Provider Insider

Issue 1

Table of Contents

Leadership message

A message from Dr. Austin Bailey

Welcome to the first issue of Provider Insider. Our goal is to share information about Coordinated Care that will benefit you, your practice and your patients.


Perhaps the most important message for the inaugural issue is to reinforce “why” Coordinated Care and “why now.” The simple answer is to improve population health in our communities and drive down costs in the process. But there’s a little more driving this need, and it’s helpful if we’re all aware and united as we move forward.


There are two fundamental forces driving this paradigm shift toward integrated networks:


• A shift from local to regional, if not national, presence for many employers.

• High-performing health care delivery is more critical than ever before.


Let’s put ourselves in the shoes of the business owner for a minute. As more and more businesses consolidate, their geographical footprints get larger, and they need access to larger health care networks. For example, King Soopers and City Market are located throughout Colorado, yet they are owned by The Kroger Co., the nation’s largest supermarket chain, which purchases its health insurance at a national level.


Regional and national employers expect and need access to a network of providers that can cover all their employees, regardless of where they live. As an industry, health care is moving rapidly away from patients choosing a practice or a hospital based on one locale and quickly toward offering a list of providers or hospitals across a wide area. It makes sense: The broader the network, the more value to the employer.


In addition to desiring a broad network, employers continuously look for ways to reduce health care costs. They want to partner with networks that offer extensive reach while also illustrating an ability to improve health care outcomes and decrease costs at the same time. As a clinically integrated network, we exist to do both—improve care and reduce costs.


One final point I’d like to stress: The most important word in the previous sentence is “we.”


Coordinated Care is a united effort driven by individual providers. This is your network. Collectively, we are developing best practices—and sharing those best practices—so we can discover better ways to deliver quality care at affordable costs.


I can’t express this enough. We are in this together, and we will succeed in improving population health through everyone’s ideas and contributions.


I look forward to working by your side as we move forward in this new era of health care.


Austin Bailey, MD

Medical Director, Population Health, UCHealth

[email protected]

Practice spotlight

Associates in Family Medicine is encouraging collaboration to improve outcomes

Associates in Family Medicine (AFM) is embracing both the potential value and opportunity Coordinated Care provides to participating members. With offices in Fort Collins, Windsor and Loveland, AFM has been offering quality care in the region for nearly 60 years. Since joining Coordinated Care, the chance to deliver an even higher level of care is possible.


James Sprowell, MD, AFM’s CEO

“In a rapidly changing health care environment, a shift to value-based reimbursement presents an advantage,” says James Sprowell, MD, AFM’s chief executive officer. “The Network emphasizes provider and insurance payer collaboration, which allows us to align our common goals to deliver measurable quality medical care in a more cost-effective manner for patients.”


AFM has gained valuable insight from enhanced data collection, validation and analytic resources provided by the Network. Primary Care Panel Metrics deliver continuous monitoring of wellness and disease metrics by office and individual providers.


“Knierim Classification Index (KCI) Risk Stratification Tool is one of the risk tools AFM utilizes to identify individual patients by health risk for development and implementation of personalized care plans,” says Dr. Sprowell. “It’s making a measurable difference in quality of care.”


Prior to joining the Network, AFM developed infrastructure and processes to support a team-based, comprehensive approach to health care. On a patient, staff and provider level, AFM continues to advance this effort by hiring additional providers, clinical pharmacists, social workers, quality improvement nurses and quality improvement specialists. Coordinated Care greatly expands those partnerships and collaborative opportunities for AFM.


Another valuable advantage: the ability to follow patients’ medical care at all points of contact within the Network’s electronic medical records (EMR) system.


“Our patients appreciate the integration of the EMR system,” says Dr. Sprowell. “It allows us to avoid once cumbersome medical record transfers and registration redundancies.”



In addition to gaining efficiencies through resource integration, AFM has actively participated in the Network’s Clinical Transformation Workgroups. Having a seat at the table gives AFM an opportunity to connect at the highest levels within the Network, share best practices and participate in a blueprint for success.


“Collaboration with other Coordinated Care members has been both challenging and mutually rewarding,” says Dr. Sprowell. “Being connected with other members and influencers allows all of us to improve population health outcomes, improve patient and provider satisfaction, and reduce overall health care costs.”

Transform insight

2017 Engagement Summit: Future in focus

During our inaugural Integrated Network Engagement Summit, attendees gained valuable insight into Coordinated Care’s operations, as well as a clear and vibrant future vision from Jean Haynes, chief population health officer, and Austin Bailey, MD, medical director of population health, who shared the network’s five-point strategy for the year:

  1. Develop the capabilities necessary to manage the health of a population and the infrastructure needed to take on risk.
  2. Demonstrate value to payers, providers, employers and consumers via quantifiable results in a transparent manner.
  3. Ensure that UCHealth and its affiliates and partners go to market as one to payers, offering a high-performing network.
  4. Create a clinically integrated network comprised of owned and partnered assets across the care continuum.
  5. Select strategic payer partners to collaborate on new risk-based offerings.

