Provider Insider

Issue 11

Table of Contents


It has been a busy few months in our network, and we have much good work to report out on.


First, we are starting to hear about results from the work that was done by all our practices in 2020, and we are proud to report that all our network practices achieved shared savings in 2020! While we recognize that the COVID-19 pandemic played a role in reducing overall health care utilization, we also know that efforts in our practices helped to keep patients healthy and out of the hospital during a very tough year. Kudos to all—and thank you for all your hard work.


Second, we continue to make good progress toward our 2021 goals. We are seeing increasing engagement in the work of value-based care in the practices. Our network management team continues to develop new and better tools to support that work–data integration between both clinical and claims, more educational videos from which to choose, and increasing pharmacy and care management support.


And we are growing! We welcomed Rocky Mountain Family Practice in Loveland to the network in July, including six new providers. We are thrilled to have Drs. James Fretwell, Brian Hughes, Paul Cooper, Ammie Christiansen, Eric Mast, and nurse practitioner Diane Smith join our network.


Finally, as we all worry about a resurgence of COVID-19 going into this fall, please know that we are here to support you in the hard work of keeping patients healthy. If there is anything you think we can do better as we go forward, please reach out.


And thank you for all you are doing for your patients.

Single Scorecard and Metrics

Commitment: As you can see, we continue to get great engagement from our network practices, with more providers attending monthly meetings and getting involved. Already, 10 practices have surpassed the year-end target for education session completion.


Thank you to the following practices that have already reached the year-end target for education session completion: Longs Peak Family Practice, Children’s Clinic of Pueblo, Champions Family Medical, Stepping Stones Pediatrics, Steel City Pediatrics, Family Care Specialists, University Family Medicine, Parkview Medical Group, Christopher Vialpando, and Associates in Family Medicine.

Capabilities: We continue to focus on preventative care and getting patients in for their wellness visits.

Cost: Finally, we received data regarding our cost metrics through Q4 2020 and now have a better idea about our baselines for 2021.

Note: As we go through 2021, given the effects of the pandemic on the ED/1000 metric, we will be closely watching our results to determine if we need to allow for those effects and adjust our goals in 2021.

Education Series

We have added two new videos to our education series. Watch these videos to hear directly from your colleagues on the topic of unnecessary ED utilization, and to take a deeper look at how the work you are doing impacts patients and your practice’s bottom line.

As approved by the clinical committee, viewing of these videos counts toward single scorecard goals. After watching each video, please complete the corresponding survey. Each survey requires providers to include their NPI to receive full single scorecard credit.

Also, we are excited to announce that providers may now receive CME credit in 0.25 increments for any of our education videos that are viewed after June 14, 2021. Credits are certified by the Colorado Medical Society and managed through a tool called eeds. Links and a tip sheet are included on our website.

Value-Based Primary Care* Survey CME Link
Value-Based Care Part II Survey
Coding Patient Complexity* Survey CME Link
Single Scorecard Survey CME Link
Medicare Annual Wellness Visits Survey CME Link
Optimizing Generic Dispensing Rate Survey CME Link
Practice Challenges: Tackling Unnecessary ED Utilization Survey CME Link

*Viewing of these videos is your key to success on the new single scorecard. Watching Value-Based Primary Care and Coding Patient Complexity is required for your practice to qualify for full shared savings for the “commitment” component of the scorecard.

Care Management

Best practices in making transition of care calls.

Transitions of care (TOC) “refers to the movement of patients between health care practitioners, settings and home as their condition and care needs change.”1 Discharging from an acute setting, and for 30 days after, is increasingly recognized as a time of vulnerability for patient safety and care. The objective for the C3 transition of care program is to support the patient as they move between levels of care, reduce the likelihood of the patient returning to the hospital, and contribute to improving readmission rates by understanding reasons for 30-day readmissions.

According to Agency of Healthcare Research and Quality (AHRQ), the two most common areas of confusion among patients after a hospitalization are understanding discharge instructions and medication changes. Compliance with discharge instructions have been linked with reduced rehospitalization, improved post-hospital outcomes, and decreased health care expenditures. Medication changes or discrepancies are cited as the most frequent cause of patient misunderstanding.2

Nurse care managers review discharge instructions with patients and caregivers.

They help patients understand key points about their care such as “red flag” symptoms and who to contact for concerns and to arrange follow-up care. They also assess for social determinants of health and coordinate supportive community services, such as connection to mental health providers.

Nurse care managers reconcile medications.

Most medical records do not share data. Hospital discharge medication lists might conflict with a patient’s home list, have recommended changes in medications or doses, or not be displayed in a patient-friendly format. Care managers reconcile the hospital medication list with the active list in the primary care record, assess for discrepancies, communicate errors with primary care providers, and educate patients.

The C3 care management team supports network providers by outreaching patients following hospitalizations and ED visits. This helps reduce the risk of readmission by ensuring patients have the resources they need to self-manage at home. In Q1-Q2 2021, the C3 care management team reached out to more than 1,500 patients across the C3 network.

If your practice is not currently receiving care management support and would like to utilize this free service, please contact Jenn Countryman.


[1]   The Joint Commission, et al. “Transitions of Care: The need for a more effective approach to continuing patient care.” Digital file, June 2012.

