serve, including within Federally Qualified Health Centers (FQHCs). Their understanding of resources and barriers in their neighborhood enables ICCTs to provide highly individualized, relevant care coordination. They utilize the same workflows and platforms as RMHP-based care coordinators to create a streamlined experience for members.

The Western Slope Native American Resource Center (WSNARC) is one ICCT serving members who are American Indian and Alaska Native. WSNARC specializes in connecting families to culturally responsive, community-based services. Their specialized expertise, local knowledge and lived experiences help get our members connected to the right care and services that address their individual, whole-person needs. By embedding these teams within community organizations and local public health agencies, we aim to make care coordination even more culturally and locally relevant to our members.

For members who have chronic, complex conditions who need more prolonged and intensive support, we provide extended care coordination. A recent analysis of our population of members with complex needs who receive extended care coordination found that those members experienced a 33 percent decrease in Emergency Department utilization and a 31 percent decrease in inpatient utilization. Beyond these statistics, extended care coordination can have a profound impact on the families we serve.

Member Story: The impact of extended care coordination

When D* was born in 2022, she had significant congenital syndromes that required highly specialized, around-the-clock care. D’s family lives in Delta County, about 6 hours from the children’s hospital that provides the kind of care she needed. Once D returned home, she would require multiple therapies and types of care. The children’s hospital experienced barriers finding a licensed provider who could provide skilled care to D at home in Delta County. D’s family took on the complex, exhausting challenge of caring for the fragile infant 24/7. Despite their best efforts, D experienced a respiratory event and pneumonia diagnosis, and needed to be readmitted to the hospital.

Rocky Mountain Health Plan’s team of care coordinators immediately jumped into action to find a sustainable solution to meet D and her family’s needs. They championed the challenge of finding a local option for in-home skilled care in the rural community. The team facilitated meetings with a wide-ranging, interdisciplinary team of stakeholders including D’s parents, local heath care providers, State agency partners and community organizations. Together, this team evaluated the needs, barriers and available resources and determined that a private duty nurse would help support the D’s needs, including preventing hospitalization, reducing costs and providing the best clinical outcomes.

Our care coordination team worked tirelessly, contacting over thirty home health care agencies before identifying one agency that could meet this need. They collaborated with State partners to expedite all licensing requirements. A hospital in a neighboring county identified a Neonatal Intensive Care Nurse to provide overnight care five nights her week. Through this team’s combined efforts, D was able to start physical, occupational and speech therapies that improved her quality of life.

The team continued to facilitate care conferences to provide interventions, support and resources via the interdisciplinary team. This collaboration enabled the D’s family to access needed equipment and resources to support D’s care at home and when traveling throughout the state for care appointments. Our team continues to coordinate weekly check-ins via a community paramedic program to monitor D’s wellbeing. They helped the family navigate social services and obtain a waiver for in-home support services to reduce financial and medical burdens.

D is now growing, smiling and getting love from her family at their home in Delta. Rocky Mountain Health Plans is proud to be part of the collaborative process to help D and her family receive the care and resources they need.

*D’s name was changed to protect patient privacy.

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