By focusing on this strategy, Coordinated Care will be positioned to assume the accountability and risk for clinical quality, clinical outcomes, patient experience and costs.



Attendees also received highly valued insights from local and national experts, as well as members of the Population Health Services Organization (PHSO), in the areas of Clinical Transformation, Clinical Pharmacy and Care Management.

  • Clinical Transformation: Strategic planning improves outcomes
    Four presenters provided practical examples of how cooperative, collaborative and active engagement drive desired results—clinically and financially—for patients, payers, employers and providers.

    • Mark Earnest, MD, PhD, FACP, and professor of medicine and head of the Division of General Internal Medicine for the University of Colorado Anschutz Medical Campus School of Medicine, shared his latest accomplishment, an Innovative Approach to Hypertension. The 18-month Hypertension Impact Project achieved 70 percent hypertension control across two general internal medicine practices. The strategies to capture this sort of success can be shared across the network for vast improvement.
    • Paul Staley, MA, CACIII, who has clinical experience as a behavioral health professional and serves the PHSO as the director of network engagement, presented a means to effectively integrate behavioral health into primary care. Staley stressed that attention to the behavioral health needs of our population is the “right thing to do” and shared models of care that practices could implement for the benefit of patients.
    • Aimee English, MD, assistant professor at the University of Colorado Family Medicine Residency, shared her experience at AF Williams (Denver, Colo.) in the design and implementation of effective patient/family advisory committee(s).
    • Mina Harkins, assistant vice president of recognition programs policy and resources at NCQA, shared the benefits of engaging patients as it pertains to the Quadruple Aim. Both presentations brought relevant strategies practices could implement in their own practices.
  • Clinical Pharmacy: Importance of enhanced communication
    • Joseph Vande Griend, PharmD, FCCP, BCPS, BCGP, director of population health pharmacy at UCHealth and clinical associate professor at the University of Colorado Skaggs School of Pharmacy, stressed clinical pharmacists are an asset to the care team with proven effective medication management leading to better quality clinical outcomes and, thus, reduced health care costs. Dr. Vande Griend shared with the group his strategy to responsibly expand pharmacy services across the clinically integrated network.
  • Care Management: Create efficiencies across the health care spectrum
    • Melody Wright, RN, CCM, CGCM, ICM-CT, director of regional strategic partnerships/post-acute care, and co-presenter Amanda Nenaber, DNP, APRN, CCNS, ACNS-BC, interim director of collaborative care coordination, bring a wealth of knowledge from the care management industry. Wright and Dr. Nenaber presented the key strategies pertaining to care coordination across the health care continuum. The mitigation of disjointed care will improve effectiveness of clinical guidelines, safety and efficiency across the health care landscape. The network strives to spread care management services across the state.

Coordinated Care is well on its way to successful integration across the state of Colorado. Significant strides have been made in expanding our provider network footprint since 2015. Fully implementing our strategy is a tall order, but optimal patient care will be achieved through collaboration and an unending desire for improvement.


The 2017 Integrated Network Engagement Summit was the first of many ways we will share goals and best practices that benefit all of us. We look forward to sharing more opportunities for engagement in the near future, and we look forward to working closely with you to improve outcomes for patients throughout the region.


To download the presentation materials from this event, click on these links:

Integration of Medical and Behavioral Health:  Putting Things in Perspective
Care Management:  Ambulatory, Acute and Post-Acute
Division of General Internal Medicine Hypertension Impact Project
Integrated Network Engagement Summit Future Strategies of the Integrated Network
A National View of How Patient Engagement and Business Intersect
Opportunities to Achieve the Quadruple Aim:  Clinical Pharmacists Across the Clinically Integrated Network
Patient Centered Care:  Both in Individual Conversations With Patients and Practice Transformation Efforts
Coordinated Care:  How Far We Have Come and Where We Are Going

Quadruple Aim progress report

Measuring performance and setting targets

Here’s the exciting news: Coordinated Care’s Clinical Committee obtained approval from the board of directors to monitor a clearly defined set of key performance indicators (KPIs). These metrics are a means to quantify the performance of the clinical quality improvement efforts implemented by our network partners, agnostic of value-based arrangements (i.e., payer arrangements and government programs).


The Clinical Committee selected six (6) KPIs for 2018 and 2019, across two domains: Chronic Disease Management and Prevention. How were they selected? The Clinical Transformation Workgroup used these guiding principles to nominate, discuss and refine each of the KPIs mentioned below:

  • Do they positively influence patient outcomes?
  • Do they positively influence the Quadruple Aim (improvement in population health, patient experience, per capita cost and provider experience)?
  • Do they positively influence the quality performance among the Network’s value-based arrangement?


Diabetic patients a primary focus

Care for our diabetic patients was chosen as the Network’s main focus for 2018. Here’s why:

  1. A single focus allows Coordinated Care to explicitly assign resources for optimal outcomes.
  2. Allows the Network to evaluate the direct correlation between improvement efforts implemented and improved patient outcomes.
  3. Diabetes is a high-cost disease, both monetarily and physically.
  4. Diabetes is a chronic condition tracked by all our value-based arrangements (commercial and government payers).
  5. Since diabetes increases in prevalence among older populations—and our Medicare programs are a majority of the lives managed—addressing this chronic condition will positively affect a significant portion of the population.
  6. There is significant improvement to be captured in obtaining ophthalmology/optometry records.