2    Agency for Healthcare Research and Quality (AHRQ). Chartbook on Care Coordination: Transitions of Care. Retrieved from


Effective July 1, 2021, C3 has a new value-based program offering with UnitedHealthcare Commercial specific to a product called SelectColorado. UnitedHealthcare has collaborated with both UCHealth and SCL Health for a tiered product which focuses on improved quality and reduced cost. C3 participants will be in Tier 1 of the product, which offers better benefits to UnitedHealthcare members.

Risk Coding

We have launched a medical risk coding program to help guide providers in their efforts to tell the best patient story and appropriately document medical complexity, while meeting coding guidelines required by Medicare and commercial payers. Our program offers providers the following:

  • Individual meetings with practices tailored to the needs and areas of opportunity specific to the practice.
  • Chart audit to identify education opportunities and workflow enhancements.
  • 1-on-1 coaching.
  • Disease state coaching.
  • Rapid improvement events.
  • Workflow redesign assistance.
  • Individualized data analysis and review.

Risk coding tip: “History of Prostate Cancer” vs. “Prostate Cancer”

If your patient’s prostate cancer has been successfully treated and the patient is in remission, then you do not need to code the active diagnosis of “Prostate Cancer” (C61) to get your patient’s annual PSA level test covered. Medicare will cover the lab test as long as you do not order the “Total and Free” combination test.

For help or to schedule a clinic visit, please contact Tamara Ellis.


Process improvement project success: Children’s Clinic of Pueblo

Throughout the last 18 months, many of our network practices have indicated that the rate of anxiety and depression amongst their population has seen an uptick, particularly in our pediatric practices. The Children’s Clinic of Pueblo was no exception. When they compared the number of depression diagnoses in the first 6 months of 2020 to the last 6 months of 2020, they saw a 500% increase. Based on that alarming increase, they chose to focus their process improvement project on the depression screening and follow-up care gap. To them, managing a patient’s mental health is a key component of the annual well visit and critical to the patient’s overall health:

  • Their goal: Increase the completion rate of depression screenings (using modified PHQ-9) to 90% of their total patient population, ages 11-19, by the end of the year.
  • Improvement: Baseline–3.65%; Q1–26%; Q2–46%
  • Intervention: Assigning specific goals to every team member in the practice; ensuring each team member is committed to the goal and modified workflows; making the work top-of-mind by discussing and evaluating at each practice meeting; coordinating appropriate care for all positive screens.


Welcome new members

New practices:

Please join us in welcoming Rocky Mountain Family Practice to our network. Established in 1995 to serve the Longmont community, this independent practice is comprised of six providers and has broad experience with value-based contracts. We are excited to work with them going forward. Welcome, team!

Network support:

Jessica Bailey

Jessica Bailey joined UCHealth Coordinated Care Colorado as a population health coordinator in June 2021. She earned her Bachelor of Science in public health from the University of Arizona in May. Prior to transitioning to C3, she spent over 3 years with UCHealth Patient Line, working primarily with UCHealth Medical Group clinics, and she also interned with C3 doing patient outreach and quality work before graduating. She plans to obtain a master’s degree in public health in the future. Outside of work, Jessica enjoys hiking, cooking and traveling.

Dawn Jachter

Dawn Jachter moved to Colorado from New Mexico about 5 years ago with 20+ years of health care experience. She has worked in corrections, women’s care, general surgery and the operating room, to name a few areas of specialty. Dawn taught a medical assisting program for many years as well.

Dawn joined UCHealth in October 2016 as a care coordinator on the newly formed care management team. There, she learned about the benefits of value-based care through the group’s participation in CPC+ and was able to participate in quality improvement focus groups. As a result, Dawn helped develop workflows to support individual practices with decreasing ED utilization, providing support to patients during transitions of care, and building lasting relationships through longitudinal care management. Dawn likes to spend her free time with her adult son, two Frenchie puppies and lots and lots of crafting. She also enjoys travel and road trips with loud music.

Noel Mason

Noel Mason has been with UCHealth Poudre Valley Hospital (PVH) for more than 18 years, with over 10 years in care management and 5 years in workers’ compensation. Prior to care management, she worked bedside in the neuroscience unit at PVH. Noel was raised in Loveland, Colorado after her family moved there in 1980 from Southern California. She earned her Bachelor of Science in nursing from Regis University. Prior to joining UCHealth Coordinated Care Colorado, she worked for UCHealth Medical Group for 3½ years, where she provided care management support for many of the clinics in northern Colorado. Noel’s goal is to obtain her CCM by the end of 2022. In her free time, Noel enjoys being with her family, friends and 3 dogs. She enjoys traveling, reading, shopping and gardening.

Valerie Valdiviez

Valerie Valdiviez hails from Nebraska, where she graduated from Creighton University. She is residency-trained and a board-certified pharmacotherapy specialist who brings a broad history of experience in ambulatory pharmacy settings. She has spent time working in both primary care and specialty clinics. Valerie worked at the Veterans Affairs ambulatory care clinics in Tucson, Arizona, and at an FQHC in Phoenix, Arizona before moving to Colorado, where she joined UCHealth Medical Group. For the past three years she has worked in the northern Colorado region, improving population health medication metrics for our patients. Valerie lives in Fort Collins with her husband, two children and her dog. In her limited free time, she likes to bake, read and enjoy the outdoors.