CHRONIC DISEASE MANAGEMENT is for conditions where high-quality primary care intervention can potentially prevent the need for hospitalization, or where early intervention can prevent complications or more severe disease.

  • KPI 1. Diabetes Composite Metric—unique patients ages 18–75 years of age who have type 1 or type 2 diabetes diagnosis on their problem list, have had an A1c > 6.5 percent in the past 24 months, have had two (2) encounters with a diabetes diagnosis in the past 24 months, compared to patients who satisfy the criteria for the four (4) components of the diabetes composite:
    • HbA1c Control—the percentage of patients 18–75 years of age with diabetes who had A1c > 8 percent or no A1c value in the past 12 months.
    • Diabetes Blood Pressure Control—unique patients 18–75 years of age who have a diabetes diagnosis on their problem list who have had an encounter within the past 24 months AND whose most recent blood pressure is < 140/90 mmHg.
    • Diabetes Eye Exam—percentage of patients 18–75 years of age who have a diabetes diagnosis on their problem list who had an eye exam performed to screen for diabetic retinal disease.
    • Diabetic Nephropathy Prevention and Treatment—the percentage of patients 18–75 years of age who have a diabetes diagnosis who are on an ACE or ARB OR have completed a nephropathy screening within the past 12 months.
  • KPI 2. Hypertension—percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure was < 140/90 mmHg during the reporting period.

PREVENTION and diagnostic interventions detect or monitor health issues to maintain patient well-being or mitigate complications. Here are the four areas of focus:

  • KPI 3. Breast Cancer Screening—the percentage of patients ages 50–74 who have had a mammogram in the past two years.
  • KPI 4. Colorectal Cancer Screening—the percentage of patients ages 50–75 who have had the appropriate screening for colorectal cancer.
  • KPI 5. Pneumococcal Vaccine—the percentage of patients 65 years of age and older who have ever received or have documented historical administration in the administration in the immunization module of a 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) OR a 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23).
  • KPI 6. Cervical Cancer Screening—the percentage of women ages 21–64 who have completed the appropriate cervical cancer screenings.

Sharing information is critical to success

Now that we have identified our KPIs, tracking and reporting is important. Beginning in 2018, regularly scheduled reports will be disseminated to the appropriate groups through a multitier approach to ensure awareness, engagement and action. Want to play a role in accelerating our Quadruple Aim vision? Get involved. Talk to your peers. Share our progress with your staff, and encourage new and innovative ideas.


Tier 1 Sample Report

Tier 2 Sample Report

Tier 3 Sample Report

Pharmacy integration insights

Optimizing antiplatelet therapy to reduce vascular events in high-risk patients


Our primary objective in sharing this information is simple: Demonstrate the success Coordinated Care is experiencing through engagement and collaboration with clinical pharmacists across the clinically integrated network, including those from the University of Colorado Skaggs School of Pharmacy, CU Medicine’s Office of Value Based Performance, the University of Colorado Hospital Department of Pharmacy, Associates in Family Medicine, and those working at UCHealth community pharmacies in the north and south. We are making a measurable difference, and we look forward to sharing additional insights in the near future.


Antiplatelet therapy with aspirin or clopidogrel can reduce the risk of myocardial infarction, stroke and vascular death in patients with established atherosclerotic vascular disease by more than 20 percent. Despite these important benefits, preliminary findings within Coordinated Care suggest that 10-15 percent of high-risk patients are not appropriately receiving this therapy. For patients without established vascular disease, the evidence for aspirin is less clear, presenting challenges when determining which patients need therapy.


Clinical pharmacists across the Network strive to improve the use of aspirin therapy in high-risk patients. Using work begun by CU Medicine’s Office of Value Based Performance, clinical pharmacists work with the Denver Internal Medicine Group clinic, as well as the Snow Mesa Internal Medicine Clinic in Fort Collins, to identify patients within the Medicare Shared Savings Program (MSSP) with established vascular disease, but no aspirin therapy was documented in their medical record.


Approximately 35 percent of identified patients were able to initiate aspirin, 15 percent were already taking it but needed documentation, and 30 percent had at least one contraindication for therapy (e.g., older age or bleeding risk). There were patients not interested in initiating therapy, as well as patients with no clear diagnosis of atherosclerosis upon chart review. With this collaborative work, nearly 95 percent of MSSP patients at high risk for vascular disease at these two clinics are receiving antiplatelet therapy.


There is data supporting the use of antiplatelet therapy for both primary and secondary cardiovascular prevention. It is hoped we can improve the appropriate use of antiplatelet therapy for patients who will most benefit from this therapy. I look forward to any insights or best practices you have to share.


Joseph Vande Griend, PharmD, BCPS, BCGP
Director of Population Health Pharmacy
[email protected]